The impact of drug policy liberalisation on willingness to seek help for problem drug use: A comparison of 20 countries

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Abstract

Background

While the impact of changing drug policies on rates of drug use has been investigated, research into how help-seeking behaviour changes as drug policies become more public-health focused is limited. This paper investigates reported changes in confidence to utilise drug services following hypothetical changes in national drug policy among a sample of individuals who report recent illicit drug use. We predict that liberalising national drug policy will increase the propensity for people who take illegal drugs to utilise health services.

Methods

The data were drawn from a sample of self-reported responses to the 2014 Global Drug Survey. Respondents were asked if they would be more confident seeking help if each of the following policy changes were made in their country; a) drugs were legalised; b) penalties for possession of small amounts of drugs were reduced to a fine only; c) drugs were legally available through governments outlets. Multiple correspondence analysis and multinomial logistic regression with post-estimation linear hypothesis testing were conducted.

Results

Individuals residing in countries with relatively liberal drug policy regimes report their help-seeking behaviour is unlikely to change given the hypothetical policy amendments. Individuals from countries with prohibition-based drug policies reported a far greater propensity for changing their help-seeking behaviour in the event of hypothetical policy amendments, citing reduced fear of criminal sanctions as the major reason. Age and sex differences were also found.

Conclusion

The current study demonstrates the capacity for national drug policy reform to influence drug use risk by facilitating or impeding health service engagement among individuals who use illicit substances. We suggest national drug policy requires careful consideration of both prevention goals and the needs of individuals already engaged in illicit substance use; more liberal drug policies may actually encourage the adoption of harm reduction strategies such as health service engagement.

Introduction

In the past few decades, there has been a transformative shift in the nature of many countries’ drug policies. Harm reduction drug policies are becoming increasingly favoured over more traditional prohibitionist drug policies and call for a drug law reform. Harm reduction policies focus on public health and aim to minimise harms associated with drug use. Effective drug policies require careful consideration of international law, national culture, public health, order and civil liberties; negotiating a balance between these concerns is a major challenge for jurisdictions across the world. Currently, national drug policies tend to favour either a public health or criminal justice approach (Goldberg, 2005). Western world countries, in particular, are moving away from traditional prohibition approaches towards harm reduction approaches (Bewley-Taylor, Blickman, & Jelsma, 2014; Goldberg, 2005; Hall, 2017; Hurley, 2016; Stone, 2016).

Throughout the 20th century, in line with international conventions, many countries supported prohibitionist approaches to the supply and use of illicit drugs. Previously even the United Nations (UN) supported this policy approach; in 1990 the United Nations General Assembly Special Session on Drugs (UNGASS) stated the aim of the committee was to protect mankind from drug abuse and trafficking. Just eight years later, in 1998, UNGASS announced that in 10 years’ time, the world would be drug-free (Brownstein, 2016; Jelsma, 2016). The United States (US) led this aggressive ‘war on drugs’ throughout the 1990s relying on zero tolerance policies that resulted in mass incarcerations while doing little to reduce drug related harms. European countries were the first to adopt harm reduction approaches to drug use after suggestions that prohibition policies were inconsistent with human rights norms (Csete et al., 2016) and rising concerns that prohibition policies created a lucrative black market economy that contributed to violence in communities with higher levels of drug use (Csete et al., 2016).

Countries such as the Netherlands, Switzerland, Spain and Portugal currently address drug use through pragmatic public health and social inclusion policies and have done since the mid-1990s (International Drug Policy Consortium, 2017); Latin American countries began to follow suit towards the beginning of the 21st century (Jelsma, 2016). Traditional examples of harm reduction strategies include needle exchange programs, opioid substitution therapy, and drug education programs. The decriminalisation of illegal drugs is also a harm reduction strategy because it minimises the potential for negative impacts from a criminal record on the future well-being of people who use drugs. Legalising substances can also reduce the potential for harm through regulated manufacturing that ensures quality control, consistent composition, and transparent information exchange between consumer and supplier. A growing number of countries are adopting drug policy reform to reduce drug-related mortality, health problems, social disorder and disadvantage (Reuter & Trautmann, 2007).

The shift in national drug policies, away from prohibition and towards harm reduction, is likely driven by country-level political and economic factors in combination with international pressures from forums such as the European Union (EU) and the UN. For example, upon joining the EU in 1994, Swedish policy-makers responded to pressure from other EU members by abolishing the nation’s firm zero-tolerance drug policy and instead implementing a harm reduction regime including needle exchange services and regulated access to some previously prohibited substances through pharmacies (Goldberg, 2005). The advent of new drugs (e.g. novel psychoactive substances), changes in supply and purchasing methods (e.g. dark web), cultural and attitudinal shifts, globalisation and an aging population of people who use drugs are just some of the other factors forcing countries to reassess current drug strategies (Berridge, 1998; Radimecký, 2007). National economies also play an important role in informing policy decisions. Harm reduction policies tend to be more cost effective than criminal justice approaches. In the US alone it is estimated that federal spending on drug control is around $15 billion annually (Miron & Waldock, 2010; Office of National Drug Control Policy, 2010). Harm reduction approaches also have indirect benefits for individuals’ future capacity to contribute to society and community health and wellbeing (Csete et al., 2016).

Despite evidence of the benefits of harm reduction over prohibition, many countries continue to resist a public health approach to drug use. According to Babor et al, in some countries this resistance stems from long-standing cultural beliefs and social stigma associated with drug use (2009). Other countries face unique challenges to adopting harm reduction approaches such as addressing mass production and international supply hubs, lack of appropriately trained professionals and health care resources, endemic drug use and health problems concentrated in stigmatised/discriminated sections of the population (Babor et al., 2010). For example, in Mexico, whilst the use of illicit drugs is lower than in many Western countries, drug trafficking is considered a national security problem with consequences for international relations, in particular with the neighbouring US. As such all drug laws are enforced by federal agencies and any changes in drug policy would be highly scrutinised (Babor et al., 2010). This example demonstrates that while globally there is a trend towards harm reduction as a more effective and acceptable approach to drug use than prohibition, this should not imply that “one size fits all” (Babor et al., 2010). Finally, Babor et al. (2010) also encourage that country level characteristics should be taken into account during policy development and implementation.

Variation across countries in individual responses to drug policy is also an important consideration. To assess the capacity of harm reduction policies to achieve public health aims across different national contexts it is necessary to understand how people who use drugs perceive and respond to drug policy changes. One of the main problems with zero tolerance approaches to drug regulation is that they deter people who use drugs from accessing health services (Godlee & Hurley, 2016; Deryabina & El-Sadr, 2017; Joshua, 2017; Pūras & Hannah, 2017). Harm reduction approaches aim to encourage ‘help-seeking’ by reducing fear of criminal sanctions, decreasing social stigma and making drug services more accessible for the individuals and their support network. While the capacity for drug policy liberalisation to increase the propensity for individuals who use drugs to engage in help-seeking has been implied in the literature, it has not been investigated empirically (Degenhardt et al., 2008; Eastwood, Fox, & Rosmarin, 2016; Reuter & Stevens, 2007).

Help-seeking in the context of drug use can include counselling from family, friends or professionals, being more likely to visit the emergency room following an overdose, accessing needle exchange services for sterile injecting equipment or visiting medical professionals or help centres for support. The propensity for individuals who use drugs to engage in harm reduction by seeking help for their substance use is determined by a coalescence of social, structural, political and individual factors. Structural barriers such as the availability and quality of treatment services and attitudinal barriers, including personal beliefs of consumers and their social network about whether or not treatment is necessary or beneficial are arguably two of the biggest impediments to seeking help (Csete et al., 2016; Kazatchkine, 2017). National drug policies play an integral role in shaping attitudes towards and propensity for help-seeking given that they provide the legislative framework that informs the development of these factors. For example, access to treatment services, particularly for economically and socially disadvantaged people is facilitated by national approaches to drug use that prioritise harm minimisation (Department of Health, 2017). Social stigma and attitudes towards drug use, individuals who use drugs and services aimed at harm reduction are improved through integrated partnerships between government and non-government agencies in areas such as education, health, social welfare and justice; such partnerships can only be achieved under liberalised drug policies that prioritise harm minimisation.

Prohibition policies which impede access to evidence-based treatment for people who use drugs provide a few examples of structural barriers to help-seeking behaviour (Kazatchkine, 2017). In this paper, we suggest that the adoption of harm reductist approaches to drug use, as opposed to justice system responses, reduce structural barriers to help-seeking by re-directing resources to service provision. We also argue that the national perspective on drug use plays a significant role in shaping community attitudes towards people who use drugs; reduced stigma, as a result of drug law liberalisation may facilitate engagement with harm minimisation services. Stigma has long been labelled a barrier to treatment by researchers (Marlatt, Tucker, Donovan, & Vuchinich, 1997). Individuals are less likely to access services if they feel their substance use will be judged poorly by their peers and the community (Marlatt et al., 1997). In the United States, where prohibitionist approaches continue to dominant drug policy, citizens tend to express high levels of stigma towards individuals who use drugs. A 2014 John Hopkins study found that Americans have lower opinions of substances use disorders than mental health problems (Barry, McGinty, Pescosolido, & Goldman, 2014). The criminalisation of common illicit drugs reinforces this stigma. Studies on the effects of drug use and behaviours in Portugal following the decriminalisation of drugs have shown that following the policy change, more people presented to treatment facilities for help with drug use problems (Greenwald, 2009). This could be ascribed to a harm reduction policy that targeted both structural and attitudinal barriers to help-seeking.

In this study we examine changes in confidence to engage in help-seeking among a sample of individuals who reported recent drug use in the context of three hypothetical, national drug policy changes: a) drugs were legalised; b) penalties for possession of small amounts of drugs were reduced to a fine only; c) drugs were legally available through governments outlets. For reasoned outlined above, we hypothesised that individuals residing in countries where the current drug policy is relatively liberal will report minimal change in their willingness to access health services whereas residents of countries with prohibition drug policies will report significant increases in confidence to seek help for drug related issues in the context of drug policy liberalisation. We stratified the analyses by sex and age because both factors influence drug use, health service engagement and attitudes to drug policies. Rhetoric surrounding harm reduction policies paints a very positive picture of the potential benefits of these approaches for reducing fear of criminal sanctions and subsequently encouraging help-seeking among individuals who use drugs. Evidence shows strategies such as needle and syringe programs and opioid substitution therapy (OTS) services have reduced drug related harms in countries where they have been introduced (Abdul-Quader et al., 2013; Busch, Grabenhofer-Eggerth, Klein, & Weigl, 2015; Fernandes et al., 2017; MacArthur et al., 2014). What remains unclear is whether or not changes in drug policy at the national level alters individuals’ confidence to engage with these types of health services or alternately, whether the individuals who utilise these services represent those who were already confident to seek help. To encourage help-seeking among the very diverse population of individuals who use drugs it is necessary to understand the effectiveness of drug policies for achieving primary aims – reduction in drug-related mortality and morbidity- and the mechanisms through which these aims are met (e.g. engaging in help-seeking).

Section snippets

Designs and procedures

The data was drawn from the 2014 Global Drug Survey (GDS), a cross-sectional online survey developed by academics and experts (for a list of names on the core research team and expert advisory board see https://www.globaldrugsurvey.com/about-us/). The 2014 GDS was conducted between November and December 2013 and was available in 8 languages. The survey was promoted through online media outlets, in magazines, over social media and in newspapers. All responses are anonymous and results were

Results

The final analytic sample included 36 506 respondents from 20 countries 74.2% male; 52% aged 16–26, 35.3% aged 27–40 and 12.7% aged 41–80. Ages were grouped into these three categories in order for the results to be better visualised by our multiple correspondence analyses. These categories were retained for the multiple logistic regression models in order to maintain consistency. The age categories were determined according to general social definitions of youth, early to mid-adulthood and

Discussion

The purpose of this study was to investigate the effect of hypothetical changes in national drug policy on reported changes in confidence in help-seeking among a sample of people who use drugs. The results show that respondents residing in countries that currently adopt more liberal drug policies including Switzerland, Belgium and the Netherlands, tended towards reporting that national policy changes would not make them more confident about seeking help. Individuals residing in Ireland, Sweden,

Conclusions

National drug policies remain an issue of contention in countries around the world. A multitude of complex, dynamic factors influence the way in which countries develop and implement drug policy and, in turn, the impact of these policies on individuals who use drugs. Harm reduction policies have gained popularity in the last decades with a growing number of countries adopting public health approaches to drug use. In this current period of transformative change in global drug policies, there is

Conflicts of interest

Adam Winstock is the founder of the annual Global Drugs Survey. Jason Ferris, Monica Barratt and Larissa Maier are all part of the GDS core research team. For all other authors no conflicts are declared.

Acknowledgements

The authors would like to thank Steffi Cooke for her assistance during preparation of this manuscript.

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