In the final analysis, drug policy based on prohibition fails to meet the test of fairness and justice in the lives of those most directly affected.
Alex Wodak (Pearls and Irritations, 24th April 2018) argues cogently for overturning the “iron law of prohibition” pointing to the hold drug-traffickers have over importing and distributing illicit drugs rather than supply being regulated by government through social and health policy.
The UN’s drug policy-making body, the International Narcotics Control Board (INCB), has promulgated prohibition-oriented global policies since 1968. Australian legislation follows the international conventions and state and territory governments control the access to controlled substances through Poisons and Therapeutic Goods Acts.
The failings of prohibition
Prohibition-led policies are based on interdiction and eradication and lead to mass incarceration (disproportionately affecting women). They result in extreme abuses of human rights, such as extrajudicial killings in the Philippines and use of the death penalty. Police are readily corrupted and access to the processes of justice denied. Epidemics of HIV/AIDS, hepatitis B and C and TB result, and there is drug trafficking, violence and corruption. Yet, most drug offences are simply for drug possession.
Global macro-drug policy:
- fails to address underlying causes;
- neglects the health and welfare of those who bear the consequences;
- subverts the humanitarian roles of doctors and other health workers;
- excludes alcohol and tobacco; and
- does not, and cannot, keep pace with new psychoactive substances
In the final analysis, drug policy based on prohibition will fail to meet the test of fairness and justice in the lives of those most directly affected.
In the US opioid crisis, physicians have observed that social conditions and despair drive up the incidence of addictions, alcohol and drug problems, mental disorders and suicides. These problems result, not from the drug alone, but from the social environments in which vulnerable individuals interact with drugs. Which means, ”drug” policy should be shaped by the values and strategies of social welfare and health. Of course, it is about justice. Not criminal justice, but practical justice acted out in the lives of marginal and devalued others.
Root causes
In the Boyer Lectures – Fair Australia: Justice and the Health Gap – in 2016, Sir Michael Marmot spoke about the ‘causes of causes’ – the underlying social mechanisms that drive the patterns of disease and exposure to the risks of drugs and mental health. That is a step too far for governments, as to tackle the starting points, in childhood and adolescence, does not have the electoral appeal of the much-vaunted policies on cannabis or ‘ICE’ or other drugs.
Australia started to get it right in the 1980s, at the national summit convened by Prime Minister Hawke. There was a shift away from endless criminal justice reports to an inclusive humanitarian approach. The resulting campaign’s prime objective was to minimise the harms from all substances, not only illicits. It aimed to reduce the demand for drugs and to improve access to treatment and rehabilitation. It was a cooperative effort, involving all sectors, with a ‘common approach’ which held sway for over two decades. But fracture-lines have started to appear in the last two decades, driven by the obsession with crystalline methamphetamines, confected as an ‘ICE epidemic’, and the problems of prescribed opioids.
In 2016 there was welcome movement at the international level. The UN General Assembly on drugs, drawing on its principles of – protecting human rights, public health, proportionate sentencing and the global Sustainable Development Goals went beyond the prohibition-oriented conventions. The Assembly’s report was about human rights, women and children, international cooperation and development – aiming to minimise the health and social consequences of drug abuse; to end by 2030 – the HIV/AIDS, TB, blood borne virus and other communicable disease epidemics. And, significantly, to support demand reduction, prevention, treatment and rehabilitation and to remove the barriers of access to controlled substances for the relief of pain and suffering and for research.
What needs to be done?
The lessons are that Australia needs to stand on its own feet, as it did in the 1980s, with harm minimisation, and drug policy needs to be set as a key element of social and health policy with clear demarcation from the criminal law and enforcement. The social causes, and the panoply of drug and related problems, become lost in the exaggerated responses to specific drugs. The responses to ‘ICE’, to the opioid crisis in the US, and to the rise of fentanyl, are recent examples to be set against past conflagrations about marihuana, heroin and ‘crack’ cocaine.
The Hawke Summit, in 1985, left us the legacy of the current national drug strategy. A strategy which aims to “minimise – alcohol, tobacco and other drug-related – health, social, cultural and economic harms”. In principle, it gives equal weight to demand, supply and harm reduction and emphasises prevention, cross-agency cooperation and priority of ‘at risk’ groups. However, the full potential of such a broadly-based strategy is not being realised, as law enforcement funding dwarfs the funding of social and health measures, especially prevention and treatment services.
Never-the-less, the national drug strategy provides a flexible framework and guidance for preventing and managing drug problems – where they occur, in communities, and in whom they affect – the drug user. Proscriptive drug policies are a poor fit and potentially unfair to the predicaments of drug users and their families and communities.
State drug policies can also create difficulties for GPs
A key doorway through which nascent drug (and alcohol) and addiction problems become evident, and where the first crucial steps can be taken, is primary health care – the GP. And, in most settings, it is the GP who will continue to carry the medical care of people with these problems, not the specialist.
An especially vexed problem for GPs is in the management of people in unremitting pain when some medical disciplines are dead set against the use of opioid analgesics, and when, so often, drug fatalities are characterised as careless prescribing or the actions of unscrupulous doctors.
For patients who need an opioid analgesic, GPs must negotiate with state health authorities for approval to prescribe these medicines; but this can turn out to be a frustrating and time-consuming experience for them. In the environment of a busy general practice, the accompanying tensions and complexities can create an unhealthy and hostile attitude towards treatment-seeking patients.
It would be more sensible, and fair to patients and doctors, if regional/local health networks, familiar with the skills and resources available in the local area, could authorise the prescription of controlled substances by competent GPs for patients in their community. Far better than anonymous interactions with a centralised committee which never sees or hears directly from the patients or their doctors. These arrangements would lead to fairer decisions for patients and their doctors.
Unfortunately, when treating patients with drug problems, GPs commonly ‘fly blind’ as there is no secure way to check the drugs a patient has been prescribed by other doctors or services.
- An online interactive pharmacy data and monitoring system would ensure safer prescribing of controlled substances. Such a system has been advocated by addiction physicians for many years, but it has yet to occur.
- Another reform which would help obviate problems of this kind would be for patients to be registered with one GP, as in UK, NZ and Europe.
There are compelling reasons to base future drug policy on human rights, rather than prohibition and criminal justice, and to ensure that ‘drug’ policies facilitate medical decision-making so that patients with these complex predicaments are dealt with fairly.
Emeritus Professor Ian Webster, AO, was Professor of Community Medicine from 1975 to 1989, and Professor of Public Health from 1990 to 2001, at the University of NSW. He has been involved in a wide range of organisations and public affairs related to community health.
Ian W Webster AO is Emeritus Professor of Public Health and Community Medicine of the University of New South Wales. He has worked as a physician in public and regional hospitals in Australia and UK and in NGOs dealing with homelessness, alcohol and drug problems and mental illness.
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