BMJ Editorial-Evidence based policy for elicit drugs #drugpolicy

 

Editorials

Evidence based policy for elicit drugs

An ethical obligation for those working in the field of drug addiction

Systematic reviews have shown that methadone maintenance treatmentsignificantly reduces heroin use compared with other treatments,¹ and it also reduces HIV risk behaviour among injecting drug users.² Not surprisingly, it is on the World Health Organization's list of essential medicines.³ In the linked prospective cohort study (doi:10.1136/bmj.c3172) Kimber and colleagues describe the effect of opiate substitution treatment on mortality and time to long term injection cessation.⁴

The study, which is based on observational data from a single primary care facility in Edinburgh, found that longer duration on opiate substitution treatment (primarily methadone) was associated with reduced mortality, but that it was also associated with a lower likelihood of injection cessation. Although the association with improved survival might be expected on the basis of pastresearch,^1 2 the negative association between opiate substitution treatment and injection cessation is curious. Despite the limitations of the study, which Kimber and colleagues acknowledge, the study overall supports the already extensive evidence base for using methadone as a first line treatment for opioid addiction.^1 2

However, despite the wealth of evidence demonstrating the benefits of opiate substitution treatment, the availability of the drug is limited—often where it is needed most.⁵ For instance, in Russia, where most new cases of HIV are attributable to heroin injection, and where the United Nations Joint Programme on HIV/AIDS estimates that more than 1% of adults aged 15-49 are alreadyinfected with HIV, methadone remains illegal.⁶ Sadly, as discussed in the linked article by Rhodes and colleagues,⁷ the situation with methadone in Russia is only one example of a global pattern of effective interventions being severely limited and ideology trumping scientific evidence when it comes to policies on illicit drugs.^8 9

Doctors and scientists therefore have a crucial role in increasing the importance of scientific evidence when shaping drug policies. However, given that society continues to respond to drug addiction primarily as a law enforcement problem while effective interventions remain limited or even illegal, it could be argued that those who work in the field of addiction have long been shirking this obligation.¹⁰ This is because evidence clearly shows that drug law enforcement has failed to achieve its stated objectives and has instead caused serious harms.

For instance, under the current global drug control regimen, a massive illicit market has emerged which the UN estimates is worth $320bn (£218bn; 261bn) annually.¹¹ In many settings, these illegal revenues drive corruption and violence, as has been seen recently in Mexico and Afghanistan. Other consequences include record levels of incarceration of non-violent drug offenders, and the spread of HIV among injection drug users including those in prison.¹² Importantly, ever increasing expenditure on drug laws and expanding prison populations have not prevented the growth of this market; instead, an overall pattern of increasing drug purity and falling drug prices has occurred.¹¹

The ineffectiveness and unintended consequences of drug control efforts in the United States recently led to a unanimous resolution at the 2007 annual US Conference of Mayors, which concluded that the "war on drugs" had failed and a "new bottom line" in US drug policy was needed, with a focus on reducing the negative consequences associated with drug misuse. As a result of the harms of drug prohibition, as discussed in the linked article by Stephen Rolles, regulatory models for drug control are now creating international interest.¹³

The limitations and harms of enforcement based drug strategies have been known for many years, but meaningful reform has been slow to come. In 1919 in the American Journal of Public Health, Professor Ernest Bishop wrote in frustration that drug addiction was being framed as a criminal justice matter rather than a health problem and stated that: "The worst evil of the narcoticsituation in the past few years, and especially since the enforcement of restrictive legislation without provisions for education and adequate treatment, is the rapid increase and spread of criminal and underworld and illicit traffic in narcotic drugs. This exists because conditions have been created which makesmuggling and street peddling and criminal and illicit traffic tremendously profitable, and it would not exist otherwise."¹⁴ More than 90 years later, Bishop's words still ring true.

Some doctors and scientists have spoken out about the need for evidence based approaches to tackle the illicit drug problem,⁸ but this has been far too rare in the field of addictions.¹⁵ Although there are social forces that seek to maintain the harmful status quo in the drug policy arena,⁹ these forces wouldbe overwhelmed if the medical, public health, and scientific communities stood together and called for evidence based approaches to tackle drug related harms.¹⁰ In the face of the global public health emergency presented by both drug addiction and HIV, this is a clear moral and ethical obligation for those who work in the addictions field.

Cite this as: BMJ 2010;340:c3374

Evan Wood, associate professor

¹ University of British Columbia, BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6

uhri-ew@cfenet.ubc.ca

Research, doi:10.1136/bmj.c3172

Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the author) and declares: (1) No financial support for the submitted work from anyone other than his employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouse,partner, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.Cochrane Database Syst Rev 2003;2:CD002209.[Medline]
2. Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R. Substitution treatment of injecting opioid users for prevention of HIV infection.Cochrane Database Syst Rev 2008;2:CD004145.[Medline]
3. Kerr T, Wodak A, Elliott R, Montaner JS, Wood E. Opioid substitution and HIV/AIDS treatment and prevention. Lancet 2004;364:1918-9.[CrossRef][Web of Science][Medline]
4. Kimber J, Copeland L, Hickman M, Macleod J, McKenzie J, De Angelis D, et al. Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitute treatment. BMJ 2010;341:c3172.[Abstract/Free Full Text]
5. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.Lancet 2010;375:1014-28.[CrossRef][Web of Science][Medline]
6. United Nations Joint Programme on HIV/AIDS. 2008 report on the global AIDS epidemic. 2008.www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp.
7. Rhodes T, Sarang A, Vickerman P, Hickman M. Health potential of harm reduction for drug users. BMJ 2010;341:c3439.
8. A collapse in integrity of scientific advice in the UK. Lancet2010;375:1319.[CrossRef][Web of Science][Medline]
9. Wood E, Montaner JS, Kerr T. Illicit drug addiction, infectious disease spread, and the need for an evidence-based response. Lancet Infect Dis 2008;8:142-3.[CrossRef][Web of Science][Medline]
10. Porder S, Chan KM, Higgins PA. Scientists must conquer reluctance to speak out. Nature 2004;431:1036.[Web of Science][Medline]
11. United Nations Office on Drugs and Crime. World drug report 2005. 2005. www.unodc.org/pdf/WDR_2005/volume_1_web.pdf.
12. Taylor A, Goldberg D, Emslie J, Wrench J, Gruer L, Cameron S, et al. Outbreak of HIV infection in a Scottish prison. BMJ 1995;310:289-92.[Abstract/Free Full Text]
13. Rolles S. An alternative to the war on drugs. BMJ 2010;341:c3360.
14. Bishop ES. Narcotic drug addiction: a public health problem. Am J Public Health (NY) 1919;9:481-8.[CrossRef]
15. Kerr T, Montaner JS, Wood E. Science and politics of heroin prescription. Lancet 2010;375:1849-50.[CrossRef][Web of