Substance use and associated disorders are increasingly recognised as a global health issue. As attitudes towards drug use disorders evolve, varying drug control policies worldwide are called into question. Nations such as the United States of America utilise the criminal justice system to place sanctions on those contravening drug control policy, which often results in cycles of incarceration, further drug use, and poverty. In contrast, Portugal has revolutionised its approach to drug control since the turn of the century by decriminalising all drugs to great effect. In view of this wide spectrum of attitudes towards drug control, the future of Australia’s approach to drug control policy is examined.
The International Classification of Diseases defines substance use disorders as “continuing drug consumption despite severe adverse consequences”. A report by the office of National Drug Control Policy in 2010 outlined the detriments of substance use disorders using a biopsychosocial paradigm (Figure 1).[1, 2]
Substance use disorders are managed through three main drug policy approaches: decriminalisation, criminalisation, and harm minimisation. Decriminalisation involves prohibiting and regulating drugs but excluding sanctions from criminal law jurisdiction, whereas criminalisation is the attribution of criminal offences to drug-related activities.[3, 4] Harm minimisation strives to decrease adverse consequences without aiming to reduce consumption. Substance use disorders are perpetuated by social stigma and thus the political context is a key determinant of long-term health outcomes.
Benefits and detriments of different policy approaches
Criminalisation of drugs, and the subsequent incarceration of drug users, provides the immediate benefit of removing the individual from an environment that exacerbates their drug use, and prevents the community from being threatened by drug-affected behaviour. Additionally, incarceration allows the government to demonstrate the work being done to tackle drugs in a manner that is tangible and easily understood by the general public. However, punitive drug law enforcement alone may fail to address or even worsen health complications of drug use. It can marginalise populations at risk of poorer health and increase barriers to seeking health services, as illustrated by the growing epidemic of HIV/AIDS and hepatitis C amongst injecting drug users. Moreover, drug law enforcement has minimal impact on the drug market itself, although there is some evidence that it may alleviate a degree of associated harm.[1, 6]
Advantages of the harm minimisation approach include curbing the progression of the HIV/AIDs epidemic through safe needle programs and deterring criminal behaviours.[1, 7] This is achieved through demand and supply reduction, prevention campaigns, and improved access to treatment and harm reduction. Critiques of this approach include maintaining demand for the illicit drug market, and ineffectively addressing all biopsychosocial facets of substance use disorders.
The main benefit of decriminalisation is that it reframes drug use as a public health problem, which allows for reallocation of funds from drug-related criminal justice proceedings and the prison system to rehabilitation services focusing on long-term health outcomes. This, coupled with a shift in criminal justice focus to high-level drug offenders, ultimately results in less drug use and better long-term health outcomes. Decriminalisation addresses substance use disorders in a biopsychosocial context and identifies it as a key public health issue, both key steps in arresting the perpetuation of stigma which only serves to isolate drug users from health services. Criticisms of decriminalisation include potential for increased accessibility to drugs and a cheaper street value, which could result in increased uptake of drug use.
In 2009, Antonio Costa, the executive director of the United Nations Office on Drugs and Crime, affirmed that “drug use should be treated as an illness in need of medical help”, and appealed for universal access to drug treatment. In 2011, the Global Commission on Drug Policy emphasised that it was time to “end the criminalization, marginalization and stigmatization of people who use drugs but who do no harm to others”. The World Health Organization and the United Nations echoed this view in their joint statement published in June 2017, stating that to ignore such a call to “[review] and [repeal] punitive laws….[including] drug use or possession of drugs for personal use” would be to “[violate] the most fundamental human rights protected in international treaties and in national laws and constitutions”. This strong stance against discrimination in health care settings reflects the global shift in attitudes towards drug policy, from incarceration to rehabilitation of drug offenders.
Drug control approaches worldwide
Criminalisation: the United States
The United States (US) has a strong stance of criminalisation towards illicit drugs and has a low threshold to prosecute drug offenders. Its prison population has increased by almost 800% since 1980, in marked disproportion to its population growth, with 47% of all inmates imprisoned for drug-related crimes, and many with drug use disorders. In 2010 alone, US $80 billion was spent on continuing incarceration of inmates. Drug users, possessors and traffickers are treated equally in this criminal system, with mandatory minimum prison sentences.
Without adequate rehabilitation services or emphasis on drug use and use disorders as a public health issue, the high rates of recidivism are unsurprising, often resulting in a cycle of criminality, incarceration and poverty, with subsequent economic burden on the community. This is an issue fuelled by media sensationalism, portraying
Where drug courts – legal committees which redirect non-violent drug offenders from incarceration to treatment – have been trialled in the US, they have proven to decrease crime rates (7-14%) and recidivism (up to 35%), and improving rehabilitation uptake, treatment outcomes and stability of the family unit. Such models are estimated to reduce health care costs related to substance use disorders by US $4 for every US $1 spent.
While marijuana is considered illicit under US federal law, states are able to make independent laws, which are only disregarded in cases concerning juveniles, cross-border trafficking, or organised crime.[9, 11] Presently, over half of American states have legalised medicinal marijuana, and eight have further allowed recreational use. Given the relatively recent legalisation of marijuana, data on its impact on usage patterns is currently conflicting, and more time is required for reliable assessment. Studies have indicated that diversion of black market marijuana from legalised to criminalised states is likely to decrease marijuana prices, although the degree and impact of this is uncertain.[12, 13] Notably, there are significant economic benefits associated with the legalisation of marijuana. In Colorado, where recreational marijuana use is legal, marijuana tax and licensing fees have been implemented, together generating over US $70 million in the first year alone. This revenue was subsequently funnelled into school construction and youth and substance use programs).
Criminalisation: Central Asia
Central Asian countries, such as Tajikistan, Kazakhstan, and Uzbekistan, have adopted an increasingly stringent approach to drugs. In the year following the September 11 attacks, these countries received US $187.5 million from the US government to improve border control, counter-terrorism measures and counter-narcotics initiatives. Between 2004 and 2007, a strong criminal justice-based approach was further reinforced in Central Asia with funding from international agencies, other foreign governments and national budgets directed to legal action against drug use.
Further, national campaigns in Central Asia often label drug users as evil, increasing the stigma and discrimination which perpetuates cycles of drug use. Little or no rehabilitation or treatment is available for substance users, with such countries preferring a model of criminalisation and incarceration. For example, opioid substitution treatment is prohibited in Tajikistan and Turkmenistan, minimally available in Uzbekistan and Kyrgyzstan, and non-existent in Kazakhstan. The lack of treatment for drug users and increasing accessibility of opiates has resulted in a growing HIV epidemic in Central Asian prison systems with poor long-term health outcomes.
Prior to 2001, drug use was criminalised in Portugal, yet rates of heroin use and drug trafficking continued to increase. Consequently, the Portuguese government drafted a law decriminalising all drugs purchased, possessed or consumed for personal use. This law also had a public health focus towards rehabilitating those with substance use disorders, and a punitive focus towards high-level drug trafficking. This involves a committee of two medically-trained persons and one legally-trained person, deciding first whether an offence is protected by this law, and then whether the offender is suffering from a drug use disorder. This law only aimed to decriminalise low-level drug offences; strict laws remain against high-level offenders and drug traffickers who propagate this vicious cycle and endanger the general community.
After this law was passed, Portugal reduced its burden on the criminal-justice system, allowing more funding allocation towards public health endeavours, including prevention campaigns, treatment, and facilities. Treatment uptake consequently increased, resulting in decreasing rates of drug-associated illnesses.[4, 18] During the four years following decriminalisation in 2000 to 2006, there was a significant decrease in the incidence of new cases of HIV/AIDS amongst drug users in Portugal, from almost 1400 to 400 persons. Decreased rates of new hepatitis B and C infections have also been evident, attributed to the improved treatment and rehabilitation programs afforded by decriminalisation.[17, 18] Moreover, absolute numbers of drug-related deaths by each prohibited substance decreased; the total number of drug-related deaths decreased from 400 in 1999 to 290 in 2006.
Importantly, while some speculated that decriminalisation would lead to lower prices of drugs and subsequent higher rates of usage, the cost of drugs did not decrease. In fact, the rates of cannabis and cocaine use after decriminalisation have been three times lower than before. Further, data extrapolations have predicted lower lifetime prevalence rates of drug use for almost all drug categories post-decriminalisation.
Decriminalisation: West Africa
West African countries must contend with both international drug cartels and the growing transit of illicit substances to Europe and North America. Consequently, local consumption of illicit substances has increased, especially among younger persons, with significant economic, health and social consequences. While data is scarce, in 2008 it was estimated there were 1.8 million intravenous drug users in Sub-Saharan Africa, of whom 12% were thought to be living with HIV.[20, 21]
In 2014, the West Africa Commission on Drugs published a declaration specifically stating that “criminalisation of drug use worsens health and social problems, puts huge pressures on the criminal justice system and incites corruption”, and that “drug use must be regarded primarily as a public health problem”, mirroring the movements of Portugal. Despite these recommendations, there is currently no evidence that any West African countries have been successful in implementing drug decriminalisation policies.
Drug policy in Australia and the way forward
In 1985, the Australian Government adopted an official national drug policy of harm minimisation. In the 2002-03 financial year, the Australian Government allocated $3.2 billion to managing illicit drugs, 75% of which was spent on drug law enforcement, aiming to decrease drug and drug-related crime, and improve public health and safety.[1, 16] Despite this investment, a staggering 400 Australians die yearly from heroin overdose, and most areas have a demand for substitution products far out-weighing the supply, notwithstanding the costly co-payment. The methadone substitution program and syringe exchange services available in Australia have made an impact, yet with a growing affected population and the root cause unaddressed, the need is largely unmet. Harm minimisation still perpetuates discrimination and marginalisation of drug users, instead, decriminalisation can reduce stigma and is essential to better health outcomes.
The Australia21 report, published in 2012, was effective in initiating a debate on drug reform. The report not only illustrated the harmful effects of criminalising possession and personal use on drug-dependent individuals in an Australian context, but also highlighted the potential health benefits of some currently illicit drugs.[1, 8] This report left Australians to decide which legal system would allow for better biopsychosocial health and economic stability for the community with respect to those consuming drugs – rehabilitation or incarceration.
Australia should act to follow countries like Portugal that have prospered from revolutionising drug policy with respect to low-level offences and reform to decriminalise all drugs. As supported by the Global Commission on Drug Policy, a move towards decriminalisation of low-level drug offenses in Australia would allow for decreased economic burden on the criminal justice system, reallocation of funds to drug rehabilitation programs, and a sharpened focus on the illegality of high-level drug trafficking offenses. Viewing drug use as a public health problem is the key first step to reducing stigma and consequently improving access to treatment and long-term health outcomes.
Criminalisation marginalises those afflicted with drug use disorders, who are already burdened with significant health, social and economic disadvantage. Where there is demand, there is supply, and tackling drug use disorders with criminal law is simply too late to create a meaningful impact on the individual or society at large. Poverty breeds poverty; while incarceration may remove the immediate threat from society, it does nothing to address the root cause.
Substance use disorders are a medical condition and public health problem, not a moral choice. Epitomised by Portugal, decriminalisation of drugs and rehabilitation fortifies a community, not just immediately, but with long-term positive effects in the workforce and crime rates, spanning generations. Substance use disorders, therefore, need to be reframed from a criminal, punitive problem, to one befitting the biopsychosocial model of health. Fortunately, throughout the world this is increasingly becoming the case.
Raquel Maggacis is a final year medical student at the University of Queensland. She has a keen passion for public health endeavours and hopes to one day intertwine this with a career as a medical physician.
Sophie Lim, Vector Associate Editor
Conflict of Interest
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