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FOR DEB ATE doi:10.1111/j.1360-0443.2009.02536.x

Ten years after the United Nations General Assembly Special Session (UNGASS): assessing drug problems, policies and reform proposals

Peter Reuter

School of Public Policy and Depar tment of Criminology, University of Mar yland, College Park, MD, USA

ABSTRACT

In 1998 the United Nations General Assembly Special Session resolved that governments would reduce drug produc- tion and consumption greatly within 10 years. With that period now elapsed, there is an interest in reviewing how successful this was and considering how drug policy could be improved. The demand for drugs in the world has stabilized mainly as a result of the interaction of epidemic forces, culture and economic development. Supply has become more concentrated and the menu of drugs has changed surprisingly slowly. Drug policy is shifting to a more explicitly tolerant configuration in Europe and a few other countries, but retains its ferocity in most of the world. The most prominent innovations under discussion have limited potential effects (heroin maintenance), have as yet been unproductive of policy interventions (‘addiction is a brain disease’) or have no political appeal (legalization). The option with the most scope is increased effort at diverting arrested drug users out of criminal justice systems. No prevention, treatment or enforcement strategies have demonstrated an ability to substantially affect the extent of drug use and addiction. The best that government interventions can do is to reduce the damaging consequences of drug use and drug control. More attention should be given to reductions in the intensity of drug enforcement, which has many unintended adverse consequences and yields few of the claimed gains.

Keywords Drug enforcement, drug policy, heroin maintenance, legalization, UNGASS, unintended consequences.

Correspondence to: Peter Reuter, School of Public Policy and Department of Criminology, University of Maryland, College Park, MD 20742, USA. E-mail: preuter@umd.edu

Submitted 29 September 2008; initial review completed 12 December 2008; final version accepted 6 January 2009

INTRODUCTION

In 1998 the United Nations General Assembly Special Session (referred to universally and uneuphoniously as UNGASS) resolved that the global drug problem would be eliminated or reduced substantially within 10 years [1]. The 2009 debate on UNGASS 1998, particularly at the

2009 Commission on Narcotics Drugs (CND) meeting in Vienna, is seen generally as an opportunity for a discus- sion about the shape of drug policy throughout the world. It is clear that a discussion is needed; it is less clear that there is any sustained governmental interest in having one. There is a stasis on drug policy in most of the world, with some subtle shifts. This paper begins by sum- marizing briefly changes in global drug problems and drug policies of the last 10 years. It then discusses what might be regarded as the major ideas for reform that are currently in play. Finally, it argues that prevalence, the

major indicator in many countries, is insensitive to policy

and that there is a strong argument for less enforcement of drug prohibitions. Readers should be warned that the breadth of the description of problems and policies ensures that nuances will be missing; for example, state- ments about global trends do not include the Middle East and Africa, for which epidemiological and other data are particularly sparse.

In brief, the demand for drugs in the world has stabi- lized mainly as a result of the interaction of epidemic forces, culture and economic development. Supply has become more concentrated and the menu of drugs has changed surprisingly slowly. Drug policy is shifting to a more explicitly tolerant configuration in Europe and a few other countries, but retains its ferocity in most of the world. The most prominent innovations under discussion have limited potential effects (heroin maintenance), have as yet been unproductive of policy interventions (‘addic- tion is a brain disease’) or have no political appeal (legal-

ization). The option with the most scope is increased effort

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Ten years after UNGASS 511

at diverting arrested drug users out of criminal justice systems. No prevention, treatment or enforcement strat- egies have demonstrated an ability to substantially affect the extent of drug use and addiction; the best that gov- ernment interventions can do is to reduce the damaging consequences of drug use and drug control.

DRUG PROBLEMS

Consumption

In most of the world, drug use has changed only modestly in the last 10 years. Heroin use has stabilized throughout the rich world at least since 2000 [2] and has actually declined markedly in Australia, a medium-sized country (population 20 million) which had a large heroin problem in the late 1990s [3]. China’s heroin problems seem to be fairly stable, confined to some large western provinces but not yet showing up in the rich eastern cities, where stimulants are emerging, perhaps as a sign of modernity [4]. The big heroin event of this decade was the conclusion of a major epidemic in Russia and Central Asia [5]. Like most heroin epidemics, it did not last many years but has left those countries with major problems of heroin addiction and human immunodeficiency virus (HIV), although probably little additional crime. Cocaine use is spreading in Europe, particularly in the United Kingdom and Spain [6], but does not seem likely to reach US prevalence levels, which are also now declining. Cannabis, although its prevalence is declining in most western nations, remains by far the most widely used drug throughout the Western world; it is fairly rare in many Asian nations [7].

The development of large middle classes in many Asian nations has not been accompanied by the expected epidemics of drug use. Cultural factors seem important. For example, Japanese teenagers may be the early adopt- ers of every new technology and fashion but they have shown the traditional Japanese lack of interest in exotic forms of intoxication. The same holds for Korea and, perhaps, for India. Stimulant consumption is a moder- ately important exception in some Asian countries [5].

One puzzle is why more new drugs do not succeed in the market-place. There is a constant flow of new prod- ucts that seem very attractive. Some, such as methylene- dioxymethamphetamine (MDMA), gain a measurable share of the market but then generally fade within a few years [8]. Occasionally an indigenous psychoactive drug moves out from its traditional use populations, as khat has done in the last decade [9]; however, these are epi- sodic and small-scale events. Apart from some diverted pharmaceuticals such as Oxycontin, that are now traf- ficked widely in the United States [10], the mix of drugs

being sold illegally has been fairly stable.

Supply

Drug production, always concentrated in a few nations, has become still more concentrated. Afghanistan is no longer one of two large opium producers; it is instead the sole large producer, now accounting for over 90% of the world market [11]. Burma has seen large falls in opium production, mainly the result of coercive policies of an authoritarian separatist group, the United Wa State Army [10]. Colombia has come and gone as a niche heroin producer for the US market [12]. Stimu- lants pour out of poor countries in Asia [13]. Cocaine is now produced mainly in Colombia from local leaf, with Peru and Bolivia, previously the dominant producers, consigned to secondary status even for growing [12]. The US drug supply problem can be summarized in two words: Colombia and Mexico. These two nations domi- nate the production and/or trafficking of cocaine, heroin and methamphetamine entering the United States. They are high-cost producers but low-cost smugglers.

Trafficking problems have clearly spread and intensi- fied. Mexico’s drug gang violence was horrifying 10 years ago; it is much worse now, with perhaps as many as 5000 drug-related homicides in 2008 [14]. There is a concern, not yet documented, that the killings are with guns imported from the United States through the same chan- nels that exported the drugs. The central Asia heroin epidemics are a consequence of the development of new trafficking routes from Afghanistan to Russia. Trafficking does not always generate this kind of problem. For example Turkey, the corridor for most of Europe’s heroin, has, if anything, seen a decline in its modest domestic heroin market [15].

Governments are seizing an increasing share of the drugs that are shipped. In the case of cocaine, at least one-third is interdicted; it might even be one-half [5]. Heroin seizures are also much higher throughout the world compared to 10 years ago; the 2008 World Drug Report estimates the share seized to be 13% in 1996 and

23% in 2006. Higher seizure rates make little difference to price in Europe and the United States, because when seized near the production countries the drugs are cheap to replace. In Iran (which interdicts more heroin and morphine in most years than any other country) a kilo that is seized will cost only $5000 to replace, but will sell for more than $100 000 in retail units (less than 1 gram) on the streets of London [11].

The nearly relentless decline in retail prices of cocaine and heroin in the West has continued. For example, in the United States heroin prices in 1998 were barely one-third of their 1988 levels; by 2004 they had fallen another

30% [16]. In Europe the available data suggest similar

trends, although the Taliban ban on opium reversed this

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512 Peter Reuter

briefly [17]. Cocaine shows very similar trends, although there has apparently been a spike in the United States in

2007 [18].

There are two puzzles here. First, why have the prices of drugs declined in face of increasing toughness in the United States, United Kingdom and various other coun- tries? Secondly, why have rapidly declining prices not trig- gered a new epidemic? The first is hard to explain, and no one has made a great effort to do so; the decline in demand in a few countries contributes to the price fall but probably only modestly. The second puzzle is simply a reminder of how much psychoactive drugs are fashion goods; once cocaine or heroin gains a bad reputation there is little that dealers can do to encourage new cus- tomers to try the drug.

DRUG POLICY

Although arrests have generally increased, the West has moved consistently towards harm reduction [2]. Even countries with a rhetorical hard line (notably France and Sweden) are now supporting the basic harm reduc- tion innovations, such as methadone maintenance and needle exchange; the French shift to substitution treat- ment for opiate addiction has been particularly dramatic [19]. Portugal has joined Italy and Spain in removing criminal penalties for possession of any drug for personal use [20]. Heroin maintenance experiments are under way in half a dozen countries and Germany is in the process of following the Netherlands and Switzerland in introducing heroin-assisted therapy as simply another treatment option [21]. The European Union is now mainly a single voice at international meetings, with a strong and explicit harm reduction tone, even though there are signs of modest retreat from some of the bound- aries of harm reduction, such as the Dutch government cutting of the number of coffee shops licensed to sell cannabis [22].

Iran, with perhaps the most serious drug use problem in the world [5], has taken important harm reduction measures, such as creating a large number of methadone maintenance programs [23]. Iran now seems to execute only a few dozen individuals a year, down from hundreds in the 1990s, but it still has an incarceration rate for drug offenses that is comparable to the United States [24]. Russia, which has a very large heroin problem, seems to have reduced the ferocity of its enforcement effort at low- level users but still prohibits methadone.

Cannabis continues to generate controversy in many countries, quite out of proportion to the harms it causes. The United Kingdom has already shifted twice, in oppo- site directions, on how cannabis possession should be treated legally; the most recent shift occurred when the

Prime Minister toughened the scheduling of the drug

even before the review by the Advisory Council on the Misuse of Drugs was complete [25]. The highest German court effectively decriminalized marijuana possession in the early 1990s, although individual provinces (Laender) handle it in varying ways [26]. In Australia an increasing number of lower level jurisdictions have attempted to lessen the severity of possession penalties, as well as those for growing cannabis for personal use. France has quietly stopped arresting users [27], but then the French are quiet about drug policy generally. In Switzerland, seen generally as a reform nation on drug policy, a cannabis liberalization proposal was defeated resoundingly in a

2008 referendum.

The medical marijuana movement in the United States may have achieved some gain for those who want the drug for therapeutic purposes by the passage of refer- enda on this matter in a number of states, but it has not changed attitudes towards marijuana use in general [28]. Recent research showing a connection between marijuana use and schizophrenia [29], even if it does not have significant population-level implications, will rein- force those favoring tough enforcement of marijuana prohibitions.

The United States is increasingly an outlier among western nations on drug policy. The number of people incarcerated for drug offenses has risen relentlessly: from less than 50 000 in 1980 (including those in local jails) to approximately 500 000 in 2005 [30]. This has occurred even as the scale of the US problem gradually declined, mainly through the natural processes of an epi- demic [31]. The US government has taken an aggressive stance against harm reduction (most prominently needle exchange) in international gatherings, continuing its his- torically dominant role in pushing for tough prohibition [32].

However, in the larger world it is the Europeans who are isolated. Asia is hawkish, as are the Middle Eastern and African nations (fairly invisible on these issues). The Chinese national government has permitted methadone maintenance, but in the face of local government resis- tance the vast majority of heroin users in treatment are effectively in labor camps [33]. Japan is often aggressive in its support of tough policies. Latin America is moving in the harm reduction direction, although only a few Latin countries have much of a drug use problem [5].

THE BIG IDEAS

A fair reading is that the stasis on drug policy extends to the reform community. Apart from legalization (discussed below), fights are focused mainly upon a narrow set of issues affecting injecting drug use (e.g. syringe exchange programs and safe injecting facilities). These are impor- tant interventions, but affect relatively small numbers of

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people. This may reflect both the lack of much ongoing research (as opposed to advocacy) on policy options as well as the distaste and pessimism about drug policy in the United States, which results in intellectual disengage- ment from the issue.

Some of the ‘big ideas’ that are in play at present are as follows.

Heroin maintenance

Heroin maintenance appears to have real potential to transform the lives of current heroin addicts. There have now been completed experiments in at least five countries (Canada, Germany, the Netherlands, Spain and Switzer- land), all with positive findings [21,34]. Switzerland now has more than 10 years of experience of offering the option as a routine to experienced users; one sign of success is that in a November 2008 referendum, 68% of voters were in favor of continuing to provide it.

However, the Swiss experience, although positive, sug- gests that it has modest population effects. Only about 5% of Switzerland’s addicts are in heroin-assisted therapy, perhaps because it is structured in such an unattractive way [35]. The clinics, to make a poor pun, turn injecting heroin into a sterile experience. The addict must leave the clinic very promptly after taking his medicine in a booth on his own; he must turn up at least twice a day during specific and short time-periods. At a minimum one might regard it as undignified; many users regard it as degrad- ing. The program has made a real contribution to helping the participants and in reducing Switzerland’s drug problem (including reductions in the availability of drug selling labor) but it is far from transformational. Whether a less clinical approach would make much difference is a reasonable question, which may be tested in the Nether- lands where the fact that most clients are smokers rather than injectors allows for a quite different atmosphere [35].

Moving arrested drug users out of the criminal justice system

This can be viewed as an attempt, within the prohibition framework, to minimize the dead weight loss of law enforcement against users and user/dealers and to use the criminal justice system in a paternal way to help users. Somewhat surprisingly, the United States has been the leader, with a number of countries (e.g. Australia and the United Kingdom) starting ‘drug courts’ (where a judge acts very much like a probation or parole officer in encouraging and monitoring drug using offenders) in imitation of a 20-year-old US innovation [36]. In the United States, despite the growth in the number of drug courts, the share of arrestees going through are quite small. Typically, the eligibility rules exclude those with

long and serious criminal histories, thus ensuring that most of the nation’s ageing cocaine and heroin addicts cannot participate [37]. Evaluations have generally found positive effects with the relatively less serious offender population that they usually handle [38].

Drug courts can be seen as the most prominent of an array of programs with the same goal of diverting drug involved offenders from the criminal justice system into treatment. In the United Kingdom, various diversion schemes have contributed substantially to the doubling of the population in treatment in the last 5 years [39]. The evaluation literature on the various UK programs has not produced promising results, but that has not stopped the government from claiming that the simultaneous decline in crime is a consequence of these placements [40].

This innovation has broad appeal politically. For liber- als it means that the criminal sanction is used construc- tively; for conservatives it combines treatment with coercion. It has the potential to make a difference in the lives of many people with drug dependency problems. Drug reformers outside the United States are uncomfort- able with the use, and potential misuse, of coercion [41] but it may still spread broadly, at least in the western world.

‘Addiction is a brain disease’ [42]

Although easily caricatured [43], this might be a big idea if only it had generated some useful interventions. Excit- ing developments in the understanding of the biological bases of addiction have not led to any major innovations in treatment. Indeed, it is remarkable just how stagnant the treatment system is: marginal developments in various behavioral therapies (e.g. contingency manage- ment) and a few alternative opiate substitutes to supple- ment methadone (most prominently buprenorphine) that have some advantages for some patients. There is talk of cocaine ‘vaccines’, but that is as far as it has come and vaccines raise some difficult ethical problems [44].

Legalization

The arguments for legalization are intellectually compel- ling. Most of what currently concerns society as the drug problem is the consequence of prohibition and the poli- cies implementing it; the violence in Mexico, the HIV associated with needle sharing in Russia and the acquisi- tive crime of addicts in Britain are all proximately the result not of drug consumption, but of the conditions that have been created by prohibition. However, the unanswerable question is how much drug use and depen- dence would increase if prohibitions were removed. Robert MacCoun and I spent 10 years trying to project the consequences of legal change and believe that there is no way of producing convincing projections [45]. Even if

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good projections were possible, it would be difficult to per- suade a population that has trouble distinguishing the effects of drugs from the effects of policies to take the proposition seriously. Without a credible base for saying that addiction rates would not soar, there is little hope for major changes in the legal status of drugs such as amphetamines, cocaine and heroin. Legalization advo- cates will remain at the edges of drug policy debates this year.

This list is, of course, not comprehensive, and not everyone will agree that these are the most important ideas. For example, human rights issues related to drug policy have been given much more prominence in recent Commission on Narcotic Drugs (CND) debates. Resolu- tions that the death penalty is never an acceptable penalty for drug trafficking and that there is a right to treatment for drug addiction are now taken seriously. There has also been a campaign to allow Afghanistan to enter the legal opiate market and thus cut the supply to the illegal market, which has a highly questionable eco- nomic logic [11].

TAKING ACCOUNT OF THE LIMITS OF POLICY AND TAKING HARM

REDUCTION SERIOUS LY A S A CONCEPT

Encouraging governments to do less harm is the big idea that no one takes up. I use the United Kingdom as a ref- erence here because I have studied its drug problems and policies closely [39], but think that the analysis has broad application.

It is striking that, despite the long-standing political prominence of the drugs problem in the United Kingdom and despite relatively coherent strategies and substantial public investment, Britain, particularly England, has fared so poorly. Heroin addiction rates rose almost without pause from 1975 to 2000 [46]. As measured by use and dependence rates, Britain is at the top of the European ladder. This did not happen as the consequence of one short epidemic burst, but is the result of a steady worsening in the last quarter of the 20th century. It is encouraging that the problem does not seem to have worsened since 2000 [39], but that is the strongest posi- tive statement one can make confidently.

This illustrates the most fundamental point about drug policy; namely, that once a drug has been prohibited there is little evidence that the government can influence the number of drug users or the share of users who become dependent. There is no research showing that tougher enforcement, more prevention or even increased treatment has reduced substantially the number of users or addicts in a nation [47]. Numerous other cultural and

social factors appear to be much more important.

What are the principal determinants of rates of drug use?

Surely fashion or popular culture has to be given consid- erable weight. For example, in most nations throughout the western world, from Australia to Finland, there was an upturn of about one-half in rates of cannabis use among 18-year-olds between approximately 1992 and

1998, although from very different base rates in the various countries. Some of those nations had become tougher in their cannabis policies during that time (e.g. the United States), most made no change and others became more tolerant (e.g. Australia); the policy stance seemed to have no effect [7]. It is hard to identify which underlying cultural values drove these changes simulta- neously, but their breadth and consistency make it very likely that the increasingly globalized popular culture has a prominent role. After about 1998, the growth stopped as abruptly as it had started in most of these countries; again, there is no policy intervention to which one can turn for an explanation. Similarly, the timing of epidem- ics of heroin use in different nations seems unrelated to government policy and appears to be driven instead by the confluence of broad demographic, social and eco- nomic changes. Russia, in an era of transition, experi- enced a major heroin epidemic [48], as did Spain in the early post-Franco era. On the other hand, in the Nether- lands much earlier, the presence of heroin-using Ameri- can GIs may have been an important initiating factor, as it was for a small epidemic in Australia [11].

This suggests that it is simply unreasonable to assess the government’s performance against measures of the prevalence of drug use, as no one can offer guidance as to what is likely to reduce prevalence; yet that is the indica- tor to which the public turns instinctively. It has been an important part of the British government’s own targets [49], despite its emphasis on harm reduction, as well as those of almost every other country. There is a transpar- ency to this measure which connects to the principal drug concern of many people, particularly parents: the risk of their children becoming involved with dangerous substances.

It is politically implausible to ignore population preva- lence measures, but analysts and advocates should give more weight to other indicators, particularly related to harm such as drug-related crime and disease. The UK government has developed a Drug Harm Index [50]; however, it is not particularly useful because, for example, it attributes too much crime to drug use [51], but it does represent an important step forward in focusing policy upon the dimensions that the government can plausibly affect.

More positively, this pessimistic view of policy also has

a liberating effect. The UK government, like many others,

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emphasizes the importance of not sending ‘the wrong message’ about drugs. That has been used to justify the current drug classification scheme; for example, keeping ecstasy in Class A [52]. However, if such classification and programmatic decisions have minimal consequences for drug use, then the ‘message’ argument fails and the government is permitted to make these decisions on the grounds of justice and efficiency.

Further, as is broadly recognized, there are many unintended negative consequences of drug policy, par- ticularly enforcement, that have been tolerated on the basis of the presumed necessity. For example, the use of imprisonment for all categories of drug offences has increased in the last two decades in the United Kingdom [39]. The costs of this imprisonment are heavy for the taxpayer. If, as it appears, the majority of these offenders have been in prison for relatively low-level drug offences, then one might question reasonably whether average sentences of 3 years are useful. The claim that increas- ingly tough enforcement sends a message that will reduce drug use is not supported by the evidence [30]. Moreover, there has been a disproportionate impact on black people, who are more likely to be arrested and imprisoned for drug offences [39]; indeed, that is true for minorities in many nations. To justify long prison sentences requires a strong showing of community benefit to compensate for the suffering of the individuals and their families.

The message, then, is that the protection of society against a flood of drug use does not require a great deal in terms of drug enforcement. Just a little use of criminal justice system may gain most of whatever benefits there are to prohibition. More than that, stringent enforcement is both expensive and inhumane without any of the intended gains. The fact that drug prices in high enforce- ment settings are no higher than those in low enforce- ment settings, although intellectually troubling, provides a reasonable basis for this claim.

The Executive Director of the United Nations Office on Drugs and Crime, in his report to the Commission on Narcotic Drugs in 2008, presented an interesting analy- sis of five unintended adverse effects of the existing system. The first three are straightforward: the creation of a large black market, geographic displacement and the displacement from less to more dangerous psychoactive drugs [53]. The other two are more subtle: the displace- ment from health to criminal justice and the way that prohibition reshapes how societies deal with drug users, increasing the tendency to marginalize and stigmatize them rather than treating their problems. The demoniza- tion of drug sellers, as embodied in tough sentencing, reinforces both these tendencies as highlighted by Costa.

That provides further support for the negative big idea:

less enforcement. On the positive side, the mantra of treatment advocates is still right. Treatment works in the

sense that it reduces harms; that is true even of not very effective drug treatment, which is the most common type. Treatment is unique in that there is a strong evidentiary base that it reduces harm [54]. No nation has succeeded in treating its way out of a major cocaine or heroin problem, but treatment can reduce substantially the health burden of drug abuse, drug-related crime and the quantity of drugs consumed. It can make only relatively modest reductions in the number of men and women who misuse drugs, or who have ongoing abuse or depen- dence disorders.

There will be much discussion of the global regime in

2009, and that regime constrains experimentation [7]. The International Narcotics Control Board has been par- ticularly criticized for its lack of transparency and for its narrow interpretation of what is allowed under the inter- national treaties [55]. Progress in the creation of an international framework for tobacco and steps towards a similar treaty for alcohol suggest that it is possible to make major improvements in the handling of psychoac- tive substances at the international level. However, the most important changes in drug policy will occur at the national level. The desirable changes for experimental Switzerland are very different from those right for the doctrinaire United States; accordingly, this brief essay is not the place to make recommendations. However, all discussion of policy should pay more attention to how few of the intended effects are achieved by most policies and how many and troubling are the unintended effects, particularly of tough enforcement.

Declarations of interest

None.

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