To serve and protect? Toward a better relationship between drug control policy and public health

The USA has the highest rate of incarceration in the world; over 2 million people are behind bars and another 4.5 million are on probation or parole. The number of incarcerated people in the USA has almost doubled over the last decade [1,2], due at least in part to penally-oriented US drug policies. In their paper [3], Friedman et al. examine the extent to which legal repressiveness – measured through drug-related arrests, police per capita and corrections expenditures per capita – influences HIV infection in 89 major US metropolitan areas. In an elegant analysis, the authors show that their three indices of legal repressiveness had no effect on drug use measures, but all three were associated with higher HIV prevalence. The growing body of literature surrounding policing and HIV risk [3–9] has important implications for both research and policy. In terms of research, there is a need to determine the extent to which the relationship between policing practices and HIV infection is causal, and if so, whether the effect is direct or indirect. Literature exists to support both direct and indirect pathways. Police can have a direct effect on where, with whom, when and how injection drug users (IDUs) administer their dose. Studies from the USA and elsewhere show that police pressure is associated with use of shooting galleries where needles are rented or sold and needle sharing is commonplace [5–7]. Police can also have an indirect effect on HIV risk, for example by discouraging IDUs from utilization of syringe exchange programs (SEPs) [8] or displacing IDUs to areas with limited or no access to SEPs or drug treatment [8,9]. Friedman and colleagues [3] provide yet another piece of evidence that the US war on drugs is having serious, often devastating health effects that can be reduced through public health interventions. The war on drugs, which the USA has prosecuted with single-minded vigor at home and abroad, is a losing proposition. Yet one can hardly conclude that abandoning collective efforts to reduce harmful drug consumption would produce a net benefit to society: drugs, both legal and illegal, can carry significant health hazards. In legal and illegal markets, the profit motive drives producers and sellers to market as effectively as possible. Thus, the issue is not whether to continue drug control efforts, but which sorts of efforts, and in what combination, will have the greatest positive impact on drug abuse and the type, severity and distribution of harms. Experiences with nicotine, alcohol and heroin all have something to teach us about regulatory models and their health effects. The prescription for policy is not obvious. Reducing demand, incarcerating fewer drug users, improving and expanding harm reduction services and drug treatment options are all sensible pieces of a new drug policy, but we have no more consensus about what policies work than we do on the question of which ones do not. Moreover, we do not have one global drug problem but many, varying with place, culture, economic conditions and so on. Drug policy poses the sort of problems for which solutions are unlikely to emerge from top-down or expert-driven processes. Instead, a decentralized process of local, state and national experimentation is required to identify policies that protect both public order and public health. In the USA, we have the tradition of policy development by states, which, as Supreme Court Justice Brandeis once suggested, can act as laboratories to ‘try novel social and economic experiments without risk to the rest of the country’ [10]. Internationally, we have independent nations with the capacity to develop and test their own approaches to healthy drug policies over the next few decades. What stands in the way of such a process? Attitudes are clearly one such barrier. Dogmatism on drug policy is rife, and dogmatism of any type is antithetical to innovation. Drugs and drug policies have been deeply divisive issues for a long time. There are people on all sides of the debate whose minds will not change in the short term, but a decentralized process of policy experimentation may maximize the chances that open-minded people of good will can form and influence policy. Such a process will need to be open to evidence, and accept the validity of views that are not readily harmonized: about the risks and benefits of drugs, about individual rights and social order, about the nature of drug use as an illness and sometimes, a choice. Another barrier is the law, which now works to prevent serious policy experimentation. In the USA, the Supreme Court has upheld the power of the national government to stifle drug policy innovation in the states, most recently in a decision to back the Attorney General's interference with California's medical marijuana scheme [11]. Internationally, the interlocking set of treaties on drug policy, which have been drafted to place rather strict limits on states trying to move away from a prohibitionist approach, are a tool for pressure on new policy initiatives, and are difficult to change [12]. Friedman and colleagues [3] have added to the body of evidence showing the need for a more health-oriented approach to drug control policy. Indeed, the evidence is one more reason to rethink the relationship between policing and public health more broadly [13]. What we need now is not agreement on a specific policy solution, but consensus on the need for a sustained period of health-law enforcement co-operation and vigorous, creative policy development. Acknowledgements Dr Strathdee acknowledges support from the foundation for the Harold Simon Chair, as well as grants from the National Institute on Drug Abuse (DA014499, DA09225 and DA019829). Professor Burris acknowledges support from the National Institute of Drug Abuse (DA17002).