“The criminalisation of drugs doesn’t break dependence, but it deters people from seeking help,” says Louise Arbour. “It’s a completely self-defeating public policy.”
Arbour, a former United Nations high commissioner for human rights, is a member of the Global Commission on Drug Policy—an independent panel of world leaders and political, economic, and cultural experts who advocate for drug policies grounded in scientific evidence and human rights.
Their report, published this week, finds that over 40% of the world’s known executions in 2023 were for drug offences.1 The commission says that the prohibition focused approach that’s been a hallmark of the “war on drugs” for the past 50 years has failed to curtail the production and consumption of drugs such as cannabis, opiates, and heroin. Meanwhile, illegal drug markets controlled by organised crime have grown dramatically.2
An estimated nine in 10 people who use illegal drugs don’t experience dependence. The commission urges governments to tackle the underlying issues that may trigger drug use and dependence, such as trauma, homelessness, and self-medication, which criminalisation of drugs often exacerbates.
Arbour tells The BMJ that the starting point is to break away from absolute prohibition and criminal offences and instead to treat drug use as a public health issue. This would then allow healthcare and social service professionals to occupy that space and yield better results.
Harm reduction
The Global Commission on Drug Policy’s new report recommends establishing and promoting access to harm reduction interventions, such as test strips for checking the content and purity of drugs, needle and syringe programmes, overdose prevention centres, and opioid agonist therapy to prevent deaths from overdose, reduce bloodborne infections, and support public health and safety.
Research among injection drug users in the United States has found that new participants of syringe service programmes were five times as likely to enter methadone treatment and nearly three times as likely to reduce or stop injecting altogether as users who never participated in the programmes.3 Private spaces where people can take drugs using sterile materials and under medical supervision have also been found to reduce not only the risk of overdose and bloodborne viruses but also local crime, public injecting, and drug related litter.1
The commission also proposes discontinuing court mandated drug treatments and ensuring that all treatment is voluntary and based on informed consent. Even voluntary treatment isn’t always successful the first time around, and forced treatment is even less likely to be effective, says Arbour. Compulsory treatment and rehabilitation are not only unethical but also ineffective for improving health and public safety outcomes, says the UN Office on Drug and Crime.4
In cases where people experiencing drug dependence don’t want to seek treatment or have sought it but failed, Arbour says that the first thing to do is to ensure their survival: “all the overdose protection measures are absolutely critical.”
The commission advocates for implementing safer supply programmes, which involve providing regulated, pharmaceutical grade drugs to people at risk of overdose due to toxic drug supplies from illicit markets. This harm reduction intervention aims to keep people alive and is an overdose prevention strategy rather than a treatment for dependence.1
Scientific evidence reviewed by the commission suggests that safer opioid supply programmes in Canada have improved clinical outcomes among people who use drugs—reducing the frequency of unregulated opioid toxicity events, increasing access to healthcare, and improving quality of life.15
Inequality
But harm reduction is concerned not only with reducing the harms of drug consumption through public health measures but also tackling the harms caused by prohibition, incarceration, discrimination, and abuse by police, says Arbour. The commission’s report therefore urges governments to divest from criminalisation and reallocate funds to health and social services instead.
For instance, the US state of Oregon decriminalised the small scale possession of illicit drugs in 2021 and reduced the offence from a felony or misdemeanour to a civil violation. Savings from decriminalisation and tax revenues from cannabis legalisation amounted to more than $300m (£236m; €285m) that was used to expand health screenings, housing services, employment support, and other support services.1 However, a new bill signed earlier this year re-criminalised drug possession in the state, threatening to overburden public defence caseloads even further.6
In some cases, the use of illicit substances is a response to living without shelter, sanitation, and clean water.1 Arbour says, “One has to go back to the roots of the social determinants, and if we can improve those, chances are that we will reduce dependence in the longer term.”
Investing in health, housing, and broader social responses can help tackle the factors that increase the likelihood of drug dependence. The commission points to Housing First programmes operating in various European countries such as Finland, Norway, and the UK, which acknowledge housing as a fundamental right and aim to provide it without the condition of a person being drug free. A 2024 report by the charity Homeless Link found that residents in England’s Housing First programme reduced their substance use and increased their engagement with drug and alcohol services steadily over a three year period.7
People from marginalised and lower socioeconomic backgrounds are also disproportionately criminalised for drug offences and are at greater risk of harm from drugs and drug policies, says the Global Commission on Drug Policy. Ensuring that robust social safety nets are in place could reduce the likelihood of economically disadvantaged people from becoming low level actors in the illegal drug market.
Arbour hopes that the commission’s report informs people about “the demonstrated failure of the criminal model of drug control—and not only its failure but the terrible harm that it causes.”
Footnotes
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Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
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Provenance: Commissioned, not externally peer reviewed.
