Fifty years into the world “war on drugs”, the drugs are winning. Global levels of drug use and production, as well as drug-related deaths and incarcerations, are at all-time highs and experts say the fight against the epidemic has been a “total failure”.
Leading proponents of drug-policy reform who gathered at the International Harm Reduction Conference in Melbourne last week said it was clear that the world needed to adopt a new approach.
“The irony of the profound failure of the war on drugs is that it has actually driven the illicit production of more and more substances and led to more toxic drug supply,” said Naomi Burke-Shyne, executive director of Harm Reduction International, the UK-based drug-policy justice NGO that convened the conference.
“To save lives, we must offer overdose prevention and supervised space for people injecting drugs, along with pill testing, to understand the potency, adulteration or toxicity of a substance,” she said.
Health Policy Watch reports that Helen Clark, chair of the Global Commission on Drug Policy and former Prime Minister of New Zealand, called the war on drugs “a complete failure”.
“It is completely counterproductive. It has failed, and we need to try new approaches,” she told the conference, saying that worldwide, drug use was escalating, with millions imprisoned for drug possession and millions more unnecessarily contracting HIV and hepatitis C because of lack of access to effective harm reduction measures.
“We’re not dealing with new issues here,” she said, “but with totally inappropriate and wrong ways of tackling them.”
Criminalisation has long been a hallmark of the war on drugs, but advocates say the practice of confining high-risk populations to prisons actually multiplies the risk of infection.
Criminalising drug use “only serves to overpopulate the prison services and the risks, therefore, multiply”, said Kgalema Motlanthe, former president of South Africa and a commissioner at the Global Commission on Drug Policy. “Those who are literally sleeping over each other in prisons that are overcrowded end up really being exposed to more risks.”
Research from the French Institute of Health and Medical Research (INSERM) showed that people who inject drugs in medically supervised settings were less likely to overdose, share needles, report emergency room visits, or develop abscesses, compared with people without access to such facilities.
Their 12-month study is the first-ever controlled trial on the efficacy and impacts of medically supervised injection rooms – hygienic facilities where addicts can inject drugs supervised by medical staff.
They are government-operated, stocked with drug-testing kits and overdose-prevention medications like naloxone, and allow patients to access other health services like mental health support, blood tests and essential primary care.
The study compared the behaviour of people who injected drugs in the supervised injection sites in Paris and Strasbourg to users in Bordeaux and Marseille, where no centres exist. Apart from the benefits to health and overdose reduction, the study found that people with access to supervised injection services were also far less likely to inject in public spaces or commit crimes.
Today, 16 countries officially operate medically supervised injection rooms, including The Netherlands, the US, Canada, Australia and Switzerland – which pioneered the approach by legalising prescription heroin in 1994.
Results from a control study at New York City’s new supervised injection site are expected by the end of June.
Fentanyl fears multiply
As the consequences of the push by Purdue Pharma to mainstream the prescription of high doses of the opiate Oxycontin continues to ravage the US, a new lethal drug has taken over: fentanyl.
The synthetic opiate, which is up to 50 times stronger than heroin and 100 times stronger than morphine, was identified in 66% of US drug overdose deaths in 2021. The growing infiltration of fentanyl in the country’s drug supply has resulted in many users unintentionally taking the drug – with deadly consequences.
In New York City, where drug overdose deaths have nearly tripled since 2015, only 18% of people who inject drugs reported intentional fentanyl use, yet more than 80% tested urine-positive for fentanyl.
Fentanyl is used by cartels and drug-smuggling networks to cheapen their up-front costs for heroin, which is more expensive to produce. Cutting heroin with fentanyl greatly increases their profit margins at the cost of heightened danger for users unaware their supply is mixed with a far more potent drug.
More than 1 500 people die from opiate overdoses every week in the US. In the year leading up to March 2022, 110 366 people lost their lives to drug overdoses – nearly 20 times the per capita death rate of the European Union.
Needle-borne diseases critically underfunded
Medical advances in recent years have made hepatitis C highly treatable. While the medications are affordable in most low- and middle-income countries, chronic underinvestment in hepatitis C and harm prevention programmes have handicapped efforts to eradicate the disease.
Last week, UNITAID announced a $31m commitment to prevent hepatitis C in high-risk populations like people who inject drugs and prisoners. The investment represents a 20% increase in global harm prevention efforts, which UNITAID said would also help curb the transmission of other blood-borne diseases like HIV.
While people who inject drugs make up just 10% of the world’s 58m people infected with hepatitis-C, injecting drugs contribute to 43% of new infections: 80% of people infected with hepatitis-C live in low- and middle-income countries.
Study details
Impact of drug consumption rooms on non-fatal overdoses, abscesses and emergency department visits in people who inject drugs in France: results from the COSINUS cohort
P Roux, M Jauffret-Roustide, C Donadille, L Briand Madrid, C Denis, I Célérier, C Chauvin, N Hamelin, G Maradan, M P Carrieri et al.
Published in the International Journal of Epidemiology in April 2023
Abstract
Background
The effectiveness of drug consumption rooms (DCRs) for people who inject drugs (PWID) has been demonstrated for HIV and hepatitis C virus risk practices, and access to care for substance use disorders. However, data on other health-related complications are scarce. Using data from the French COSINUS cohort, we investigated the impact of DCR exposure on non-fatal overdoses, abscesses and emergency department (ED) visits, all in the previous 6 months.
Methods
COSINUS is a 12-month prospective cohort study of 665 PWID in France studying DCR effectiveness on health. We collected data from face-to-face interviews at enrolment, and at 6 and 12 months of follow-up. After adjusting for other correlates (P-value < 0.05), the impact of DCR exposure on each outcome was assessed using a two-step Heckman mixed-effects probit model, allowing us to adjust for potential non-randomization bias due to differences between DCR-exposed and DCR-unexposed participants, while taking into account the correlation between repeated measures.
Results
At enrolment, 21%, 6% and 38% of the 665 participants reported overdoses, abscesses and ED visits, respectively. Multivariable models found that DCR-exposed participants were less likely to report overdoses [adjusted coefficient (95% CI): −0.47 (−0.88; −0.07), P = 0.023], abscesses [−0.74 (−1.11; −0.37), P < 0.001] and ED visits [−0.74 (−1.27; −0.20), P = 0.007].
Conclusion
This is the first study to show the positive impact of DCR exposure on abscesses and ED visits, and confirms DCR effectiveness in reducing overdoses, when adjusting for potential non-randomisation bias. Our findings strengthen the argument to expand DCR implementation to improve PWID injection environment and health.
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