International Journal of Drug Policy

Children and drug law reform

Fernando Henrique Cardoso — 2011-11-10

In June 2011 the Global Commission on Drug Policy, of which I am proud to be the chair, released its report calling for fundamental reforms to drug policies. Together with my colleagues – former and serving heads of state including Ruth Dreifuss, George Papandreou, Ernesto Zedillo and Cesar Gaviria, prominent business people and intellectuals, and former high level UN officials including Kofi Annan – we called for urgent action to stem the tide of drug-related harm, organised crime and drug-related violence ().

Employment amongst people who use drugs: A new arena for research and intervention?

Lindsey Richardson, Susan G. Sherman, Thomas Kerr — 2011-10-13

Employment is widely recognised as a robust determinant of health. For this and other political, social and economic reasons, governments throughout the world invest heavily in efforts to promote employment and reduce unemployment amongst the general population. Unfortunately, when it comes to people who use illicit drugs, employment is typically relegated to the status of a second order problem, and the role of employment, particularly for non-treatment enrolled individuals, has been largely ignored in the scientific literature. The limited attention that employment amongst active illicit drug users has received has focused primarily on how drug use affects labour market participation in large representative samples, on whether or not people enrolled in addiction treatment become employed as an indication of a successful rehabilitation process, or occasionally on employment status as a risk factor for negative health outcomes. Whilst most individuals who use illicit drugs are employed (), chronic unemployment and socio-economic vulnerability are fundamental, daily and intractable challenges for many. This is often particularly the case for individuals with high intensity illicit drug use patterns, who face multiple social and economic disadvantages or who experience concurrent health problems. Generally confined to the margins of the labour market, it is for these individuals that finding viable income generation may pose the greatest challenge, but for whom it may usher the greatest benefit. Given the well-established link between employment and health, and widespread concern for levels of unemployment, particularly in times of economic hardship, why is labour market participation not more emphasised, or emphasised in the same way, amongst vulnerable people who use illicit drugs?

If supply-oriented drug policy is broken, can harm reduction help fix it? Melding disciplines and methods to advance international drug-control policy

Victoria A. Greenfield, Letizia Paoli — 2011-06-21

Abstract: Critics of the international drug-control regime contend that supply-oriented policy interventions are not just ineffective, but, in focusing almost exclusively on supply reduction, they also produce unintended adverse consequences. Evidence from the world heroin market supports their claims. The balance of the effects of policy is yet unknown, but the prospect of adverse consequences underlies a central paradox of contemporary supply-oriented policy. In this paper, we evaluate whether harm reduction, a subject of intense debate in the demand-oriented drug-policy community, can provide a unifying foundation for supply-oriented drug policy and speak more directly to policy goals. Our analysis rests on an extensive review of the literature on harm reduction and draws insight from other policy communities’ disciplines and methods. First, we explore the paradoxes of supply-oriented policy that initially motivated our interest in harm reduction; second, we consider the conceptual and technical challenges that have contributed to the debate on harm reduction and assess their relevance to a supply-oriented application; third, we examine responses to those challenges, i.e., various tools (taxonomies, models, and measurement strategies), that can be used to identify, categorize, and assess harms. Despite substantial conceptual and technical challenges, we find that harm reduction can provide a basis for assessing the net consequences of supply-oriented drug policy, choosing more rigorously amongst policy options, and identifying new options. In addition, we outline a practical path forward for assessing harms and policy options. On the basis of our analysis, we suggest pursuing a harm-based approach and making a clearer distinction between supply-oriented and supply-reduction policy.

Henceforth harm reduction?

Dan Ciccarone — 2011-08-18

Going forward… The argument put forth by has the same “intuitive and perhaps innate appeal” that the authors suggest “harm reduction” has in drug consumption policies and public health. The authors suggest a bold leap in adapting the philosophy and goals of harm reduction, which have thus far mostly pertained to drug consumption, and apply them to drug supply-oriented policies. In this they are making a shift from policies and activities which aim to decrease drug related harms to individuals to understanding those which may decrease harms to macro systems including nations and regions, particularly those involved in the growing and manufacture of drugs. The premise this is built upon is that current drug supply control policies are ineffective, at times enabling political unrest, fomenting economic disruption and – at best only holding the floodgates of supply, whilst at worst producing paradoxical results. They strongly suggest that expanded risks and benefits analyses of current supply-reduction policies can minimize macro harms.

Measuring drug law enforcement—From process to outcomes

Mike Trace — 2011-08-18

looks at the utility of the concept of harm reduction when applied to drug law enforcement and supply reduction activities. Attention to this issue is very welcome, as it expands consideration of the concept of harm reduction beyond its traditional focus on public health issues.

Harm reduction is not enough for supply side policy: A human rights-based approach offers more

Damon Barrett — 2011-08-18

At the International Harm Reduction Association's 21st international conference in Liverpool in 2010 I organised (with the Transnational Institute and the Institute for Policy Studies) a major session entitled “Harm reduction for producer nations? Farmers’ perspectives on the war on drugs”. In the run up to the conference and as the discussions unfolded I struggled with the question posed in the title. Can harm reduction be applied to supply side issues? Is it a useful paradigm for this? Does this discussion in fact expose the limits of harm reduction? Reading , which sets out their vision of the application of harm reduction to supply-oriented policy, has helped me to clarify my thinking. It can, in a nutshell, be summed up in four broad statements. Each, of course, open to debate.

The term and the vision

Jonathan P. Caulkins — 2011-08-18

I am an unabashed fan of paper and the general idea of grounding law enforcement prioritization in a broader framework than use reduction. Fulsome praise makes for boring commentary, so I will challenge them on terms and vision.

Harm reduction for the supply-side: Its time has come

Martin Jelsma — 2011-08-18

In their article put to rigorous scrutiny the highly relevant question of whether the harm reduction concept could be usefully applied to supply-oriented policies. The question itself is not new. In the development field the idea has been tentatively played with for quite a while now with regard to policies around the cultivation of drug-linked crops in poverty and conflict-stricken environments (see for example ). Those earlier attempts came perhaps too early to gain wider acceptance at times when the ideological fight about the concept of harm reduction even for the consumption side was still raging on at the UN level.

The policymaker's Hippocratic oath

Vanda Felbab-Brown — 2011-08-18

By calling for a “harm-reduction” approach to supply-side counternarcotics measures, make an important contribution to drug policy. In a sense, they call for a comprehensive cost-benefit analysis to supply-side counternarcotics measures, with costs and benefits broadly defined. Positively, costs in their definition include not only the negative effects of a policy, but also the resources needed to carry out the policy. By advocating a careful specification of baselines and suggesting a way to integrate the different costs and benefits, they propose a systematic policy evaluation framework that, if adopted by policymakers, would provide a much sounder basis for policy decisions as well as clearly improve the supply-side measures. Indeed, such a careful and comprehensive cost-benefit analysis should be the basis for any public policy, be it in the field of drug control or international maritime security.

Drug prohibition: It's broke, now go and fix it

Alex Wodak — 2011-11-21

consider the possibility that drug law enforcement may be ineffective, expensive and accompanied by serious unwanted adverse consequences. But why are they so tentative? Their tone is reminiscent of Emperor Hirohito explaining his decision to surrender after WWII: “the war situation has developed not necessarily to Japan's advantage”. These days hardly a week passes without a police chief, senior politician or judge announcing () that the War on Drugs has failed dismally and that further attempts to achieve success are futile. Once it was just retired officials. But these days many senior serving officials demand that alternatives are considered.

Mortality of those who attended drug services in Scotland 1996–2006: Record-linkage study

Elizabeth L.C. Merrall, Sheila M. Bird, Sharon J. Hutchinson — 2011-07-04

Abstract: Background: We examine major causes of death amongst persons in contact with drug-treatment services across Scotland during April 1996–March 2006, hereafter Scottish Drug Misuse Database (SDMD) cohort.Methods: Drug-treatment records were linked to national registers of deaths and hepatitis C virus (HCV) diagnoses. For eras 1996/97–2000/01 and 2001/02–2005/06, we calculated cause-specific death-rates and standardised mortality ratios (SMRs) using age-, sex- and calendar-rates of the general Scottish population. Major causes of death were identified by high SMRs (>5 across eras) or rates (>50 per 100,000 person-years in either era), and their time-specific influences characterised by proportional hazards analyses.Results: The SDMD cohort comprised 69,456 individuals, 350,315 person-years and 2590 deaths. The overall SMR reduced from 6.4 (95% CI: 6.0–6.9) to 4.8 (95% CI: 4.6–5.0) between eras. We identified five major causes of death: drug-related (1383 deaths), homicide (118) and infectious diseases (90) with high SMRs; suicide (269) and digestive system disease (168) with high rates. HCV diagnosis marked individuals with at least double the risk of cause-specific mortality, including adjusted hazard ratio (HR) for no HCV diagnosis of 0.46 (95% CI: 0.41–0.53) for drug-related deaths (DRDs) and 0.15 (95% CI: 0.10–0.22) for death from digestive system disease. Increased DRD risk at older age (>34 years) appeared specific to HCV-diagnosed individuals (interaction: , p=0.01). Alcohol misuse increased HRs: for DRD (1.76, 95% CI: 1.50–2.06), suicide (1.88, 95% CI: 1.35–2.60), deaths from digestive system disease (3.19, 95% CI: 2.21–4.60) and non-major causes (1.87, 95% CI: 1.49–2.35). Stimulant misuse increased suicide risk: adjusted HR 1.91 (95% CI: 1.43–2.54).Conclusions: Drug-users in Scotland are exposed to variously increased mortality risks. HCV-diagnosed individuals are particularly vulnerable, and may need additional support.

A high proportion of users of low-threshold facilities with needle exchange programmes in Switzerland are currently on methadone treatment: Implications for new approaches in harm reduction and care

2011-06-27

Abstract: Background: Increasingly, patients receiving methadone treatment are found in low threshold facilities (LTF), which provide needle exchange programmes in Switzerland. This paper identifies the characteristics of LTF attendees receiving methadone treatment (MT) compared with other LTF attendees (non-MT).Methods: A national cross-sectional survey was conducted in 2006 over five consecutive days in all LTF (n=25). Attendees were given an anonymous questionnaire, collecting information on socio-demographic indicators, drug consumption, injection, methadone treatment, and self-reported HIV and HCV status. Univariate analysis and logistic regression were performed to compare MT to non-MT. The response rate was 66% (n=1128).Results: MT comprised 57.6% of the sample. In multivariate analysis, factors associated with being on MT were older age (OR: 1.38), being female (OR: 1.60), having one's own accommodation (OR: 1.56), receiving public assistance (OR: 2.29), lifetime injecting (OR: 2.26), HIV-positive status (OR: 2.00), and having consumed cocaine during the past month (OR: 1.37); MT were less likely to have consumed heroin in the past month (OR: 0.76, not significant) and visited LTF less often on a daily basis (OR: 0.59). The number of injections during the past week was not associated with MT.Conclusions: More LTF attendees were in the MT group, bringing to light an underappreciated LTF clientele with specific needs. The MT group consumption profile may reflect therapeutic failure or deficits in treatment quality and it is necessary to acknowledge this and to strengthen the awareness of LTF personnel about potential needs of MT attendees to meet their therapeutic goals.

Initiation into prescription opioid misuse amongst young injection drug users

2011-06-21

Abstract: Background: Prescription opioids are the most frequently misused class of prescription drugs amongst young adults. Initiation into prescription opioid misuse is an important public health concern since opioids are increasingly associated with drug dependence and fatal overdose. Descriptive data about initiation into prescription opioid misuse amongst young injection drug users (IDUs) are scarce.Methods: An exploratory qualitative study was undertaken to describe patterns of initiation into prescription opioid misuse amongst IDUs aged 16–25 years. Those young IDUs who had misused a prescription drug at least three times in the past three months were recruited during 2008 and 2009 in Los Angeles (n=25) and New York (n=25). Informed by an ethno-epidemiological approach, descriptive data from a semi-structured interview guide were analysed both quantitatively and qualitatively.Results: Initiation into prescription opioid misuse was facilitated by easy access to opioids via participant's own prescription, family, or friends, and occurred earlier than misuse of other illicit drugs, such as heroin. Nearly all transitioned into sniffing opioids, most injected opioids, and many initiated injection drug use with an opioid. Motives for transitions to sniffing and injecting opioids included obtaining a more potent high and/or substituting for heroin; access to multiple sources of opioids was common amongst those who progressed to sniffing and injecting opioids.Conclusion: Prescription opioid misuse was a key feature of trajectories into injection drug use and/or heroin use amongst this sample of young IDUs. A new pattern of drug use may be emerging whereby IDUs initiate prescription opioid misuse before using heroin.

Public sentiment towards alcohol and local government alcohol policies in New Zealand

Brett Maclennan, Kypros Kypri, John Langley, Robin Room — 2011-07-11

Abstract: Background: In many countries, including New Zealand, alcohol availability and promotion have increased markedly in the last three decades as a result of liberalised central and/or state government alcohol policies. Accordingly, communities are increasingly relying on local government to manage alcohol-related problems. New Zealand's states the purpose of local government as facilitating public decision-making and promoting community well-being. We sought to describe public sentiment towards alcohol and local government alcohol policies.Methods: A cross-sectional survey was conducted in 2007 with a sample of 2337 residents aged 18 years and over in a diverse set of New Zealand communities. Data were collected via a self-administered pen-and-paper questionnaire.Results: There were responses from 1372 individuals (response: 59%). Problem drinking amongst youth (<25 years of age) was considered the leading problem by the majority of respondents in six of seven areas. Alcohol was considered to play a major role in incidents of violence, vandalism, dangerous driving and traffic crashes. Fifty-eight percent of respondents agreed that “it is up to local government to make sure alcohol does not become a problem in the community”. There was strong support for local governments to restrict the hours of operation of on-licenced premises, to use liquor bans to control drinking in public places, and for local governments and police to be stricter in their enforcement of drinking laws.Conclusion: There is strong support for local government alcohol policies that restrict the availability and promotion of alcohol. The study findings are important in light of the stated purpose of local government in New Zealand and the recently completed “once in a generation” review of alcohol laws and policies.

Reconciling incongruous qualitative and quantitative findings in mixed methods research: Exemplars from research with drug using populations

2011-06-16

Abstract: Mixed methods research is increasingly being promoted in the health sciences as a way to gain more comprehensive understandings of how social processes and individual behaviours shape human health. Mixed methods research most commonly combines qualitative and quantitative data collection and analysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate the findings from one method with the findings from another, seeking convergence or agreement between methods. Cases in which findings from different methods are congruous are generally thought of as ideal, whilst conflicting findings may, at first glance, appear problematic. However, the latter situation provides the opportunity for a process through which apparently discordant results are reconciled, potentially leading to new emergent understandings of complex social phenomena. This paper presents three case studies drawn from the authors’ research on HIV risk amongst injection drug users in which mixed methods studies yielded apparently discrepant results. We use these case studies (involving injection drug users [IDUs] using a Needle/Syringe Exchange Program in Los Angeles, CA, USA; IDUs seeking to purchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Francisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects, summarize lessons learned, and make recommendations for how to more successfully anticipate and manage the integration of findings. Despite the challenges inherent in reconciling apparently conflicting findings from qualitative and quantitative approaches, in keeping with others who have argued in favour of integrating mixed methods findings, we contend that such an undertaking has the potential to yield benefits that emerge only through the struggle to reconcile discrepant results and may provide a sum that is greater than the individual qualitative and quantitative parts.

SimAmph: An agent-based simulation model for exploring the use of psychostimulants and related harm amongst young Australians

2011-06-30

Abstract: Background: Computer simulations provide a useful tool for bringing together diverse sources of information in order to increase understanding of the complex aetiology of drug use and related harm, and to inform the development of effective policies. In this paper, we describe SimAmph, an agent-based simulation model for exploring how individual perceptions, peer influences and subcultural settings shape the use of psychostimulants and related harm amongst young Australians.Methods: We present the conceptual architecture underpinning SimAmph, the assumptions we made in building it, the outcomes of sensitivity analysis of key model parameters and the results obtained when we modelled a baseline scenario.Results: SimAmph's core behavioural algorithm is able to produce social patterns of partying and recreational drug use that approximate those found in an Australian national population survey. We also discuss the limitations involved in running closed-system simulations and how the model could be refined to include the social, as well as health, consequences of drug use.Conclusion: SimAmph provides a useful tool for integrating diverse data and exploring drug policy scenarios. Its integrated approach goes some way towards overcoming the compartmentalisation that characterises existing data, and its structure, parameters and values can be modified as new data and understandings emerge. In a companion paper (), we use the model outlined here to explore the possible consequences of two policy scenarios.

Regime change: Re-visiting the 1961 Single Convention on Narcotic Drugs

David Bewley-Taylor, Martin Jelsma — 2011-10-13

Abstract: Background: March 2011 marked the 50th anniversary of the Single Convention on Narcotic Drugs. This legal instrument, the bedrock of the current United Nations based global drug control regime, is often viewed as merely a consolidating treaty bringing together the multilateral drug control agreements that preceded it; an erroneous position that does little to provide historical context for contemporary discussions surrounding revision of the international treaty system.Method: This article applies both historical and international relations perspectives to revisit the development of the Convention. Framing discussion within the context of regime theory, a critique of the foundational pre-1961 treaties is followed by detailed content analysis of the official records of the United Nations conference for the adoption of a Single Convention on Narcotic Drugs and, mindful of later treaties, an examination of the treaty's status as a ‘single’ convention.Results: The Single Convention on Narcotic Drugs represents a significant break with the regulative focus of the preceding multilateral treaties; a shift towards a more prohibitive outlook that within international relations terms can be regarded as a change of regime rather than the straightforward codification of earlier instruments. In this respect, the article highlights the abolition of drug use that for centuries had been embedded in the social, cultural and religious traditions of many non-Western states. Further, although often-overlooked, the Convention has failed in its aim of being the ‘single’ instrument within international drug control. The supplementing treaties developed in later years and under different socio-economic and political circumstances have resulted in significant inconsistencies within the control regime.Conclusion: Having established that a shift in normative focus has taken place in the past, the article concludes that it is timely for the international community to revisit the Single Convention on Narcotic Drugs with a view to correcting past errors and inconsistencies within the regime, particularly those relating to Scheduling and traditional drug use.

Switzerland, HIV and the power of pragmatism: Lessons for drug policy development

Joanne Csete, Peter J. Grob — 2011-08-18

Abstract: Switzerland in the 1980s was an epicentre of HIV as open drug injection became part of the urban scene, especially in Zurich. Cracks appeared in Switzerland's long commitment to policing as the main drug-control strategy as law enforcement was unable to contain the health and social consequences of the rapid spread of drug injection. In the early stages of the epidemic, the pioneering health care providers who brought technically illegal harm reduction services into the open drug scene in Zurich helped open the exploration at the federal level of more balanced drug policy. Carefully evaluated pilot experiences in low-threshold methadone, needle exchange, and eventually heroin-assisted therapy yielded evidence of significant HIV prevention and crime reduction that was convincing not only to policy-makers but also to a skeptical Swiss public. Whilst not all countries have Switzerland's resource base, the Swiss experience still holds many useful lessons for establishing evidence-based policy on illicit drugs.

An estimation of the prevalence of opioid dependence in New Zealand

2011-06-22

Abstract: Background: An accurate prevalence estimate for opioid dependence in New Zealand, and hence the extent of unmet treatment need, is lacking.Methods: Opioid users were recruited via snowball sampling, with participants initially recruited from opioid substitution treatment (OST) services and dedicated needle exchanges in Auckland, Tauranga and Christchurch. Participants estimated the number of people they knew personally who were receiving OST and who were not receiving OST, but were using opioids daily or almost daily. From these estimates a multiplier of the ratio between these two groups was derived and applied to the known number receiving OST in New Zealand to arrive at the total population estimate.Results: The mean multiplier estimate, weighted for treatment site, for 84 recruited participants was 2.015. The multiplier was higher for Christchurch. Initial recruitment source did not influence the value of the multiplier estimate. When the multiplier was applied to the known size of the New Zealand OST treatment population the total opioid dependent population was estimated to be 9142 (95% CI: 8248–10036), of whom half were not receiving OST.Conclusion: This figure was lower than for previous less robust estimates, but still represents a substantial level of unmet need. Greater effort needs to be made to close this treatment gap.