Unpacking Rhetoric

Nazlee Maghsoudi & Lisa Campbell

The need to take a “public health approach to drug policy” is language we have heard over and over at this year’s CND. We can’t help but wonder, however, what exactly does this mean? As the two side events we cover in tonight’s blog post demonstrate, addressing drug use from a public health perspective can look very different depending on who you ask.

CSSDP had the opportunity to hear experts share their understanding of a public health approach to drug policy today at a side event organized by the Canadian HIV/AIDS Legal Network and Transform Drug Policy Foundation. Milton Romani, National Drug Coordinator of the Government of Uruguay, emphasized that a public health approach to drug policy prioritizes respect for human rights above all other objectives, including the goal of combating illicit drug production, trafficking, and consumption. A human rights framework is at the centre of their government’s decision to regulate the recreational marijuana market. According to Mr. Romani, “our current framework has done nothing to ensure human rights.” In addition to respect of human rights, Richard Elliot from Canadian HIV/AIDS Legal Network, added that a true public health approach to drug policy must include three components: harm reduction, decriminalization, and regulation. The extent to which the current international drug control regime restricts or discourages these elements of a public health approach is a matter of concern, and indicates that we need to revisit the regime.

Steve Rolles from Transform Drug Policy Foundation elaborated significantly on the notion of regulation as a public health approach to drug policy. We need to start from a place of reality when discussing a public health approach to drug policy: people use drugs, and a drug free world will never be possible. What we can do, however, is identify public health risks and seek to mitigate them. A regulated approach to illicit substances allows governments to intervene by identifying and reducing risks that are currently a significant challenge in drug production and supply, as well as consumption. Regulation allows governments to achieve better public health outcomes by controlling potency, putting health information on packaging, setting advertising restrictions, and adopting other similarly intended strategies. Importantly, and as CSSDP pointed out at the Civil Society Hearing on Monday, regulation can be much more effective than prohibition at keeping drugs out of the hands of youth. As any organization working on the ground can tell you, youth can easily access illicit substances despite their illegality. In a regulated market, age restrictions can be imposed to prevent this current challenge. Mr. Rolles stressed that regulation is achievable, as we already have an international regulatory framework for non-medical and non-scientific uses of a drug… tobacco! Mr. Rolles also noted the problematic concept of a balanced approach between public health and law enforcement that is frequently discussed at the UN. According to Mr. Rolles, “We can’t balance something that works against something that doesn’t.”

Regulation can also be a viable solution for addressing the challenges in drug producing and transit countries where the impact of harm reduction and decriminalization can be limited. Lisa Sanchez from Mexico Unido Contra la Delincuencia brought this important perspective to the panel, reminding us that in some countries, “drug policies kill more than drugs themselves.” Mexico is a case in point, as the level of homicides has risen threefold since the war on drugs was declared, with currently 10,000 murders per year. Prevalence of drug consumption has increased a meagre 0.2%. A public health approach needs to focus on the whole population, including those that are subject to drug market violence, which is unavoidable under prohibition.

In conclusion, the side event highlighted that a public health approach will be different in consumer, transit, and production countries, but it undoubtedly must have a respect for human rights at its core, and would incorporate harm reduction, decriminalization, and regulation. This was far from what was discussed as a “public health approach to drug policy” at the next side event we attended.

Organized by Europe Against Drugs (EURAD), Community Anti-Drug Coalitions of America, and the Norwegian Policy Network on Alcohol and Drugs (Actis), the second public health side event of the day took a different approach, by zeroing in on epidemiological data on drug use trends and associated harms, and also focused on recovery and the dangers of a commercial market for cannabis in the United States. To begin the panel, Fay Watson from EURAD made a strong statement supporting the movement towards a public health approach in the UNGASS process. Ms. Watson encouraged attendees to consider the social determinants of health that shape drug use, and not view addiction as a choice. Problematic substance use can emerge due to a variety of social phenomena like age, gender, genetics, wide social norms, laws, and social, economic, and environmental factors. There is no single risk factor that predicts drug use, or drug use becoming problematic, and our prevention programs need to acknowledge that.

Next up, Maria Renstrom from the World Health Organization (WHO) presented on global drug trends, but said little on the interventions needed to combat the global epidemic, thereby lacking a true explanation of what a public health approach to drug policy entails. In particular, Ms. Renstrom had some excellent slides on global prevalence of opiates, and highlighted that while over prescribing might be an issue in some regions, others experienced barriers to accessing essential medicines. While Ms. Renstrom challenged the audience, “What is required to reduce health effects of substance abuse?” she never really answered her own question. She was correct in pointing out that there are a number of poor health outcomes for key affected populations such as injection drug users, yet she did not attribute them to policy but to their own behaviours. There was no analysis of the environmental factors that lead to poor health outcomes for drug users such as criminalization, imprisonment, stigma, isolation, or poverty. In addition to no explicit mention of harm reduction services, Ms. Renstrom also failed to include the WHO’s position on decriminalization, namely that “Countries should work toward developing policies and laws that decriminalize injection and other use of drugs and, thereby, reduce incarceration.” This was truly a shame given the obvious importance of decriminalization in a public health approach to drug policy.

Kevin Sabet from Smart Approaches to Drugs closed the panel with a surface level critique of what he called “commercialization.” Mr. Sabet strived to demonstrate that a regulatory approach is incompatible with a public health approach to drug policy. Yet his presentation was riddled with inconsistencies, thereby completing undermining his argument. Mr. Sabet explained that the recent reductions in tobacco use in the USA have been due to driving the tobacco industry out by imposing high restrictions, and he believes the opposite is happening in Colorado with cannabis legalization. Evidently, there is an inherent inconsistency in his argument. He is stating that the desired outcome of reduced use was achieved when tighter restrictions were imposed on industry. Regulating illicit substances does exactly that. Regulation would put restrictions on a market that currently has, in effect, no restrictions at all. 

According to Mr. Sabet, Colorado is the “first implementation” of commercialization globally, and as such he was concerned about the number of people who use cannabis heavily, the increased concentration of THC in cannabis products, and impaired driving. Unfortunately, Mr. Sabet neglected to note that for many youth in North America, it is drug policy which ultimately hurts young people. While Mr. Sabet was quick to point out that in the USA incarceration is low for cannabis consumers in the general population, he neglected to mention how youth of colour are targeted by cops simply for walking down the street.

A fundamental flaw in Mr. Sabet’s argument was his assertion that the increase in the number of children who accidentally consume marijuana under legalization puts a “strain on the state as they need to have more people in poison control centers and emergency rooms.” What about the reduction in burden on the state in terms of the number of law enforcement personnel that are no longer needed to enforce cannabis prohibition? Mr. Sabet later went on to say that the annual number of children needing medical help for accidental marijuana consumption has increased from one to fourteen. Not only does this lead us to wonder what exactly Mr. Sabet’s threshold is for “strain on the state,” it also guarantees that the reduction in law enforcement has been a more significant saving.

Another matter regarding Mr. Sabet’s concern about accidental ingestion is that this argument can be used for all drugs, in particular prescription opiates which Ms. Renstrom demonstrated is at epidemic proportions in North America. States with medical cannabis access are shown to lower opiate use, thus reducing the risks for when children do end up dipping into the medicine cabinet. Mr. Sabet was very concerned that 93% of Americans thought cannabis was non-addictive, but many consumers of pharmaceutical drugs do not even think of them as drugs period. The USA is experiencing a prescription drug epidemic which is rooted in over prescribing, so Mr. Sabet is right to be cautious. In the USA, prescription drug overdose is the number one cause of accidental death, more than car accidents. We agree that we need “smart approaches to marijuana” but just as much so the USA needs to come up with substitution therapy options, of which cannabis shows promise.

While Mr. Sabet is very worried about young people using cannabis, he doesn’t seem to acknowledge that research has shown that when teenage consumption of cannabis goes up, the more harmful trend of binge drinking goes down. Although we appreciate Mr. Sabet’s concern about the developing brains of young adults, unlike alcohol there is no risk of death through consuming cannabis. We agree with Mr. Sabet that there is data emerging about the effects of cannabis on long term memory for teens, but it’s important not to over exaggerate the risks. Most importantly, in a regulated market cannabis would be a controlled substance like alcohol and cigarettes, decreasing underage consumption, and creating new tax revenue to fund youth prevention, harm reduction, and treatment services. Cannabis has now surpassed tobacco use for youth in the US, so if we really want to decrease use we need to legalize and regulate cannabis.

Later today, we met with the Canadian delegation to discuss some of our perspectives on key issues at this year’s CND, including the engagement of civil society and other UN agencies in the process leading up to and at the UNGASS, tomorrow’s vote on scheduling ketamine, and new psychoactive substances. We are very grateful for the opportunity to meet and are also very pleased that members of the Canadian delegation attended our side event yesterday. We hope that the Canadian delegation takes to heart the concerns we expressed at both our meeting and side event, and CSSDP look forwards to continuing conversations with them on this important policy area.