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Countries wanting to try new approaches to drug legislation would have to move beyond existing international treaties

which have done little to prevent drug misuse

Lancet

International treaties governing laws on illicit and non-medical drug use prevent innovative approaches and have done little for the cause for which they were intended. Furthermore, in order to escape UN sanctions or censure, any country wishing to try a new approach to dealing with drugs would have to withdraw from these treaties and re-enter them with special clauses or reservations enabling such approaches. The issues around international drug conventions are covered in the third paper in the Lancet Series on Addiction, written by Professor Robin Room, Turning Point Alcohol and Drug Centre and School of Population Health, University of Melbourne, Melbourne, VIC, Australia, and Professor Peter Reuter, School of Public Policy and Department of Criminology, University of Maryland, College Park, MD, USA.

The international treaty system has three components. The 1961 Single Convention on Narcotic Drugs required nations to make the non-medical use of cannabis, cocaine, and opioids a criminal offence. The 1971 Convention on Psychotropic Substances then extended the system to cover synthetic pharmaceuticals--eg, amphetamines, benzodiazepines, opioids, and lysergic acid diethylamide (LSD). This was followed by the 1988 Convention Against Illicit Trafficking in Narcotics and Psychotropic Substances, which promoted police suppression of illicit markets and was extended to cover drug precursor chemicals. The Commission on Narcotic Drugs, a part of the UN system, is the political body with responsibility for these treaties.

The authors argue this international drug control system has not ensured adequate medical supply of opioids (for pain relief), particularly in low-income and middle-income countries. They say*: "The system has not effectively restricted the non-medical use of controlled drugs, and illicit drug use and the contribution of illicit drugs to the burden of disease have increased worldwide over the past decade." Furthermore, they add*: "The system's emphasis on criminalisation of drug use has contributed to the spread of HIV, increased imprisonment for minor offences, and contributed to legitimating extremely punitive national policies (including executions, extra-judicial killings, and imprisonment as a form of treatment), all of which have caused harm to drug users and their families."

The UN Office on Drugs and Crime (UNODC) is the specialised UN agency on drug issues that serves as the secretariat for the Commission on Narcotic Drugs. It advises governments on effective law enforcement and treatment systems and methods of estimation of illicit drug production and consumption. UNODC, with a tiny core budget, depends on earmarked funding from donor governments, limiting the coherence and effectiveness of its work. National delegations to the Commission on Narcotic Drugs, or in international bureaucratic positions, have a vested commitment to the existing system and have kept civil society at bay, despite a growing presence of drug-policy reform movements.

Informally, the USA has long had a leading role in the international system. The USA has strongly opposed harm-reduction approaches to illicit drug problems, such as needle and syringe programmes, supervised injecting centres, and heroin maintenance treatment, with support from other nations such as Japan and Russia. The USA now accepts needle and syringe programmes but still objects to use of harm reduction wording in UN documents. UNODC used to share this objection, but has become more accepting of measures such as needle and syringe programmes.

WHO moved projects on reduction of HIV infection among drug users to the UN agency on AIDS, in order to protect such projects from direct pressure from individual countries. WHO's relationship with UNODC has often been strained, with WHO's advice on occasion having been ignored by the UNODC and the Commission on Narcotic Drugs. However, WHO and UNODC have more recently resumed cooperation. In 2009 a UNODC and WHO programme jointly produced drug treatment guidelines and a discussion paper on the role of coercion in the treatment of addiction. The authors say: "Nonetheless, the international system devotes more of its resources--as shown in its budget allocations and the topics of debates by the Commission on Narcotic Drugs-- to suppression of illicit drug markets than to direct protection of public health and wellbeing."

Eight countries (Australia, Canada, Germany, Luxembourg, the Netherlands, Norway, Spain, and Switzerland) have provided supervised injecting centres to reduce blood-borne virus transmission and overdose and to increase drug users' contact with treatment services. These changes, which have largely been made without legislation to remove criminal penalties for use, have been criticised by UNODC and the International Narcotics Control Board as contrary to the treaties. UNODC has now accepted that needle and syringe programmes and treatment diversion programmes comply with the treaties, but the International Narcotics Control Board continues to argue that the status of supervised injection centres is unclear.

The authors say that these treaties lack flexibility. UNODC and the Commission on Narcotic Drugs worsen this problem by their frequent failure to consider evidence in making decisions. For example, studies of the introduction or removal of criminal penalties for use and possession of cannabis show no substantial effects on the prevalence of use or on health-related harm.

The most feasible way for an individual country to try a new approach to dealing with drugs (eg, legalisation of possession) would be to withdraw from one or more of the treaties and then re-accede with specified reservations. For example, Switzerland and the Netherlands ratified the 1988 treaty with a reservation against the provision that required the criminalisation of use and possession. The authors say: "National experimentation in approaches to prevention and reduction of drug-related harm should be allowed. The international drug treaties in their present form seriously constrain governments' capacities to engage in such policy experiments. They have restricted the freedom of action to change penalties for personal use, with the result that reduction in penalties has sometimes counterproductively increased the numbers of young people penalised for drug offences. Countries that wish to experiment with different ways of regulating drug use and reducing drug-related harm will need to consider opting out of provisions of the existing drug control treaties.

The authors conclude: "The cultural positions of different drugs vary enough to preclude universal policies on how to deal with all illicit or indeed licit drugs. From the perspective of public health, we need to move towards a control system that is more aligned with the risks that different drugs pose to users and shows an understanding of the effects of different regulatory approaches on drug use and harm."

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Professor Robin Room, Turning Point Alcohol and Drug Centre and School of Population Health, University of Melbourne, Melbourne, VIC, Australia. T) 61-3-8413-8430 E) robinr@turningpoint.org.au

Note to editors: *quotes not exactly as they appear in text of paper

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