Врачи должны требовать политики, базирующейся на этике и научных доказательствах
Такую статью опубликовала главный редактор BMJ Fiona Godlee. Вот ее текст:
«People have always consumed psychoactive substances, risking harm.1 2 A quarter of a billion adults—one in 20 worldwide—took an illegal drug such as cannabis, cocaine, or heroin in 2014.3 A quarter of UK 15 year olds are estimated to have ever taken an illegal preparation of unknown quality and potency,4 and most street sex work and much acquisitive crime funds drug taking.5 6
Three United Nations treaties, the oldest from 1961, seek to “advance the health and welfare of mankind” by prohibiting the non-medical use of some drugs. To this end, countries criminalise producers, traffickers, dealers, and users at an annual cost of at least $100bn.7
But the effectiveness of prohibition laws, colloquially known as the “war on drugs,” must be judged on outcomes. And too often the war on drugs plays out as a war on the millions of people who use drugs, and disproportionately on people who are poor or from ethnic minorities and on women.1
Prohibition and stigma encourage less safe drug consumption and push people away from health services.1 Sharing of injection equipment has led to huge epidemics of bloodborne infection, including HIV and hepatitis C.1 And just one in every six of the 29 million people worldwide with a drug use disorder received treatment in 2014.3
The ideological goal of a “drug-free world” encourages ideologically driven medical practice. For example, patients in Crimea died after the Russian invasion because they were forced to stop taking methadone, which is viewed as opioid misuse and illegal in Russia.8 The UK government’s promotion of abstinence at the expense of proved maintenance treatment may have contributed to a doubling in opioid related deaths between 2012 and 2015.9
Drug control policies effectively deny two thirds of the world’s population—more than five billion people—legitimate access to opioids for pain control.10 And they impede research into medical use of cannabis and other prohibited drugs despite evidence of potential benefit.11
All wars cause human rights violations, and the war on drugs is no different. Criminally controlled drug supply markets lead to appalling violence—causing an estimated 65 000-80 000 deaths in Mexico in the past decade, for example.12 Mandatory sentencing for even minor drug offences has helped the United States attain the highest rate of incarceration in the world.13 The Philippines has seen 5000 extrajudicial killings since July, after President Rodrigo Duterte’s call for vigilantism against drug dealers.14
It is no surprise, then, that there have been calls for reform, including from the World Health Organization, UNAIDS, the UN Development Programme, and the UN human rights agency,15 as well as non-governmental organisations,16 former heads of state,10 UK parliamentarians,17 some law enforcers, and medical journals.
At a UN general assembly in April, many countries asked for health and human rights to be prioritised over punitive responses.
Many countries have removed criminal penalties for personal drug possession. Portugal replaced criminal sanctions for drug use with civil penalties and health interventions 15 years ago.10 The UK Psychoactive Substances Act 2016 criminalises importation, production, and sale but not use of these substances.
Jurisdictions such as Canada, Uruguay, and several US states, now including California, and have gone further, to allow regulated non-medical cannabis markets, retaking control of supply from organised crime. The Netherlands has tolerated regulated cannabis sales for decades.
Of course, drug use without medical indication has particular risks, and harmful substances should not be available without restriction. Tough enforcement of prohibition surely reduces drug use but at what cost? Jurisdictions with low drug use—for cultural reasons perhaps—have less impetus for change. But where harms are higher there is an imperative to investigate more effective alternatives to criminalisation of drug use and supply.
This year a thorough review of the international evidence concluded that governments should decriminalise minor drug offences, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible, and scientifically evaluate the outcomes to build pragmatic and rational policy.1
Prescription drugs, alcohol, and tobacco provide lessons to inform models of regulation.18 Different drugs with different harms in different contexts may need different approaches. And any change must be supported by investment in evidence based education, counselling, and treatment services to deter drug use and increase safety among users.
Health should be at the centre of this debate and so, therefore, should healthcare professionals. Doctors are trusted and influential and can bring a rational and humane dimension to ideology and populist rhetoric about being tough on crime.
Some doctors’ organisations have called loudly for change, including International Doctors for Healthier Drug Policies and the UK Royal Society for Public Health and the Faculty of Public Health.19 Recent BMA policy is for the Department of Health to take responsibility for UK drug policy and for “legislative change” to prioritise treatment over punishment of drug users.20 But such calls are far from universal—and far from loud enough.
Doctors and their leaders have ethical responsibilities to champion individual and public health, human rights, and dignity and to speak out where health and humanity are being systemically degraded. Change is coming, and doctors should use their authority to lead calls for pragmatic reform informed by science and ethics.
Footnotes
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Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
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Provenance and peer review: Commissioned; externally peer reviewed.
References
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