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The Lancet Addiction Series: Special Release

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Date Published:
6 Jan 2012
Contact person:
Marion Downey
02 9385 1080

Key points:

  • Around 200 million people using illicit drugs worldwide each year, with use highest in high-income countries; drug-related burden of disease appears similar to that caused by alcohol in these developed countries
  • Many drug control initiatives to date based on insufficient evidence, but emerging evidence-based interventions could reduce drug-related harms
  • Countries wanting to try new approaches to drug legislation would have to move beyond existing international treaties, which have done little to prevent drug misuse
  • Lancet Editorial with the Series

Around 200 million people using illicit drugs worldwide each year, with use highest in high-income countries; drug-related burden of disease appears similar to that caused by alcohol in these developed countries

The first paper in The Lancet Series on Addiction addresses the global burden of disease due to illicit drug use, and reports estimates that some 200 million people (range 149-271 million) worldwide use illicit drugs each year. This figure represents 1 in 20 people aged 15-64 years, and use is highest in developed countries. Furthermore, the burden of disease due to drug use in high-income countries such as Australia is a sizeable proportion of that caused by alcohol consumption, but much less than that caused by tobacco. The paper is by Professor Louisa Degenhardt, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, and the Burnet Institute, Melbourne, Australia; and Professor Wayne Hall, University of Queensland Centre for Clinical Research, Brisbane, Australia.

The illegality of opioids, amphetamines, cocaine, and cannabis precludes the accurate estimation of how many people use these drugs, how many people are problem users (including people who are dependent), and what harms their use causes. The authors note that this is a major unintended consequence of the prohibition of such drug use. They also note that due to limitations in the data on extent of use, and the nature of related harms, the burden attributable to MDMA (ecstasy), hallucinogenic drugs, inhalants, or non-medical use of benzodiazepines (such as valium) or anabolic steroids has never been estimated. Available data suggest that, in the total illicit drug users mentioned above there are 125-203 million cannabis users, 14-56 million amphetamine users, 14-21 million cocaine users and 12-21 million opioid users. There are an estimated 15-39 million problematic users of opioids, amphetamines, or cocaine, and 11-21 million people who inject drugs.

According to estimates made by the UN Office on Drugs and Crime, cannabis use appears to be highest in Oceania (Australia/New Zealand) with up to 15% of 15-64 year olds using the drug, while opioid use including heroin was highest in the Near and Middle East (up to 1.4%). For amphetamines, again Oceania came out highest with up to 2.8% of this age group using drugs such as speed and crystal meth (but not including ecstasy), and cocaine use was highest in North America (1.9%).

The authors highlight that no gold-standard method exists for the estimation of the true size of the population of illicit drug users, and that no one method is ideal for all drugs or all countries.

Four broad types of adverse health effects of illicit drug use exist: the acute toxic effects, including overdose; the acute effects of intoxication, such as accidental injury and violence; development of dependence; and adverse health effects of sustained chronic, regular use, such as physical diseases.The authors highlight that cannabis causesvery few deaths (no overdoses or blood-borne virus infections) though it may cause some accidental deaths. However it clearly causes many users to become dependent and probably contributes to mental disorders. Opioids have been shown to have all four types of health effects: they have the highest risks of dependence affecting perhaps 1 in 4 of lifetime users, and are major contributors to premature death due to overdoses, often in combination with other drugs, as well as accidents, suicides and violence, HIV/AIDS and hepatitis.They are also major contributors to disability, through dependence, chronic infections, and liver disease.

The most recent data reported by the World Health Organization (2004) suggest that 250,000 deaths worldwide were due to illicit drug use, compared with 2.25 million due to alcohol and 5.1 million due to tobacco. Years of life lost due to drug use (2.1 million) were more than those recorded for alcohol (1.5 million), because drug deaths generally affect younger people, while alcohol deaths (and tobacco deaths) tend to affect middle-aged and elderly people. Furthermore, alcohol can have a protective effect when used in moderation in middle age. However, when years lost due to disability (DALYS) are considered, illicit drugs cause 13 million DALYS (0.9 of global DALYS), some 20% of those caused by alcohol (69 million/4.5% of global DALYS ) and 23% of those caused by tobacco (57 million/3.7% of global DALYS). The burden due to drugs does not, however, include adverse social effects on drug users, such as stigma and discrimination, or the adverse effects that drug-related behaviour has on communities, such as drug dealing, discarded injection equipment, endangerment of public safety, violence between drug dealers, and property crime.  The authors  add that on the basis of available evidence, most of the disease burden attributable to illicit drugs is concentrated in problem or dependent drug users, especially people who inject drugs.

However, the above figures are the overall global picture. In a high-income country such as Australia, illicit drugs are responsible for 2.0% of DALYS, compared with 2.3% for alcohol and 7.8% for tobacco. And opioids cause 80% of the drug DALY burden in Australia. Illicit drugs caused 1.3% of all deaths in Australia, compared to 0.8% for alcohol and 11.7% for tobacco. This was based on the assumption that moderate alcohol use reduced cardiovascular heart disease mortality in middle-aged adults. Patterns of drug-related DALYS distribution are likely to be similar in the USA and UK*. In terms of trends of drug use in Australia, cannabis is the most widely used drug although recreational use of this drug appears to be declining (with less marked changes in problematic cannabis use). Amphetamine use is more common than cocaine use, but cocaine, although comparatively very expensive in Australia, is rising in popularity. Use of opioids is much less common than it was in the late 1990s.

The authors conclude: “Intelligent policy responses to drug problems need better data for the prevalence of different types of illicit drug use and the harms that their use causes globally. This need is especially urgent in high-income countries with substantial rates of illicit drug use and in low-income and middle-income countries close to illicit drug production areas.”

Note to editors: *based on the World Mental Health Survey results that the picture is likely to be similar in the UK and USA and other high-income countries

Marion Downey, Communications and Media Manager, National Drug and Alcohol Research Centre. T) +61 29385 0180 E) m.downey@unsw.edu.au

Professor Wayne Hall, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia. E) w.hall@uq.edu.au

For full Series paper 1, see: http://press.thelancet.com/addiction1.pdf

For Series homepage, which will go live when embargo lifts and can be provided as a link to your readers, see: http://www.thelancet.com/series/addiction

Many drug control initiatives to date based on insufficient evidence, but emerging evidence-based interventions could reduce drug-related harms

The pursuit of public good is an appropriate objective of drug policy, and necessitates the judicious application of controls over availability, prevention, treatments and rehabilitation.  Public good may be achieved by increasing the number of people who are completely abstinent and also through reduced levels of use or changed patterns of use by those who continue to use. policy makers have pursued many drug control initiatives that lack scientific evidence for their effectiveness, and that can cause harm through unintended consequences. But evidence-based interventions are emerging that can make drugs less available, reduce violence in drug markets, lessen misuse of legal (pharmaceutical) drugs, prevent initiation in young people, and reduce drug use and its consequences among existing users. The issues are discussed in the second paper in The Lancet Series on Addiction, written by Professor John Strang, National Addiction Centre, London, King’s College London, UK, and colleagues.

The authors say: “Much public debate in drug policy is only minimallyinformed by scientific evidence. Values and politicalprocesses  are important drivers of drugpolicy, but evidence of effectiveness and cost-effectivenesscan help the public and policy makers to select policiesthat best achieve agreed goals.”

Regarding drug supply, the evidence backs a number of conclusions, firstly that if law enforcement can keep prices high, drug initiation and use will be reduced. The very illegality of drugs makes them far more expensive than if they were legal, taxed, products. But keeping prices high can be hard, with one study in America showing that a 4.6 times increase in prisoners detained on drug-related offences only saw a 5% to 15% increase in the price of cocaine. There is no evidence that alternative development programmes (e.g. subsidies to grow different crops) in source countries have reduced drug use in final market countries at the other end of the drug distribution chain. But supply shocks can sometimes affect the drugs market and reduce use, purity, and harms related to drugs, as the examples of the Taliban opium ban, and 1989-90 war on Columbian Drug Traffickers, the restrictions on crystal meth precursors in the USA, and the Australian heroin shortage suggest. The authors add that wide-scale arrests and imprisonments have limited effectiveness, whereas drug testing of individuals under criminal justice supervision, accompanied by specific, immediate, and brief sentences (eg, overnight), have produced substantial reductions in drug use and offending.

Controlling prescription drugs is a different problem, and abuses are common and increasing, for example the steady rise in misuse of sustained-release opioid painkillers in the USA and Canada. Sourcing of prescription drugs occurs through different forms of diversion—eg, double doctoring (having two family doctors), prescription drug fraud, and thefts and robberies. Family and friends are also a primary source for individuals who use pharmaceuticals non-medically. Such sourcing patterns make the reduction of supply through traditional law enforcement difficult. The authors say: “Prescription monitoring systems can reduce irregular prescribing practices, but a balance is needed between the need for access to drugs for legitimate pain relief and the need to restrict access to deter inappropriate non-medicinal use.”

Screening and brief intervention programmes have, on average, only small effects, but can be widely applied and are probably cost-effective. School, family, and community prevention programmes often have little impact, although even modest impact may be appraised differently by different stakeholders. The authors say: “Ideally, preventive interventions should stop youngpeople from starting drug use, but they can also valuably delayinitiation of drug use and prevent young people frombecoming regular and dependent drug users.”

“Treatment works” is an often-quoted mantra intended to alert health professionals and the public to the various benefits of addiction treatment. But this is not true of all types of treatment given to problem drug users. The treatment with the strongest research evidence of effectiveness is substitution treatment for addiction to heroin and other opioids. Evidence is much weaker for treatment of problem use of other drugs such as cocaine, crack cocaine, and methamfetamine. Oral opiate antagonists (naltrexone) are pharmacologically highly effective (and work with alcohol also) but benefit is marred by extremely poor adherence. Extremely long-acting implant or depot versions of several of these medications have been developed and are being trialled, as are novel vaccines against specific drugs; however, the future impact of these innovations is unclear.

Behavioural and psychosocial interventions, including residential rehabilitation, also have evidence supporting their effect. The effect size from contingency management (eg, voucher reinforcement of positive behaviours) is particularly notable. Opportunistic brief interventions for drug users with very low or no contact with treatment can increase help-seeking behaviour and stimulate change in behaviour.

The authors conclude: “Drug policy has the potential to contribute more to the public good by focusing on interventions with the largest potential population effect, the strongest evidence of effectiveness and cost-effectiveness, and the closest link between the outcomes of the policy and society’s idea of the public good. Funders and researchers should pay greater attention to more policy-relevant areas in addiction research if society’s ability to adopt a more evidence based approach to drug policy is to be improved.”

For Professor John Strang, National Addiction Centre, London, and King's College London, UK, please contact Russell Guthrie on +44 (0) 20 3228 2621 or +44 (0) 7930 943973 E) Russell.Guthrie@slam.nhs.uk / john.strang@kcl.ac.uk

For full Series paper 2, see: http://press.thelancet.com/addiction2.pdf

For Series homepage, which will go live when embargo lifts and can be provided as a link to your readers, see: http://www.thelancet.com/series/addiction

Countries wanting to try new approaches to drug legislation would have to move beyond existing international treaties, which have done little to prevent drug misuse

International treaties governing laws on illicit and non-medical drug use prevent innovative approaches and have done little for the cause for which they were intended. Furthermore, in order to escape UN sanctions or censure, any country wishing to try a new approach to dealing with drugs would have to withdraw from these treaties and re-enter them with special clauses or reservations enabling such approaches. The issues around international drug conventions are covered in the third paper in The Lancet Series on Addiction, written by Professor Robin Room, Turning Point Alcohol and Drug Centre and School of Population Health, University of Melbourne, Melbourne, VIC, Australia, and Professor Peter Reuter, School of Public Policy and Department of Criminology, University of Maryland, College Park, MD, USA.

The international treaty system has three components. The 1961 Single Convention on Narcotic Drugs required nations to make the non-medical use ofcannabis, cocaine, and opioids a criminal offence. The 1971 Convention on Psychotropic Substancesthen extended the system to cover synthetic pharmaceuticals—eg, amphetamines, benzodiazepines, opioids, and lysergic acid diethylamide (LSD). This was followed by the 1988 Convention Against Illicit Trafficking in Narcoticsand Psychotropic Substances, which promoted police suppression of illicit markets and was extended to cover drug precursor chemicals. The Commission on Narcotic Drugs, a part of the UN system, is the political body with responsibility for these treaties.

The authors argue this international drug control system has not ensured adequate medical supply of opioids, particularly in low-income and middle-income countries. They say*: “The system has not effectively restricted the non-medical use of controlled drugs, and illicit drug use and the contribution of illicit drugs to the burden of disease have increased worldwide over the past decade.” Furthermore, they add*: "The system’s emphasis on criminalisation of drug use has contributed to the spread of HIV, increased imprisonment for minor offences, and contributed to legitimating extremely punitive national policies (including executions, extra-judicial killings, and imprisonment as a form of treatment), all of which have caused harm to drug users and their families.”

The UN Office on Drugs and Crime (UNODC) is the specialised UN agency on drug issues that serves as the secretariat for the Commission on Narcotic Drugs. It advises governments on effective law enforcement and treatment systems and methods of estimation of illicit drug production and consumption. UNODC, with a tiny core budget, depends on earmarked funding from donor governments, limiting its work’s coherence and effectiveness. National delegations to the Commission on Narcotic Drugs, or in international bureaucratic positions, have a vested commitment to the existing system and have kept civil society at bay, despite a growing presence of drug-policy reform movements.

Informally, the USA has long had a leading role in the international system. The USA has strongly opposed harm-reduction approaches to illicit drug problems, such as needle and syringe programmes, supervised injecting centres, and heroin maintenance treatment, with support from other nations such as Japan and Russia. The USA now accepts needle and syringe programmes but still objects to use of harm reduction wording in UN documents. UNODC used to share this objection, but has become more accepting of measures such as needle and syringe programmes.

WHO moved projects on reduction of HIV infection among drug users to the UN agency on AIDS, in order to protect such projects from direct pressure from individual countries. WHO’s relationship with UNODC has often been strained, with WHO’s advice on occasion having been ignored by the UNODC and the Commission on Narcotic Drugs. However, WHO and UNODC have more recently resumed cooperationIn 2009 a UNODC and WHO programme jointly produced drug treatment guidelines and a discussion paper on the role of coercion in the treatment of addiction. The authors say: “Nonetheless, the international system devotes more of its resources—as shown in its budget allocations and the topics of debates by the Commission on Narcotic Drugs— to suppression of illicit drug markets than to direct protection of public health and wellbeing.”

Eight countries (Australia, Canada, Germany, Luxembourg, the Netherlands, Norway, Spain, and Switzerland) have provided supervised injecting centres to reduce blood-borne virus transmission and overdose and to increase drug users’ contact with treatment services. These changes, which have largely been made without legislation to remove criminal penalties for use, have been criticized by UNODC and the International Narcotics Control Board as contrary to the treaties. UNODC has now accepted that needle and syringe programmes and treatment diversion programmes comply with the treaties, but the International Narcotics Control Board continues to argue that the status of supervised injection centres is unclear.

The treaties lack flexibility. UNODC and the Commission on Narcotic Drugs worsen this problem by their frequent failure to consider evidence in making decisions. For example, studies of the introduction or removal of criminal penalties for use and possession of cannabis show no substantial effects on the prevalence of use or on health-related harm.

The most feasible way for an individual country to try a new approach to dealing with drugs (eg, legalisation of possession) would be to withdraw from one or more of the treaties and then re-accede with specified reservations. For example, Switzerland and the Netherlands ratified the 1988 treaty with a reservation against the provision that required the criminalisation of use and possession. The authors say: “National experimentation in approaches to prevention and reduction of drug-related harm should be allowed. The international drug treaties in their present form seriously constrain governments’ capacities to engage in such policy experiments. They have restricted the freedom of action to change penalties for personal use, with the result that reduction in penalties has sometimes counterproductively increased the numbers of young people penalised for drug offences. Countries that wish to experiment with different ways of regulating drug use and reducing drug-related harm will need to consider opting out of provisions of the existing drug control treaties.

The authors conclude: “The cultural positions of different drugs vary enough to preclude universal policies on how to deal with all illicit or indeed licit drugs. From the perspective of public health, we need to move towards a control system that is more aligned with the risks that different drugs pose to users and shows an understanding of the effects of different regulatory approaches on drug use and harm.”

Professor Robin Room, Turning Point Alcohol and Drug Centre and School of Population Health, University of Melbourne, Melbourne, VIC, Austrailia. T) +61 3 8413 8430 E) robinr@turningpoint.org.au

Note to editors: *quotes not exactly as they appear in text of paper

For full Series paper 3, see: http://press.thelancet.com/addiction3.pdf

For Series homepage, which will go live when embargo lifts and can be provided as a link to your readers, see: http://www.thelancet.com/series/addiction

Lancet Editorial on the Series

For full Editorial, see: http://press.thelancet.com/addictioned.pdf