Harm reduction must replace punitive drug policies

Voici un edito du Lancet qui se passe de commentaires.... + de RDR et - de repression !

Harm reduction must replace punitive drug policies
The Lancet Global Health


Correction to Lancet Glob Health 2024; published online Dec 5. https://doi.org/10.1016/S2214-109X(24)00525-4
December 6, 2024

The so-called war on drugs has failed. In the last century, countries have increasingly attempted absolute prohibition of drug use, often via penal measures. Despite global action, these policies have not deterred drug use: we have reached record levels of “abuse, illicit cultivation and production and manufacture of narcotic drugs and psychotropic substances”, as acknowledged at the 2024 UN Commission on Narcotic Drugs. Drug trafficking networks have become increasingly sophisticated and violent, and deaths related to drug use have increased.
The disastrous impact of punitive attempts at complete drug elimination have been felt most keenly by society's most vulnerable individuals. Despite drug use being prevalent across all socioeconomic and demographic groups, arrests for and punishment of drug offences are concentrated among young people and economically disadvantaged, culturally marginalised, and racially minoritised populations, further encumbering these groups with criminal records. If the purpose of drug policy is to reduce health and social harms, we have severely botched our response. We must drastically amend our approach.

On Dec 5, the Global Commission on Drug Policy published a call-to-action report, Beyond Punishment: From Criminal Justice Responses to Drug Policy Reform. This report urges immediate humane and evidence-based reframing of the problem and the solution: to lessen the damage of illicit drug use and dependency, we must put harm reduction strategies at the centre of our response and tackle the social determinants of drug use.

Harm reduction practices pragmatically recognise that drug use will occur, but they attempt to reduce the adverse health and social effects of drugs. Effective examples include needle and syringe programmes (NSPs), which provide sterile equipment; peer-distributed naloxone, whereby people with lived experience distribute this opioid antagonist that can rapidly reverse an opioid overdose; and opioid agonist therapy (OAT), which replaces illicit opioids with safer alternatives, such as methadone and buprenorphine. Supervised consumption sites often combine several measures, enabling people to use drugs in private spaces, equipped with clean and safe drug paraphernalia, and under medical supervision in case of overdose. But despite their known benefits, a 2023 systematic review in The Lancet Global Health found that high coverage of OAT and NSPs was present in only five countries, comprising just 2% of the global population of people who inject drugs, at a considerable risk to their health. Crucially, harm reduction measures should confer no risk of sanctions (such as fines, monitoring, or enforced treatment), to ensure participation.

If we wish to reduce drug usage and dependency and the profound social and economic harms of punitive drug policies, decriminalisation for drug use, possession, personal cultivation, and non-commercial supply will be essential. Decriminalisation does not increase drug use, but it improves health outcomes by encouraging more people with substance use disorders into treatment. There are also broader societal benefits of decriminalisation, including prevention of mass incarceration (currently 20% of the global prison population is incarcerated for drug offences) and the concomitant impairments to education, housing, and employment opportunities—particularly those disproportionately applied to Black and Indigenous people—and with the additional advantage of reducing criminal justice costs to society, which can be reinvested into some of the root causes of problem drug use.

Problem drug use and physical dependency—contrary to popular belief—only affect around 10% of those who use drugs. Vulnerability to problem drug use is multifactorial, but it is predominantly triggered or exacerbated by adverse childhood experiences (such as food deprivation or domestic violence exposure), traumatic experiences (such as loss of housing), and inadequate medical management of health conditions. Those prone to addiction tend to use substances to self-medicate throughout their lifetime, even to their own detriment. Without a supportive environment, relapse is common. As such, we need broad family-oriented programmes to tackle the social determinants of substance addiction during childhood. In adults, illicit substance use can also be a response to the indignity of insecure housing or incarceration, food and health insecurity, and lack of clean water and sanitation, so these are the factors that must first be tackled to attenuate problem drug use.
Prohibition has not worked. Humane, evidence-based strategies are the only way forward.

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