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What would evidence-informed drug policies look like?

Tom Babor and colleagues [1] do for illicit drugs what Alcohol Policy and the Public Good [2] did for alcohol policy: they provide government policy makers with evidence-informed advice on the probable consequences of adopting different policies towards the prevention and amelioration of illicit drug-related harm. This is an important collaborative effort by an impressive assembly of international researchers with expertise in the major disciplines relevant to drug policy. The authors begin by discussing the role of research evidence in drug policy. In formulating drug policies, they argue, governments must strike a balance between important social values that are often in conflict, e.g. protecting public health, keeping public order, protecting young people from drug use while respecting the civil liberties of adults and so on. Given these competing moral values, drug policies should aspire to be ‘evidenceinformed’ rather than ‘evidence-based’. Babor and colleagues make clear that there is no single drug policy masterstroke that can be implemented in all countries, because the ecologies of illicit drug problems differ so much between countries. Any country’s ‘drug problem’ will be affected by: the mix of drugs that are used; users’ preferred routes of administration; the social characteristics of those citizens who use these drugs; the major health consequences of this use; the impact of drug users’ behaviour on the broader community; the cultural acceptability of different types of drug use and the social and policy responses adopted to deal with them; and so on. None the less, some broad generalizations can be made. Opioids are the major drugs of concern in many developed countries. Their use can cause fatal and nonfatal overdoses and human immunodeficiency virus (HIV) infections if users share contaminated injection equipment. Opioid users can also affect non-users adversely by engaging in property crime to fund their drug use; using violence to settle disputes around drug markets; and generating income that criminals who supply these drugs use to corrupt public officials. The adverse consequences on non-users often receive the greatest weight in public policy debate, a fact that often makes it easier to persuade governments to fund drug treatment because it reduces crime, rather than because it improves the wellbeing of drug users. Many developed societies justify the decision to criminalize the use of these drugs by a utilitarian argument, namely, that benefits of deterring people from using these drugs more than offset any increase in the harms experienced by the minority of people who use despite their illegality. As Babor et al. also make clear, a major social cost of this policy is the creation of criminally controlled black markets in which violence is the dominant method of conflict resolution. For more than a century these illegal markets have proved remarkably resilient to repressive policies by national governments and international organizations. The popularity of societal policies towards drug problems is often related inversely to evidential support for their efficacy. Supply control remains the major policy investment in most developed countries, despite the lack of research into its effectiveness. As Babor and colleagues argue, there are rapidly diminishing returns from increased funding for drug law enforcement, beyond the basic enforcement of laws against drug selling. There is arguably stronger support for the decriminalization of cannabis use as one way of reducing some of the societal and personal costs of prohibition. The evidence—the limitations of which are acknowledged in the book—suggests that decriminalization reduces some of the social costs imposed upon users without producing any large increases in cannabis use [3]. This is probably because there is, in fact, very little difference in practice between states that nominally criminalize cannabis use and those who do not; the former often only enforce the law in a discriminatory way [3]. This modest policy change continues none the less to be opposed strenuously in many countries. The prevention of illicit drug use by young people is another widely shared social goal that is often pursued using the least effective means. As Babor et al. [1] argue, the most effective prevention programmes—those that do not solely target drug use—have modest effects on drug use. Policy makers prefer to fund programmes that warn young people about the dangers of drug use, even when they have been found repeatedly to be ineffective [e.g. Drug Abuse Resistance Education (DARE) in the United States]. This is because, one suspects, that the target audience for these programmes is actually the concerned parents of adolescent children. The best-supported interventions to reduce drugrelated harm are the most contentious: opioid substitution treatment (OST) and needle and syringe programmes to prevent HIV infection. OST is often opposed by advocates of abstinence-orientated approaches who dismiss evidence of efficacy from randomized controlled trials while appealing to even weaker evidence for the efficacy of the treatments they prefer, usually on moral grounds. Babor et al. argue cogently that abstinence-orientated and harm reduction-orientated services for problem drug EDITORIAL doi:10.1111/j.1360-0443.2010.03046.x