From drug prohibition to regulation: a public health imperative

Abstract

The impacts of the COVID-19 pandemic and efforts to contain it have exacerbated many of the pre-existing public health harms associated with drug prohibition. Health services for people who use drugs—often grossly insufficient to start with—were disrupted. 1 Expanded police powers and empty streets due to stay-at-home orders made drug users even more vulnerable than usual to arrest and police harassment. 2 During the pandemic there was an increase in illicit supplies of fentanyl-adulterated drugs in the USA, leading to a sharp spike in overdose deaths. 3 This situation seems to have stabilised since, at more than 100 000 predicted overdose deaths per year. 4 Additionally, during the pandemic millions of people detained on non-violent drug charges in countries around the world suddenly faced the prospect of contracting—and potentially dying from—COVID-19, with little or no ability to comply with physical distancing and other public health recommendations. 5 In response, many countries—although by no means all—sought to mitigate these harms, often implementing steps that public health professionals and drug policy advocates had long sought. For example, to reduce disruptions to drug treatment services for people with opioid use disorder and to HIV prevention services, some countries lifted restrictions on the use of take-home methadone, waived urine test requirements to access treatment, or allowed community-based distribution of equipment used for injecting drug use. 6 To counter rising overdose deaths, New York City became the first US city to open government-sanctioned overdose prevention sites, where people can use drugs under medical supervision. 7 This intervention has been effective in reducing accidental drug overdoses and other health harms related to drug use in other countries, including Australia, Canada, and Switzerland. 8 To control outbreaks of COVID-19 in prisons, national and state authorities in many countries released hundreds of thousands of pretrial and convicted prisoners in an effort to decongest prisons and make COVID-19 prevention measures possible. 9 But none of these measures addressed the root cause of the vulnerabilities that COVID-19 exposed: the drug prohibition system itself. New York City's overdose prevention centres do not change the unsafe supply of illicit drugs that causes people to overdose; they only protect against the consequences. New Jersey's prison releases in response to the pandemic resulted in a 42% reduction in the state's prison population,10, 11 but since drug use, possession, and petty dealing remain criminal offences, the number of non-violent drug offenders in state prisons is likely to rise once the public health emergency abates. Moreover, many of the treatment measures adopted in the pandemic, such as expanded use of take-home methadone, are temporary and potentially subject to repeal. Public health professionals are advocating for the harm-reduction measures taken during the pandemic to support people who use drugs to be expanded or become permanent. But policy change is also crucial. Creating a drug-free world has been the goal of drug prohibition since the 1960s.12, 13 Yet drug use persists at fairly stable levels in every country in the world. 14 For far too long, many governments have pursued this prohibitionist approach to drugs in the name of public health, despite evidence that, as the Lancet Commission on Public Health and International Drug Policy observed in 2016, the public health “harms of prohibition far outweigh the benefits”. 15 Now that a public health crisis has once again exacerbated the health harms of drug prohibition, the public health community needs to mobilise against attempts to persist with a fundamentally flawed drug policy approach. © 2022 Kent Nishimura/Contributor/Getty Images 2022 The public health community and policy makers need to accelerate action to reduce the health risks associated with drug use and create environments where people who use drugs are not stigmatised and have access to services that keep them healthy; where jails and prisons are not filled with drug users and people who grow, smuggle, or sell drugs as a survival strategy; and where public funds are used for health and social programmes rather than militarised drug enforcement. At a time when the world is reconsidering many pre-COVID-19 practices, the public health community can be a strong voice for a new approach to drugs that is anchored in social wellbeing, health, and human rights. Importantly, the public health community brings a wealth of experience with regulation of other potentially harmful substances, such as alcohol, sugar, and tobacco. It can draw on that practical experience to help explore what regulatory models are most appropriate for different categories of drugs and how the public health impact of regulation can best be monitored and evaluated. Although the field of cannabis regulation is fairly new, some relevant lessons learned are emerging from early adopters like Uruguay and the states of Washington and Colorado in the USA, such as the importance of limiting corporate influence on cannabis science, regulation, and policy. 16 In past decades, public health luminaries such as Paul Farmer and Jonathan Mann urged policy makers to analyse and address the systems that generate structural inequalities and put people in harm's way.17, 18 It is time for the public health community to challenge the notion that prohibition is an acceptable approach. Harm reduction and other proven public health interventions need to be at the centre of a new, regulation-based approach to drugs. We declare no competing interests.