Lancet: The USA shifts away from the "war on drugs"

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4W1MMK7-B&_user=861681&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000046147&_version=1&_urlVersion=0&_userid=861681&md5=c84e12164ca7866265cdacdde024f2e0
The LancetVolume 373, Issue 967111 April 2009-17 April 2009, Pages 1237-1238
The USA shifts away from the "war on drugs"
Kelly Morris

US drug policy is shifting. Since Barack Obama's inauguration as US president, he has expressed support for repealing the ban on federal funding for needle exchanges, an end to the disparity of sentencing for crack and powder cocaine, and an expansion of drug courts for non-violent offenders. Pre-election, Obama said that federal funds should not be used to circumvent state laws on medical marijuana facilities. When the Drug Enforcement Agency continued to raid such facilities, Attorney General Eric Holder announced that Obama's position is now policy, and vowed to end raids.
On March 11, as the 52nd UN Commission on Narcotic Drugs (CND) started in Vienna, Austria, Obama announced his nomination for drug-czar-Gil Kerlikowske, Seattle Chief of Police. Seattle is known for its harm-reduction approaches and drug policy reform, including drug courts, needle exchanges, medical marijuana, and voting to put marijuana as the lowest priority for police work. At his nomination, Kerlikowske said: "the success of our efforts to reduce the flow of drugs is largely dependent on our ability to reduce demand for them", and "our priority should be a seamless, comprehensive approach".
But the drug czar post-director of the Office of National Drug Control Policy (ONDCP)-will no longer have cabinet-level status. And, although the significance of the change in status remains uncertain, ONDCP said a programme-by-programme review would start after the czar's appointment is confirmed by Congress. Hearings took place on April 1.
The CND was the first involvement in global-drug policy for the new US administration. A century after the first international gathering on opium control, and a decade since the 1998 Special Session of the UN General Assembly on drugs, advocates exclaimed that the final CND political declaration and action plan still contains no mention of harm reduction. "Clearly in terms of what the whole advocacy community was hoping for, CND was a major disappointment with its failure to explicitly endorse harm reduction", says Ethan Nadelmann, executive director of the Drug Policy Alliance. "We had hoped that the Obama administration would support harm reduction."
26 member states raised the issue of harm reduction at CND. But, says Sandeep Chawla, director of policy analysis and public affairs, at the UN Office on Drugs and Crime (UNODC), harm reduction "is a very controversial phrase among some member states, and it goes against their national drug policies. Within the range of measures under this rubric, a few-such as injecting rooms and intravenous heroin prescription-may go against the spirit of the [UN] Drug Conventions". David Johnson, assistant secretary at the Bureau of International Narcotics and Law Enforcement Affairs, acknowledges that the USA "continues to believe that the term 'harm reduction' is ambiguous. It is interpreted by some to include practices that the United States does not wish to endorse". In the opening address, UNODC executive director, Antonio Maria Costa, urged states to "treat drug dependence as an illness and devote more resources to prevention, treatment, and harm reduction". Johnson, the head of the US CND delegation, did not go that far but he points to various interventions endorsed and used within the USA. "Evidence-based approaches to reduce the negative health and social consequences of drug abuse.form parts of a comprehensive approach to substance abuse that have long-term recovery, abstinence, and social reintegration as its goal."
The controversy over harm reduction is one indication that global drug-policy is ultimately down to what member states can agree. However, Chawla emphasises the importance of the recent commitment to a balanced approach between supply-side reduction and demand reduction by the CND. Traditionally, he says, demand-side measures were left to countries. Now, the action plan puts demand reduction first. "We're trying to get the balance right", he says, acknowledging that "it's probably still askew due to the 'machinery' of the drug control", such as the fact that more measures exist for international cooperation on supply reduction.
"It's like trying to turn an ocean liner", says Nadelmann. "It turns very slowly. Now, it's turning in the right direction, but I guess we hoped it would have turned a few more degrees." However, he stresses: "there is clearly a different tenor to US involvement, with a willingness to talk about reducing harms and about public health." The process at CND was too advanced, he suggests, for the new administration to reverse a decades-long anti-harm reduction policy, but he and others are optimistic that US drug policy will continue to shift within the next year, with a notable impact on global-drug policy.
"With the arrival of the new administration, the US is back in the drug-policy business, and will develop a national drug-control strategy based on data and research", says John Carnevale, who served under four US drug czars, over three administrations. "During the Bush administration, policy was clearly driven by ideology, which doesn't work", he says. He points to the administration's changing language-to reduce drug use and its damaging consequences. "It takes a lot to change the dialogue", he notes. What Carnevale advocates now is further emphasis on demand reduction, plus diversion of people from the criminal-justice system into treatment, "which is what research suggests needs to be done". Since a series of different local drug problems exist, "we need to focus on local-based solutions to community treatment, including drug courts, to solve the national problem", and communities need to be involved in deciding measures to reduce harms.
The most pressing issues facing the new drug czar are the harmful consequences of drug policy itself, including the highest incarceration rate in the world. "Increasingly", says Nadelmann, "the problem is defined as overincarceration. One of the major roles of the drug czar will be re-examining the role of the drug war in overincarceration". Another issue is violence associated with drug production and trafficking, such as in Mexico, which has involved over 1000 deaths since January. "Our demand for drugs is fuelling this tremendous problem", says Carnevale. Costa has urged states to view health and security as complementary, not contradictory, issues, and the new US drug czar will be involved in further strategy on Mexico. The new administration give more funding to US demand reduction or increase funding for a drug-war strategy to reduce supply, if Mexico agrees?
"The bigger question", says Nadelmann, "is whether or not the new administration is open to broader debate". The unintended consequences of drug policy were raised at the 2008 CND, notes Chawla, and include the large criminal black market and the diversion of funding from public health into public security and law enforcement. In February, a report by the Latin American Commission on Drugs and Democracy, co-chaired by three former Latin American presidents, urged that the taboo on open and honest debate be broken due to harms of what it called a "failed war". Part of this debate includes potential solutions regarding production, especially of marijuana and coca leaf, such as regulation, legalisation, and/or taxation.
Opium production in Afghanistan is another thorny issue. Afghanistan became a major opium producer as production in surrounding countries was suppressed-another unintended consequence of implementing drug-control regimes. Proposed alternative solutions to eradication include legalised production for medical diamorphine. Also, since "the best way to reduce demand is to remove the heaviest users from the market", notes Nadelmann, medical prescription of heroin to addicts is an option that could be made more available.
How the debate opens up further remains to be seen. But experts are cautiously optimistic about the future of drug control with a focus on health and recognition of human rights. Globally, "because we've neglected public health, we have tended to make drug users into marginalised groups with a stigma attached", says Chawla. But, he urges, "treatment needs to be as widely available as treatment for any other medical disorder". At the CND, UNODC announced a new Joint Programme on Drug Dependence Treatment and Care, with WHO. "Public health considerations have been at the side of the stage", notes Chawla. "Now, we need to bring them back to the centre of the stage."