Pubdate: Mon, 09 Jan 2012
Source: Globe and Mail (Canada)
Copyright: 2012 The Globe and Mail Company
Author: Andre Picard


Data on illicit drug use are sorely lacking. It is no coincidence 
that public policy in this area is abysmal.

Our response to drug use is, by and large, moralistic and vengeful, 
not evidence-based.

While we spend billions of dollars on the "War on Drugs," there has 
been a pittance spent on research to understand the root causes of 
drug use (and addiction in particular), little dispassionate 
examination of the harms that result and, especially, analysis of the 
responses that will minimize those harms

If you want to fashion sound public-health policies, you need good data.

So a new series of studies, published in the Lancet, is a welcome 

The paper prepared by Louisa Degenhardt of the National Drug and 
Alcohol ResearchCentre in Sydney, Australia, has received the most 
attention. It shows that at least one in 20 people aged 15 to 64 used 
illicit drugs in the past year.

That includes an estimated:

- - 125-203 million cannabis users (marijuana);

- - 56 million amphetamine users (speed, crystal meth);

- - 12-21 million problem users of opioids (heroin, oxycodone);

- - 14-21 million cocaine users.

The researchers did not include data on use of drugs like 
hallucinogens, inhalants, steroids, or prescription drugs that are 
abused because data are unreliable.

Dr. Degenhardt said the numbers are no doubt an underestimate. "Drug 
use is often hidden, particularly when people fear the consequence of 
being discovered for using drugs, such as being imprisoned," she said.

Worldwide, illicit drug use accounts for about 250,000 deaths each 
year. That is significant but still doesn't not compare to the deadly 
impact of legal drugs like alcohol, which kills 2.3 million a year, 
and tobacco, which causes 5.1 million deaths annually.

Still, the vast majority of users of illicit drugs   particularly 
so-called soft drugs like cannabis   do not suffer appreciable harm. 
There are some societal costs like injuries from drugged driving, 
lost productivity and the violence sometimes associated with drug misuse.

But the real problems, individually and socially, stem from the 
minority of problematic or dependent users   addicts, in the common 
parlance. The new research estimates there are about 39 million 
addicts worldwide, most of them injection drug users.

Addiction is a disease, not a choice. But there is no doubt the 
disease and the drug-seeking leads to many poor choices.

In addition to the overdoses they suffer, IV drug users are at high 
risk of contracting infectious diseases like hepatitis and HIV-AIDS, 
and often turn to risky practices like selling sex and committing 
crimes like break-ins to fuel their addiction.

Paradoxically, it is those who suffer the most harm physically who 
bear the brunt of public policies, most of which focus on repressive measures.

The key question: Do those policies achieve what we want   to make 
the general population healthier and safer? For the most part, the 
answer is "No," according to a second paper in The Lancet that was 
prepared by a team led by John Strang of the National Addiction 
Centre in London (which included Benedikt Fischer of Simon Fraser 
University in Burnaby, B.C.) The main anti-drug strategy worldwide is 
to try and control supply in a bid to drive up prices and make drugs 
less accessible. This includes imprisoning drug suppliers and 
dealers. Enforcement and sanctions vary dramatically from country to country.

The research shows that incarcerating high-level dealers   like 
Colombian drug barons   can have an impact on supply and prices, at 
least temporarily, but street-level enforcement is generally costly 
and ineffective.

Prolonged imprisonment of drug users is also very expensive and does 
little to reduce illicit drug use. Researchers found, however, that 
specific, immediate and brief sentences   with mandated testing of 
offenders   is quite effective at reducing drug use and associated crime.

Legalization, or decriminalization, is often touted as a solution, 
but the study notes that most research in this area is of poor 
quality. However, there is good circumstantial evidence that 
decriminalization is effective at moving cannabis users away from 
other drug markets.

On the prevention front, the news is rather grim. School-based and 
mass media programs alike are generally ineffective at influencing 
behaviour. There is a little bit of evidence showing that 
family-based or parenting programs might help young people make 
better choices. What works best, though, is secondary 
prevention   intervening early with those who misuse drugs (or 
alcohol). In other words, they need treatment, not didactic lectures 
and not punishment.

Similarly, this is the approach that has shown to be the most 
influential with problematic users.

There is good evidence, for example, that opioid substitution with 
drugs like methadone or buprenorphine reduces mortality, heroin use, 
crime, HIV and hepatitis infections. Residential rehab programs gets 
good marks, but the quality of the research is mediocre. Rehab is 
also expensive, although less expensive than prison.

In short, the research shows that when it comes to illicit drugs, the 
focus needs to be on the problematic users, and that public-health 
measures work better than criminal sanctions.

There is no magic bullet   not zero tolerance and not supervised 
injection facilities. Rather, a broad range of interventions are 
required, targeting different drug problems.

The hardest part of this approach may be setting aside our prejudices 
and preconceived notions to adopt evidence-based approaches that are 
not always politically popular.

As The Lancet notes in an editorial highlighting the new research: 
"Few diseases can compete with addiction in their capacity to 
generate misinformation, misjudgment, or misunderstanding."

Addiction is a complex disease   a global problem that has no global 
solution, but rather many community-based solutions. 
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