Will drug law reform reduce drug-related harm?

1. Will drug law reform reduce drug-related harm? 2008 Scotland Future’s Forum 12 March 2008, Parliament House, Edinburgh Dr. Alex Wodak, St. Vincent’s Hospital, Sydney, Australia awodak@stvincents.com.au

2. Topics: • Is this the right question? • Does tough drug policy reduce harm? • What is ‘drug law reform’? • ‘Will drug law reform reduce harm’? • What is the basic problem? • Conclusions

3. Is this the right question? • ‘Will drug law reform reduce drug-related harm?’: not neutral question - favours status quo 'Legalize This! the case for decriminalizing drugs' Douglas N. Husak. Verso 2002. • ‘When did you stop beating your wife?’ • But this question usually asked, therefore must be answered • What is the right question?

4. Does tough drug policy reduce harm? • Global drug prohibition started 1909 • Steadily intensified 20th C, major intensification 1971 • But huge global : • Drug cultivation, production • Range of drug types, availability • Numbers people using drugs • Countries drugs used, drugs a problem • Health, social, economic problems

7. Tough drug policies: 2 • Increase: • Government expenditure • Official corruption • Narco-countries • Narco-terrorism • ‘Pro heroin effects of anti opium policies’ • Numerous reports failed, futile: • Strategy Unit Drugs Project, 2003 • Select Committee Home Affairs, House of Commons, 2002

8. ‘If there is any single lesson from the experience of the last 30 years, it is that policies based wholly or mainly on enforcement are destined to fail. … the best efforts of police and Customs have had little, if any, impact on the availability of illegal drugs and this is reflected in the prices on the street which are as low as they have ever been’ Select Committee on Home Affairs, House of Commons, 2002.

9. ‘A sustained seizure rate of over 60% is required to put a successful trafficker out of business – anecdotal evidence suggests that seizure rates as high as 80% may be needed in some cases. Sustained successful interventions on this scale have never been achieved’ Strategy Unit Drugs Project. London. Cabinet Office Strategy Unit 2003

10. What is drug law reform? • Threshold steps: ‘redefine drugs as primarily health & social problem requiring funding as generous as drug law enforcement’ • Objective: reduce deaths, disease, crime, corruption, # prison inmates, government spending

11. Specific steps • First: expand capacity, improve quality, increase range options drug treatment • Attract, retain most drug users in Rx • Rx, especially substitution treatment, benefits drug users, families, communities • Second: tax & regulate cannabis • Third: if above insufficient, may be role commercial retail sale small quantities, low concentration drugs?

12. Why drug law reform reduces harm? • Common assertion any liberalisation  prices,  consumption • Therefore  harm • Supportive evidence < minimal • Why reduction harm likely: • HIV prevention IDUs required DLR • DLR likely encourage less dangerous drugs replace more dangerous drugs

13. Why drug law reform reduces harm? 2 • Drug users in Rx reduce health, social, economic harms • Drugs consumed known concentration, unadulterated, not injected • May decrease incidence drug use e.g. Zurich, reduce crime, heroin seizures • Considerable harms associated with drug law enforcement • 89 US cities:  DLE, no  use,  HIV Friedman et al. AIDS 2006, 20:93–99

14. Why drug law reform reduces harm? 3 • Cannabis prohibition high social costs • Cannabis regulation: • Warning labels packages • Advertise self help services • Keep THC concentration in band • Reduce police corruption • Proof of age when purchasing • Separate market from heroin etc • Reduce police corruption

15. What is the basic problem? • Irresistible force of economics vs. immovable mountain of politics • Economics • High price ignoring powerful market forces • Global turnover $US 322 billion/year • Profit 26-58% • The inexorable law: supply & demand

16. What is the basic problem? 2 • Politics: • Supply control sounds intuitive but empirically weak • War on Drugs = political Viagra • Fear campaigns work • Drug law reform sounds counter-intuitive but empirically strong • When economics, politics clash - economics wins long run

17. Specific, evidence-based: Alcohol • Pricing and taxation, strong support: • Small increase taxes, reduce harm • Hypothecation • Ad valorem to volumetric • Large increase taxes risky Alcohol: No Ordinary Commodity Alcohol & Public Policy Group Addiction 2003; 98: 1343-1350

18. Specific, evidence-based: 2 • Regulating availability: •  availability,  harm •  number of outlets •  hours opening •  minimum legal drinking age • Enforcing restrictions sales under age • Low alcohol content beverages • Off premise monopoly sales • Excessive restriction risky

19. Specific, evidence-based: 3 • Modifying drinking context: • Responsible beverage service •  aggression, violence • Community mobilisation? • Safety measures for intoxication

20. Specific, evidence-based: 4 • Drink driving countermeasures: • Enforcement: celerity, certainty, severity • License suspension • Random breath testing • Low level BAC (e.g. < 0.08) • Ignition interlock • Graduated licensing

21. Specific, evidence-based: 5 • Regulating alcohol promotion: • Advertising promotes risk-free view • Legal restrictions advertising some reduction harms • Avoiding industry self – regulation • Education, persuasion strategies: • Small, transient benefits

22. Specific, evidence-based: 6 • Treatment, early intervention: • 40 therapeutic interventions proven by RCTs • In-patient treatment rarely • Behavioural > insight treatments • 12 step? • Pharmacological treatments • Brief interventions

23. Best supported interventions: • Tobacco taxation price disincentive • Enforce environmental tobacco smoke regulations • Volumetric alcohol taxation • Random breath testing drivers • Brief interventions alcohol, tobacco* • Treatment alcohol, drug problems* • Needle syringe programmes • Hepatitis B vaccination* * = role for doctors Loxley W, Toumbourou J, Stockwell T. MedJAust 2005; 182: 54-55

24. Conclusions: • ‘Will drug law reform reduce drug-related harm?’: wrong question • Tough drug policy: • ineffective • expensive • high collateral damage • does not reduce harms • only works politically • DLR: ‘redefine drugs as primarily health & social problem’

25. Conclusions: 2 • DLR reduces harm: • Keeps HIV under control • Getting most drug users into Rx • Shift from more dangerous, less dangerous drugs • Reduces problems inherent rely on enforcement • Basic problem: • Economics drug trade ensure drugs available • Politics WADs slows DLR • What works/what doesn’t work agreed