Towards a smarter drugs policy

The new issue of the Lancet focuses on drug policy. One piece offers key points for formulating policy:

  • Drug policy should aim to promote the public good by improving individual and public health, neighbourhood safety, and community and family cohesion, and by reducing crime.
  • The effectiveness of most drug supply control policies is unknown because little assessment has been done, and very little evidence exists for the effectiveness of alternative development programmes in source countries.
  • Supply controls can result in higher drug prices, which can reduce drug initiation and use but these changes can be difficult to maintain.
  • Wide-scale arrests and imprisonments have restricted effectiveness, but drug testing of individuals under criminal justice supervision, accompanied by specific, immediate, and brief sentences (eg, overnight), produce substantial reductions in drug use and offending.
  • Prescription regimens minimise but do not eliminate non-medical use of psychoactive prescription drugs. Prescription monitoring systems can reduce inappropriate prescribing.
  • Screening and brief intervention programmes have, on average, only small effects, but can be widely applied and are probably cost-effective.
  • The collective value of school, family, and community prevention programmes is appraised differently by different stakeholders.
  • The provision of opiate substitution therapy for addicted individuals has strong evidence of effectiveness, although poor quality of provision reduces benefit. Peer-based self-help organisations are strongly championed and widely available, but have been poorly researched until the past two decades.
  • Health and social services for drug users covering a range of treatments, including needle and syringe exchange programmes, improve drug users’ health and benefit the broader community by reducing transmission of and mortality due to infectious disease.

It’s good stuff. I particularly like its willingness to give credit where credit is due. For example, supply control can help but the benefits are often unstable and have a lot of unintended consequences. I also like the affirmation of the diversity of perspectives on the benefits of policies.

Not surprisingly, the only thing that grates me is the pushing of opiate substitution. (They weigh in a little harder in the body of the paper.) I’ve got no objection to saying it should be part of the service menu, but when they argue that it’s got the strongest evidence base, shouldn’t we ask why that is? What drives the research agenda? Who decides what to research? Who decides what outcomes are important? What are their assumptions? What are their values? Who benefits from the research agenda?

I don’t fear substitution being part of the service menu, but I fear it becoming the standard of care. I fear it setting the bar unacceptably low and creating a reflexive loop that reinforces the assumptions of researchers and treatment providers and traps addicts in a state of permanent disability and dependence upon treatment providers who believe they’re incapable of recovery.

Would the researchers and doctors recommend this treatment to a loved one? To a colleague? (Hint, they definitely don’t recommend it to colleagues. And, it’s not too expensive for the rest of us.)