Scripta Varia

How to stop the drug epidemic

Dr. Robert L. DuPont, M.D.
President
Institute for Behavior and Health, Rockville, MD, USA

            This historic meeting, under the inspired leadership of His Holiness Pope Francis and Her Majesty Queen Silvia of Sweden, is a precious opportunity to stop the modern drug epidemic. I am particularly pleased to participate in this workshop as a representative of the United States because today the Office of the US Surgeon General released Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, the first report of its kind on the drug epidemic. This cruel epidemic enslaves and degrades humanity worldwide.

            The modern drug epidemic began six decades ago with the mistaken idea that drug use is a relatively safe way to have fun. The use of chemicals that stimulate brain reward for the purpose of pleasure is “recreational pharmacology”. Although humans have a long history of drug use, prior to the modern epidemic drug use was confined to relatively small segments of populations and usually limited to a single drug used by less reinforcing routes of administration. Now large populations, especially young people, are exposed to many drugs by powerful routes of administration such as smoking and injecting. Drugs are spread by an increasingly sophisticated, global and illegal drug supply chain that effectively links drug producers to drug users and by a growing global tolerance for drug use. The drugs themselves are changing from a few established agricultural products to an ever-changing and long list of purely synthetic drugs produced in mobile, easily concealed, clandestine laboratories. The distribution of drugs is changing to make drug delivery increasingly fast and anonymous with simple Internet orders and sales in local shops.

The 19th century saw a dramatic increase in drug problems, particularly the use of opium in Asia, and later heroin and cocaine in the United States. In the early 20th century the international community began a drug control system to counter the emerging drug threat. This system separated medical drug use from nonmedical drug use, tightly controlling medicines with abuse potential and criminalizing the use and sale of drugs for nonmedical uses. Drugs with abuse potential were to be used only for medical or scientific purposes. The international drug control system was embedded in formal treaties and in institutions managed by the United Nations. The treaties include the Single Convention on Narcotic Drugs of 1961, the Convention on Psychotropic Substances of 1971, and the United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988. Each has been signed and ratified by virtually every country in the world. The treaties are monitored by the International Narcotics Control Board (INCB) and overseen by the Commission on Narcotic Drugs (CND), a subsidiary body of the UN. The United Nations Office on Drugs and Crime (UNODC) is an agency voluntarily funded by UN member states to advance drug control programs around the world.

This global drug control system was almost universally supported until recently when an alternative drug policy was proposed by some in the United States and Western Europe. This perspective, labeled “harm reduction”, rejected criminal prohibition of drug use and sale and instead proposed drug legalization. Rather than embrace no-use drug control strategies, harm reduction seeks to reduce some of the negative consequences of drug use without stopping the drug use itself. The three fundamental UN treaties which embody the long standing worldwide advocacy for the drug-free standard now are a primary target of the harm reduction movement.

Although cannabis, the world’s most widely used illegal drug, has been in the forefront of cultural changes in drug use, the harm reduction approach to drug policy extends to all drugs used for pleasure. It blurs the line separating medical drug use from nonmedical drug use, labels recreational drug use “self-medication” and claims medical benefits for many abused drugs. Today’s global drug policy debate is between those who promote the drug-free, no-use standard for nonmedical drug use and those who seek to treat drugs from cannabis to heroin with a “tax and regulate” legal approach, similar to how alcohol and tobacco are managed.

The acceptance of recreational pharmacology is a misguided public health policy. Brain science shows that the widely abused drugs stimulate normal brain reward many times more intensely than natural rewards such as sex and eating.[1] To expose populations to drugs of abuse, especially youth whose developing brains are especially vulnerable, is to encourage the chemical slavery of addiction. This observation is not politics or ideology; it is biology. The elucidation of the brain effects of drugs of abuse is a crowning achievement of modern neuroscience and of the US National Institute on Drug Abuse (NIDA) of which I am proud to have served as the first Director.

The bedrock question of drug policy is whether the principal goal of drug policy is to limit recreational drug use or to accept it, or even to promote it. A successful model of an effective and humane restrictive drug policy exists. It can be adopted worldwide. It shows the way to strongly discourage recreational drug use, to effectively promote both drug prevention and treatment and to sharply limit the use of incarceration. It is a strategy that was developed in response to an epidemic of intravenous drug use in Stockholm, Sweden in the late 1960s. At first the Swedes tried what we now call harm reduction. They encouraged physicians to prescribe amphetamines and opiates to addicted patients to wean them off illegal drugs and to keep them away from criminal drug dealers. A psychiatrist working with the Stockholm police, Professor Nils Bejerot, observed what next happened.[2] The addicts, provided drugs by their physicians, did not stop using drugs. Worse yet, they sold many of the drugs that were prescribed to them to other drug users. In other words, they used their prescribed drugs to spread the drug epidemic. Professor Bejerot, in response to what he saw happening, conceived a new way of responding to the drug problem. He observed that Sweden could never treat its way out of this epidemic. This phrase has an eerie resonance with today’s common mantra that countries cannot incarcerate or arrest their way out of the epidemic. In truth, both are correct. Sweden’s response was to develop over many decades a program of active discouragement of recreational drug use backed by a criminal justice system that promotes treatment and insists on abstinence. This approach is at the core of the Swedish drug policy. It is widely supported across the broad range of Swedish politics. This drug policy results in low levels of youth drug use and low levels of incarceration. It has a strong drug-free foundation. It uses health care and the criminal justice system working together to emphasize both drug prevention and drug treatment while limiting the use of incarceration for drug use.

A similar approach, which is increasingly used in the United States and abroad, links treatment and the criminal justice system to discourage nonmedical drug use. I call this approach the “New Paradigm”.[3] [4] The New Paradigm shows the path to make substance abuse treatment more effective at promoting long-term drug-free recovery while reducing incarceration. It includes quality substance abuse treatment, close monitoring to identify relapse and to provide immediate intervention, with strong links to peer-based recovery support. This recovery model has been pioneered by the state physician health program (PHP) system of care management in the United States.[5]

The New Paradigm which focuses on helping drug-involved persons both within and outside of the criminal justice system find a path to lasting recovery is only one part of an effective global drug policy. The fact that nearly all substance use disorders can be traced to adolescence, when the brain is still developing and is particularly vulnerable to addiction, makes prevention a high priority for future drug policy worldwide. Embracing the clear goal, based on brain science, of no use of alcohol, tobacco, cannabis or other drugs by youth for reasons of health is the foundation of improved prevention efforts.

It is no accident that this workshop is cohosted by HM Queen Silvia of Sweden. She has tirelessly devoted herself for decades to youth drug prevention. Her personal dedication and leadership has sparked impressive drug prevention programs worldwide. Queen Silvia’s voice has been raised to support strong new efforts to discourage drug use and promote healthy lives, especially for young people who are disadvantaged. The Swedish organization, Mentor International, has carried this youth prevention message to many countries, including the United States, under the impressive leadership of Yvonne Thunell.

 We owe His Holiness Pope Francis a tremendous debt of gratitude for bringing new energy and a focus on drug prevention to the world’s attention. The clarity of his statements and his determination to reduce this serious global problem are unmistakable. Using his unique authority and harnessing the uniquely high esteem in which he is held by people of all faiths, as well as those of no faith, Pope Francis has steadfastly promoted living drug-free, targeting youth but not only youth. His message, rooted in his faith, is compelling. There are no other leaders that have the clarity of message and the authority of faith that His Holiness Francis brings to the modern drug epidemic. His leadership inspires our work and makes our meeting particularly important. While there have been many impressive and useful meetings on drug policy in the past, this workshop is very special because of its sponsorship.

Drug policy benefits from being rooted in a strong foundation of human rights and fundamental values, both human and divine. The world needs to hear that nonmedical drug use creates a modern slavery, a slavery that robs millions of people of their dignity as well as their health. Drug use creates enormous safety threats including on the world’s roads and highways and it harms families, education and productivity.

The drug epidemic can be effectively and humanely turned back with a strong commitment to promoting drug-free lives and using better strategies for drug prevention and treatment, including strategies that link the areas of health and criminal justice to accomplish goals that neither can achieve alone. These new strategies are rooted in the family and faith communities. Fashioning these new drug strategies is a significant challenge of the 21st century. The international community can meet this challenge by building on its past commitment that rejects recreational pharmacology. The United Nations, with its existing drug-related treaties and organizations, must serve as the foundation of these new efforts.

Now I call on all of you, my fellow members of this distinguished assembly, to join together to produce a new manifesto – one that is brief and clear. This manifesto must show the way forward to an effective anti-drug, pro-human life strategy that discourages recreational pharmacology. The strategy begins with, but does not end with, discouraging the use of cannabis. The new manifesto also limits the use of incarceration. This approach is rooted in the values and experiences of the two extraordinary sponsors of this important meeting, His Holiness Pope Francis and HM Queen Silvia.

Because the world’s youth are especially at risk we must fulfill the mandate of the UN Convention on the Rights of the Child. This is the only UN treaty that specifically addresses drug use as a threat to human rights. It calls on every nation to ensure that all young people are protected from the harms of drug use and drug sale. It says, “States Parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances.”

We can do no less.

END NOTES

[1] DuPont, R.L., Madras, B.K. & Johansson, P. (2011). Drug policy: A biological science perspective. In J.H. Lowinson & P. Ruiz (Eds.) Substance Abuse: A Comprehensive Textbook (5th ed., pp. 998-1010). Philadelphia, PA: Lippincott Williams & Wilkins. 

[2] Hartelius, J. (2012). Nils Bejerot and the Great Swedish Drug Epidemic. Stockholm, Sweden: Swedish Carnegie Institute and World Federation Against Drugs.

[3] Institute for Behavior and Health, Inc. (2014). The New Paradigm for Recovery: Making Recovery – and Not Relapse – the Expected Outcome of Addiction Treatment. Rockville, MD: Author. Available at www.ibhinc.org

[4] DuPont, R.L. & Humphreys, K. (2011). A new paradigm for long-term recovery. Substance Abuse, 32(1), 1-6.

[5] See e.g., DuPont R.L., McLellan A.T., White W.L., Merlo L., and Gold M.S. (2009). Setting the standard for recovery: Physicians Health Programs evaluation review. Journal for Substance Abuse Treatment, 36(2), 159-171; McLellan, A.T., Skipper, G.E., Campbell, M.G. & DuPont, R.L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal, 337:a2038.

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