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Defining and Implementing a Public Health Response to Drug Use and Misuse

Policy Date: 11/5/2013
Policy Number: 201312

Related APHA Policy Statements

APHA Policy Statement 8817 – A Public Health Response to the War on Drugs: Reducing Alcohol, Tobacco and Other Drug Problems among the Nation’s Youth[1]

APHA Policy Statement 7121 – Substance Abuse as a Public Health Problem[2]

APHA Policy Statement 9123 – Social Practice of Mass Imprisonment[3]

APHA Policy Statement 9415 – Syringe and Needle Exchange and HIV Disease[4]

APHA Policy Statement 2002-12 – Syringe Prescription to Reduce Disease Related to Injection Drug Use[5]

APHA Policy Statement 8931 – Illicit Drug Use and HIV Protection[6]

APHA Policy Statement LB-12-02 – Preventing Overdose Through Education and Naloxone Distribution[7]

APHA Policy Statement 7015 – Narcotic Epidemic[8]

APHA Policy Statement 6907 – Drug Abuse[9]

Abstract

Drug use and misuse continue to create public health challenges in the United States, leading to overdose deaths, HIV and hepatitis C infections, and other chronic health conditions. Public health approaches offer effective, evidence-based responses, but some of the most effective interventions are not currently allowed in the United States owing to outdated drug laws, attitudes, and stigma. Substance misuse treatment is too often unavailable or unaffordable for the people who want it. A criminal justice response, including requiring arrest to access health services, is ineffective and leads to other public health problems. This policy statement calls on federal, state, and local elected officials and agency staff, health care professionals, community health workers, and other stakeholders to support a full reorientation toward a health approach to drug use, including the evaluation of promising practices from other countries for domestic implementation. In addition, it recommends ending the criminalization of drugs and drug consumers, prioritizing proven treatment and harm reduction strategies, and expanding (and removing barriers to) treatment and harm reduction services, including repealing any bans on funding syringe access programs.

Problem Statement

As recognized in APHA policy 8817(PP), the current “war on drugs” is a “severely flawed” approach based on “misplaced priorities and strategies.”[1] In the more than 40 years since President Richard Nixon declared a war on drugs in 1971, the United States has spent an estimated $1 trillion on drug war policies.[10–12] Yet national rates of drug use have remained relatively stable, albeit with some minor fluctuations.[13–15] Meanwhile, drug-related harms, such as the spread of blood-borne diseases[16] and accidental overdose deaths,[17–19] have grown severely worse. Overdose is second only to motor vehicle accidents as a leading cause of injury-related death in the United States.[20]

The war on drugs is a major driver of the HIV/AIDS pandemic among people who inject drugs and their sexual partners. The criminalization of people who use illicit drugs, along with the mass incarceration of people for nonviolent drug law violations, has restricted access to sterile syringes and opioid substitution treatments, and aggressive law enforcement practices have promoted risky practices that facilitate the spread of HIV/AIDS and other diseases while creating barriers to drug and HIV treatment.[16]

Failure to adopt proven harm reduction measures has significantly increased the public health harms of drug misuse. For example, legal and bureaucratic barriers still prevent people who inject drugs from accessing sterile syringes in the United States, despite decades of evidence proving that syringe access programs help to reduce the spread of diseases.[21–25] In fact, the US Congress recently reinstated a federal ban on funding of sterile syringe programs, after finally lifting the 2-decade-long ban just 3 years ago. The federal ban is estimated to have cost thousands of lives and hundreds of millions of dollars.[26] Perhaps not surprisingly, fewer than one-third of people who inject drugs surveyed by the Centers for Disease Control and Prevention (CDC) had been reached by an HIV intervention.[27] Furthermore, while the United States has relatively high HIV prevalence rates among people who inject drugs (at roughly 14%), countries that have consistently and comprehensively provided harm reduction and effective treatment options, such as syringe access and opioid substitution therapies, have rates that are far lower; in some of these nations, HIV prevalence among people who inject drugs is 1% or lower.[28]

Public funds are routinely prioritized for drug law enforcement instead of proven HIV prevention strategies. While drug war budgets have generally increased, effective treatment programs are chronically underresourced, and in the United States practically no federal funds are invested in programs that will reduce harms related to injection drug use.[29] The stigma associated with seeking and accessing drug treatment is also a barrier.[30–32]

Criminalization of substance use further stigmatizes people who use drugs, making it more difficult to engage people in health care and other services, a tendency that is often compounded by sociocultural factors associated with problematic drug-using populations, such as fear, lack of information and education, general physical and mental health problems, homelessness, and incarceration.[30–35] Criminalization also exacerbates social marginalization and encourages high-risk behaviors such as poly-drug use, binging, and injecting in unhygienic, unsupervised environments.[36] Aggressive campaigns to arrest and incarcerate people who use drugs only increase drug-related deaths, primarily because people are too afraid to call 911 if they witness an overdose.[37–41] Harsh mandatory minimum sentencing laws have also led to increased overdose deaths, because the illicit drug market encourages the sale of more potent forms of prohibited drugs.[42] Drug law enforcement has been shown to increase overdose mortality, while the provision of medication-assisted treatment has been found to have the opposite effect.[43] Moreover, aggressive drug law enforcement has been shown to increase levels of violence related to drug markets: a systematic review revealed that “contrary to the conventional wisdom that increasing drug law enforcement will reduce violence, the existing scientific evidence strongly suggests that drug prohibition likely contributes to drug market violence and higher homicide rates.”[44]

The domestic drug war has also been an engine of mass incarceration. With less than 5% of the world’s population but nearly 25% of its incarcerated population, the United States imprisons more people (and at a higher rate) than any other nation in the world,[45] largely as a result of the war on drugs. More than 1.5 million drug arrests occurred in the United States in 2011. The vast majority—more than 80%—were for possession only, and half were for marijuana law violations.[46] Seventeen percent of people in state prisons and nearly half (48 percent) of those in federal prisons were incarcerated for a drug law violation in 2011.[47] Roughly 500,000 Americans are behind bars on any given night for a drug law violation,[47,48] 10 times the total in 1980.[49,50]

Misguided drug laws and disproportionate sentencing requirements have produced grossly unequal outcomes for communities of color. Although rates of drug use and selling are comparable across racial and ethnic lines, Blacks and Latinos are far more likely to be criminalized for drug law violations than Whites.[13,51–53] People of color experience discrimination at every stage of the judicial system.[54] This is particularly the case for drug law violations. Blacks make up 13% of the US population[55] and are consistently documented by the US government to use drugs at rates similar to those among people of other races.[13] However, Blacks account for nearly one-third of drug arrests[46] and roughly 45% of those incarcerated in state and federal prisons for drug law violations.[47,56] From 1980 to 2007, Blacks were arrested for drug law violations nationwide at rates 3 to nearly 6 times higher than Whites.[57] A recent report by the American Civil Liberties Union, for example, showed that Blacks were arrested for marijuana possession offenses at roughly 4 times the rate of Whites, although rates of use are essentially no different.[58] Furthermore, Blacks and Latinos tend to be arrested for crimes that hold more serious punishments, such as selling drugs rather than just possessing them.[51,59–61]

Mass incarceration resulting from the war on drugs has devastated many families and communities. A 2012 national study published in the American Journal of Public Health showed that Black youths were less likely than Whites to use or sell drugs but more likely to be arrested; the researchers concluded that “[r]acial disparities in adolescent arrest appear to result from differential treatment of minority youths and to have long-term negative effects on the lives of affected African American youths.”[62] Approximately 2.7 million children are growing up in US households in which one or more parents are incarcerated. One in 9 Black children have an incarcerated parent, as compared with one in 28 Latino children and one in 57 White children.[63]

Punishment for a drug law violation is not only meted out by the US criminal justice system but also perpetuated by policies denying child custody, voting rights, employment, business loans, trade licensing, student aid, and public housing and other public assistance to people with criminal convictions. In addition, criminal records are cited as justification for deporting legal residents and barring other noncitizens from visiting the United States.[64] Even if a person does not face jail or prison time, a drug conviction record—particularly a felony—often imposes a lifelong ban on many aspects of social, economic, and political life. Such exclusions create a permanent second-class status for millions of people and, as with drug war enforcement itself, fall disproportionately on people of color.[64] According to a 2008 article published in the American Journal of Public Health, “[t]he popular war on drugs translates to a war on people of color in terms of their overall health and well-being…. Communities of color face an escalating public health problem created by our society’s solution to imprison those arrested for nonviolent drug offenses.”[65]

APHA recognizes that the United States leads the world in incarceration and that the war on drugs is a major driver of mass incarceration, particularly among people of color. APHA policy 9123 (Social Practice of Mass Imprisonment) states that APHA has “a long history of concern and activity aimed at correcting inadequacies in health conditions in correctional institutions, and is aware that prison health and community health are intimately related elements of public health in the US with…million[s] [of] individuals released annually from custody to community.”[3] It notes that “APHA has long-defined drug abuse as a public health problem rather than a criminal justice problem [and] called for drug treatment to be available for all who request it.”[3] It further “condemns the social practice that sanctions mass imprisonment rather than defining and changing those conditions that engender and accompany criminal behavior, including drug addiction,” and calls for alternatives to incarceration.[3]

In 2009, in the wake of the XVIII International AIDS Confer¬ence in Vienna, Austria, the international scientific and public health com¬munity issued the Vienna Declaration, a statement seeking to improve community health and safety by calling for the incorporation of scientific evidence into illicit drug policies. The Vienna Declaration calls for an acknowledgment of the limits and harms of drug prohibition, for ending the criminalization of people who use drugs, and for drug policy reform to remove barriers to effective HIV prevention, treatment, and care.[66]

Since then, an increasing number of prominent figures in and sectors of society have raised their voices against policies that criminalize people who use drugs, in favor of robust, health-centered alternatives. In 2011, former presidents Fernando Henrique Cardoso (Brazil), Cesar Gaviria (Colombia), and Ernesto Zedillo (Mexico) joined with former UN secretary general Kofi Annan, former US secretary of state George Shultz, former Federal Reserve Board chairman Paul Volcker, former Swiss president Ruth Dreifuss, and other members of the Global Commission on Drug Policy (GCDP) to launch a landmark report calling for fundamental reforms to national and global drug policies, including (1) acknowledging the failure of the “war on drugs” and its disastrous impact on human rights, violence, and corruption; (2) replacing the criminalization and punishment of people who use drugs with the offer of health and treatment services to those who need them; and (3) encouraging governments to experiment with models of legal regulation to undermine the power of organized crime and safeguard people’s health and security.[67] In advance of the International AIDS Conference in Washington, DC, the GCDP issued a second report in June 2012, The War on Drugs and HIV/AIDS, which was successful in exposing the causal links between the HIV pandemic and the criminalization of drug use.[16]

The GCDP has since been joined by former presidents Jorge Sampaio (Portugal), Alexander Kwasniewski (Poland), and Ricardo Lagos (Chile). Former US presidents Jimmy Carter and Bill Clinton have echoed most or all of the commission’s recommendations, as has former president Vicente Fox of Mexico. In 2013, the GCDP issued a third report, The Negative Impact of the War on Drugs on Public Health: The Hidden Hepatitis C Epidemic, which again called for the decriminalization of drug use and the expansion of proven, science-based solutions to reduce hepatitis C, including sterile syringe access, supervised injection facilities, and heroin prescription programs.[68]

Against this backdrop, the Organization of American States issued a groundbreaking, 2-part report in May 2013 in which it critically examined the current war on drugs and considered new approaches for the future, giving equal weight to options such as decriminalization and harm reduction.[69,70] Among the report’s conclusions is the urgent need for a “public health approach” to address drug problems, and it specifies that “the decriminalization of drug use needs to be considered as a core element in any public health strategy.”[70]

In June 2013, Human Rights Watch publicly condemned “[n]ational drug control policies that impose criminal penalties for personal drug use” as a violation of human rights, stating that the “criminalization of drug use has undermined the right to health” because “[f]ear of criminal penalties deters people who use drugs from using health services and treatment, and increases their risk of violence, discrimination, and serious illness.” Its statement continues, “Criminal prohibitions have also impeded the use of drugs for legitimate medical research, and have prevented patients from accessing drugs for palliative care and pain treatment,” a harm well documented in the literature.[71] It concludes by urging governments to “rely instead on non-penal regulatory and public health policies.”[72] And in November 2012, Colorado and Washington became the first political jurisdictions in the world to vote to permit the legal regulation of marijuana sales, cultivation, and distribution among adults 21 years of age and older within their borders, and both states are in the process of implementing their new laws in such a way as to strengthen public safety and health to the maximum extent possible.

Joining those distinguished colleagues and peers, APHA agrees that the criminalization of people who use illicit drugs is fueling the HIV epidemic and has resulted in overwhelmingly negative health and social consequences, and that a full policy reorientation is needed.

Proposed Recommendations Statement

APHA policies 7121 and 8817(PP) call for a reorientation of current US drug policies, and APHA also has adopted longstanding policies that support several aspects of a health-based response to drug misuse.[1,2] Policy 8817(PP) urges a “redirection [of] current War on Drugs policies, which are seriously flawed and have little chance of alleviating the serious drug problems facing our society today.”[1]

The present policy statement identifies the following proposals as vital elements of the redirection in US drug policy envisioned by APHA’s existing policy statements, toward the adoption and implementation of a truly public health approach to reducing the harms of drug misuse.

End the criminalization of drug possession and people who use drugs: APHA’s policies 7121 and 8817(PP) recommend the removal of criminal penalties for drug use.[1,2] Policy 7121 first expressed APHA’s belief that people who use drugs should not be criminalized: “[b]ecause substance abuse is viewed primarily as a public health problem, this Association recommends that no punitive measures be taken against the users of alcohol, marijuana, or other substances when no other illegal act has been committed.”[2]

APHA reiterated its belief that drug misuse must be primarily addressed as a public health issue, resolving in policy 8817(PP) that “[s]trict punitive measures should not take priority over drug treatment and prevention goals…punitive measures have only a limited impact on drug use and problem rates and, in many cases, have been shown to have an underlying purpose to discriminate against disadvantaged groups.”[1] Policy 8817(PP) further recommends that US drug policy give “high priority to prevention, treatment and recovery” and that “punitive measures should be used with caution and should play a secondary role.… Particular attention should be given to the special needs of young people and disenfranchised groups [and] caution must be exercised to avoid discriminatory policies.”[1]

Countries that have ended the criminalization of drug use and possession have generally been better able to cope with injection drug–related HIV/AIDS. Decriminalizing drug possession and investing in treatment and harm reduction services can provide several major benefits for public health, including reducing the number of people incarcerated; increasing uptake into drug treatment; reducing criminal justice costs and redirecting resources from criminal justice to health systems; redirecting law enforcement resources to prevent serious and violent crime; addressing racial disparities in drug law enforcement, incarceration, and related health characteristics and outcomes; minimizing stigma and creating a social, cultural, and policy climate in which people who use drugs are less fearful of seeking and accessing treatment, using harm reduction services, and receiving HIV/AIDS services; and protecting people from the wide-ranging and debilitating consequences of a criminal conviction.[36]

Some countries particularly stand out. In 2001, Portuguese legislators enacted a comprehensive form of decriminalization of low-level possession and consumption of all illicit drugs and reclassified these activities as administrative violations.[36] A person caught with personal-use amounts of any drug in Portugal is no longer arrested but, rather, ordered to appear before a local “dissuasion commission” composed of 3 officials (one from the legal arena and a pair from the health arena) who determine whether and to what extent the person is addicted to drugs. On the basis of these findings, the commission can order someone to attend a treatment program, complete other monitoring activities, pay a fine, or submit to other administrative sanctions. Drug trafficking and non-drug offenses remain illegal and are still processed through the criminal justice system.[36]

The decriminalization policy was part of a comprehensive health-oriented approach to addressing problematic drug use, especially unsafe injecting drug use, that also included a major expansion of treatment and harm reduction services. New diagnoses of HIV and AIDS among people who inject drugs have also declined in Portugal. Between 2000 and 2008, the number of cases of HIV among people who inject drugs declined from 907 to 267, and the number of AIDS cases decreased from 506 to 108. These highly significant declines are largely attributable to the increased provision of harm reduction services and efforts made possible by decriminalization.[36,73]

In addition, research has shown no significant increases in overall illicit drug use among adults in Portugal, and any slight increases in lifetime use of some drugs appear to be part of a regional trend.[36] More importantly, adolescent drug use, as well as problematic drug use—defined as use by people deemed to be dependent or addicted and by people who inject drugs—has decreased overall since 2003.[36] The number of people arrested and sent to criminal courts for drug law violations declined by more than half after decriminalization. The percentage of people in Portugal’s prison system as a result of drug-related offenses also decreased by about half, from 44% in 1999 to 21% in 2008.[36]

These positive outcomes cannot be attributed to decriminalization alone. Alongside its decriminalization law, Portugal significantly expanded its treatment and harm reduction services, including access to sterile syringes as well as methadone maintenance therapy and other medication-assisted treatments. Between 1998 and 2008, the number of people in drug treatment increased by more than 60% (from 23,654 to 38,532 people).[36] The percentage of drug-related deaths in which opiates were the primary substance involved declined from 95% in 1999 to 59% in 2008.[36]

On the basis of such evidence and APHA’s longstanding policies, eliminating criminal penalties for personal drug use and possession is an essential feature of a public health response to drugs and drug misuse, and APHA calls on state and federal governments to remove such criminal penalties.

Expand access to harm reduction interventions: Harm reduction programs including sterile syringe access, supervised injection facilities, and medication-assisted treatment should be scaled up to eliminate HIV and hepatitis C transmission among people who inject drugs. Interventions that have proven effective in other countries should be evaluated for implementation in the United States, and legal and political barriers to programs with evidence of effectiveness should be removed. Treatment providers, health professionals (including primary care physicians), community health workers (CHWs), and other stakeholders should receive professional preparation and training with respect to proven treatment and harm reduction interventions. CHWs play a critical role in making contact and building trust with hard-to-reach, drug-using populations at high risk and connecting them to health services or delivering those services to them. To expand access to these harm reduction and treatment services to every person in need, CHWs must be empowered to deliver cost-effective interventions such as syringe access programs, secondary syringe exchange services, low-threshold methadone maintenance, peer education programs, and HIV/AIDS testing, education, and links to treatment. Criminalization, by contrast, makes the essential harm reduction functions of CHWs more difficult or even impossible.

Restricting access to sterile syringes among people who inject drugs has been proven to lead to syringe sharing, a major cause of HIV infections.[26] According to the CDC, people who inject drugs represented 9% (4,500) of all estimated new HIV infections in 2009, an annual figure that has not changed significantly since 2006.[74] Such restrictions persist despite conclusive evidence from more than 200 studies conducted in the United States and abroad showing that expanding sterile syringe access—through syringe exchange programs and non-prescription sales of syringes—is a cost-effective means[75–77] of reducing the spread of HIV and viral hepatitis and that these programs do not contribute to increased drug use, drug injection, crime, or unsafe discarding of syringes.[21,23–25,78–82] According to a CDC-funded study published in the Journal of the American Medical Association, syringe access has helped reduce HIV incidence among people who inject drugs in the United States by 80% in the past decade.[83] Current APHA policy in this regard recognizes “the critical importance of access to sterile syringes to prevent disease spread, and the effectiveness of increasing sterile syringe access in reducing risk behavior”; it “urges states that criminalize possession of prescribed syringes for injection of illicit substances to modify their laws or policies to permit such possession.”[5] Sterile syringe access programs are integral elements of a comprehensive health response to problematic drug use, are necessary to reach the goal of an AIDS-free generation, and should be funded at the local, state, and national levels toward the goal of providing a sterile syringe for every injection.

Medically supervised injection facilities (SIFs) are controlled health care settings where people who use drugs can more safely do so under clinical supervision and receive health care, counseling, and referral to health and social services, including drug treatment. There are currently 92 SIFs operating in 62 cities around the world, but none in the United States. SIFs are proven to reduce unsafe injecting practices and the transmission of blood-borne viruses; prevent overdose fatalities; increase access or referrals to treatment programs, including medication-assisted treatment and detoxification services; decrease societal costs associated with emergency room visits and crime; and reduce the social harms associated with injection drug use, such as public disorder, public intoxication, public injecting, and publicly discarded syringes.[84–87]

Medication-assisted treatments, most commonly opioid-substitution programs (also called narcotic replacement therapies), have demonstrated success in improving the lives and the health of people who use heroin and other opioids. Such therapies include methadone and buprenorphine,[88–90] as well as pharmaceutical heroin treatment, and they have proven successful in many countries. Denial of these treatments can result in untreated addiction, preventable HIV risk behaviors, and heightened vulnerability to fatal overdose.[89,91,92]

APHA took a leading position in 1970 when it supported “further experimentation with organized maintenance programs using methadone and similar compounds, subject to appropriate supervision and evaluation,” in policy 7015.[8] One year earlier, policy 6907 had resolved:

“The American Public Health Association believes that the illicit profit incentive involved in the sale of drugs to drug addicts not only contributes to their misery but puts at risk entire communities in the United States, unnecessarily submitting its citizens to muggings, robberies, injuries and in some instances murder, while constantly contributing to the profits of gangsters and Mafia-like organizations. APHA…declares that it will seek and support state and federal legislation to eliminate the profit motive in the illicit sale of drugs…by making medically approved drugs and regimens of the most suitable and clinically evaluated methods readily available to known drug addicts at specially designated health centers equipped with professional staffs competent to deal with the comprehensive rehabilitation of the addict by means of: Medical care…psychological and psychiatric counseling; social, economic, and welfare counseling aimed at increased employability [and] provision of the necessary funding to enable states, communities, and consumer action groups to give priority and coordinated action to implement establishment of such centers.”[9]

Since that time the CDC,[93] the Institute of Medicine,[94] the National Institutes of Health,[95] the Substance Abuse and Mental Health Services Administration (SAMHSA),[96] the National Institute on Drug Abuse,[97,98] the World Health Organization (WHO),[92] and more than 4 decades of government-funded, peer-reviewed medical research[99–103] have unequivocally and repeatedly proven that substitution therapies such as methadone maintenance are the most effective treatments for opioid dependence.[92,93,95,96,99–104] Methadone, buprenorphine, and other existing medication-assisted treatments should be expanded to serve all who need them. Indeed, according to the National Institutes of Health, “all opiate-dependent persons under legal supervision should have access to methadone maintenance therapy.”[95] Yet, few opioid-dependent people in the United States have access to these treatments; according to SAMHSA, only 9% of substance abuse treatment facilities in the country offer specialized treatment of opioid dependence with methadone or buprenorphine.[105] Publicly funded treatment programs are far less likely than privately funded programs to offer opioid replacement therapies.[106]

Medication-assisted treatment models for opioid dependence using diacetylmorphine (heroin) have been safely and successfully implemented in several countries [107–121] and are now well supported in the academic literature as one tool in an effective, health-based response to problematic drug use, especially among those who have not responded to conventional treatments. A systematic review of all published studies to date on heroin-assisted treatment (HAT) showed significant reductions in illicit drug use and crime and improvements in the health of participants.[109] An important article in the New England Journal of Medicine on the success of the North American Opioid Medication Initiative in Canada, which provided heroin by prescription to a select group of people who had not responded to other forms of treatment, reported a two-thirds (67%) reduction in illicit drug use and other illegal activity.[112] Similar reductions in illicit heroin use were reported from HAT trials in the United Kingdom (72%)[116] and Germany (69%).[111] HAT is not only more effective in reducing street heroin (and other drug) use than methadone,[122] but it has also proven to be more cost-effective.[47,50,118–123]

Emerging literature on treating stimulant dependence with the administration of agonists or partial agonists, such as dextroamphetamine,[124–126] methylphenidate,[127] and modafinil,[128,129] has shown favorable results. Such treatments utilizing opioid and stimulant agonist and/or partial agonist substitution clearly merit research into their feasibility in the United States and should be adopted as part of the US treatment response if evaluations prove favorable.[130]

Opposing Arguments/Evidence
Opponents of the health-based drug policies called for in the present policy statement often claim that the criminalization of people who use drugs is effective in reducing drug use. As a corollary, it is often argued that reducing or eliminating criminal penalties for drug possession or expanding access to harm reduction services such as syringe exchanges, supervised injection facilities, or medication-assisted treatments enables problematic drug use; promotes the initiation of drug use; increases rates of drug misuse, crime, and related problems; and worsens public health and public safety.

Yet, available evidence does not support these assertions. Not only has the dominant drug war paradigm completely failed to curb drug use or supply,[13–15] but the evidence consistently shows that this approach has significantly amplified the harms of drug misuse and addiction. A recent evaluation by the Government Accountability Office (GAO) issued in March 2013 showed that the Office of National Drug Control Policy (ONDCP) and the federal government “have not made progress toward achieving most of the goals articulated in the 2010 National Drug Control Strategy.” The GAO concluded that, in terms of reducing youth drug use, overdose fatalities, and HIV caused by injection drug use, the ONDCP not only has been unsuccessful but in fact has lost ground.[131]

Aggressive drug law enforcement practices—and the resulting fear of arrest—drive many people who inject drugs into environments where HIV risks are greatly elevated and away from HIV testing, prevention, and other public health services.[132,133] Two studies published in the American Journal of Public Health further demonstrate that aggressive drug law enforcement exacerbates public health risks among people who use drugs. The first, a 2012 analysis of the relationship between arrest rates for heroin and cocaine offenses and the prevalence of injection drug use from 1992 to 2002, revealed that “[d]eterrence-based approaches to reducing drug use seem not to reduce IDU prevalence” and that “alternative approaches such as harm reduction, which prevents HIV transmission and increases referrals to treatment, may be a better foundation for policy.”[134] The second, a 2005 study of intense street-level enforcement near syringe exchange program sites in Philadelphia, showed that utilization of such programs fell significantly as a result of increased drug law enforcement.[135]

After studying nearly a hundred metropolitan areas in the United States, researchers found that repressive drug law enforcement was correlated with increased HIV prevalence among people who inject drugs. The researchers concluded: “This may be because fear of arrest and/or punishment leads drug injectors to avoid using syringe exchanges, or to inject hurriedly or to inject in shooting galleries or other multi-person injection settings to escape detection.”[35] Criminalization also erects multiple barriers to both HIV and drug treatment.[136,137] Research demonstrates that people who use drugs tend to have lower rates of antiretroviral therapy utilization and higher rates of death due to HIV/AIDS.[28] What is more, these factors also seriously interfere with the front-line work of CHWs to reach out to, engage, recruit, and retain hard-to-reach people in health programs, especially low-threshold and secondary harm reduction services.

Moreover, empirical evidence from jurisdictions around the world has demonstrated rather conclusively that policies that eliminate criminal penalties for drug possession or allow limited drug availability do not increase drug use to any appreciable degree. Specifically, jurisdictions that have legalized medical marijuana, decriminalized possession of marijuana and/or other drugs, or tolerated limited, retail sales (e.g., recreational marijuana “coffee shops” in the Netherlands) have not experienced significant, if any, increases in marijuana or other drug use.[36,138–149] A new study published in the American Journal of Public Health, for instance, revealed that adolescent marijuana has not increased in states with medical marijuana laws.[150] Empirical evidence from countries that have adopted less punitive policies toward drug possession shows that these countries have not experienced any significant increases in drug use, drug-related harm, or drug-related crime relative to more punitive countries.[36,139,142,143,146,151] A WHO study of lifetime drug use rates among 17 countries showed that the United States had the highest drug use rates by a wide margin, despite its punitive drug policies, noting that “[t]he US, which has been driving much of the world’s drug research and drug policy agenda, stands out with higher levels of use of alcohol, cocaine, and cannabis, despite [more] punitive illegal drug policies…than many comparable developed countries. Clearly, by itself, a punitive policy towards possession and use accounts for limited variation in nation-level rates of drug use.”[138]

The Portuguese experience is particularly noteworthy; as described above, it has not resulted in any significant increases in overall illicit drug use among adults.[36] In fact, Portugal’s drug use rates remain below the European average and are far lower than those in the United States.[36] Overall, evidence after 10 years shows that none of the fears of drug war proponents have come to pass. According to the United Nations Office on Drugs and Crime, “Portugal’s policy has reportedly not led to an increase in drug tourism. It also appears that a number of drug-related problems have decreased.”[152] A new study of European Union countries showed that countries such as Portugal that have decriminalized the use and possession of all drugs have not experienced increases in rates of monthly drug use and, in fact, have lower rates of use than countries with punitive policies.[146]

Nor have harm reduction interventions such as syringe access, SIFs, and medication-assisted treatments been shown to increase drug use. Syringe access programs, on the contrary, have been proven not to contribute to increased drug use, drug injection, crime, or unsafe discarding of syringes.[21,23–25,78–82] SIFs reduce the social harms associated with injection drug use, such as public disorder, public intoxication, public injecting, and publicly discarded syringes.[84–87] Several dozen published articles in peer-reviewed journals have confirmed the positive public health impact of SIFs, including 2 articles published in the American Journal of Public Health showing that the SIF located in Vancouver, Canada, has succeeded in attracting and retaining a population of injection drug users who are at heightened risk for infectious disease and overdose[153] without increasing initiation into injection drug use.[154] The evidence is similarly (and uniformly) positive for HAT programs: far from enabling drug use, these programs reduce illicit drug use and crime.[109] In fact, many HAT participants freely choose to move on to another form of treatment (such as methadone) or to become abstinent,[130,155] while others continue to receive HAT treatment on a long-term basis, with lasting positive results.[156]

Alternative Strategies

Some policymakers, academics, and commentators have suggested that, rather than removing or reducing criminal penalties or investing in harm reduction services, US drug policies should focus on delivering drug treatment through the criminal justice system, mainly in the form of an ever-growing number of drug court programs. The 2013 National Drug Control Strategy, for example, “supports alternatives to incarceration such as drug courts, diversion programs, enhanced probation and parole programs, and other supervision strategies” and calls for an increase in the country’s already significant investment in drug courts.[29] Some evaluations have shown reductions in drug use and recidivism for the duration of time that people are sentenced to drug court.[157]

However, available evidence shows that coerced treatment programs, such as drug courts, are costly,[158] are no more effective than voluntary treatment,[159] serve very few people,[160] and often deny proven treatment modalities such as methadone and buprenorphine.[161,162] A recent survey of drug courts revealed that while nearly every drug court in the country serves participants who are opioid dependent, fewer than half offer medication-assisted treatments such as methadone.[161] Most drug courts have not significantly reduced participants’ chances of incarceration either.[131,158,160] In fact, one study showed that because of drug courts’ nearly exclusive focus on low-level drug (especially marijuana) possession offenses, their strict eligibility requirements, and underlying sentencing laws (e.g., mandatory minimums) that render many individuals ineligible for any type of diversion, such programs are highly unlikely to reduce the number of people incarcerated.[158] That study also suggested that drug courts may have a “net-widening” effect; that is, they may actually increase the number of people incarcerated.[158] Such criminal justice programs, moreover, have absorbed scarce resources that could have been better spent on bolstering demonstrated, health-centered approaches such as community-based treatment.[163]

Finally, coerced treatment for any health condition, especially for mere drug possession, raises serious ethical concerns; a recent commentary argued that coercive treatment for people who use or possess drugs is unethical and runs counter to accepted health principles; it is also “unlikely to have large effects on population levels of drug use and crime.”[164] For these reasons, drug courts should be reserved for individuals charged with more serious (non-drug) offenses but whose behavior was motivated by an underlying drug problem; they should never be used (as they currently are) for individuals charged with mere drug possession offenses, who can be better served outside of the criminal justice system. Coerced treatment is ethically unjustifiable, especially when voluntary treatment can yield equal or more positive outcomes.[36,164]

More alternative strategies are emerging in various localities. Seattle recently instituted a pilot program known as “Law Enforcement Assisted Diversion,” or LEAD, the first pre-booking diversion program; it aims to bypass the criminal justice system entirely. Instead of arresting and booking people for certain drug law violations, including drug possession and low-level sales, police in a pair of Seattle neighborhoods will immediately direct them to drug treatment or other supportive services. LEAD allows law enforcement to focus on serious crime but to still play a key role in linking people with certain drug law violations to services before they enter the justice system.[59,165–167] In doing so, it has the potential to reshape law enforcement practices and culture.[59]

Seattle’s policy resembles aspects of the health focus that many European countries, as well as Canada and others, have adopted: a public health policy orientation often termed a “4 pillars approach.” This comprehensive strategy is based on 4 principles—harm reduction, prevention, treatment, and enforcement—and it has demonstrated dramatic reductions in public drug consumption, overdose deaths, and HIV and hepatitis infection rates.[168,169]

Programs such as LEAD, however, still rely on law enforcement as the primary point of contact with people who misuse substances. To be most successful, local, state, and national drug policies must empower health professionals to assess and deliver services to each individual. CHWs, for example, should be enabled (and given adequate resources) to serve as the point of contact, source of referrals and information, and service provider for certain low-threshold services directly.

Ultimately, the removal of criminal sanctions in favor of optional, non-punitive, proportionate, administrative sanctions—alongside a major expansion of proven, evidence-based harm reduction, treatment, and prevention services—offers more promise in achieving a health-centered approach to drug misuse.[36] Some commentators hope that various legislative changes—notably the Affordable Care Act of 2010—will expand treatment availability and resources,[170–172] potentially making it possible to deliver treatment and harm reduction services through the health care, rather than the criminal justice, system.

Action Steps

APHA believes that national and state governments and health agencies must reorient drug policies to embrace health-centered, evidence-based approaches that reduce the individual and community harms deriving from current policies and from illicit drug misuse, respect the human rights of people who use drugs, and allow for the redirection of financial resources toward where they are needed most. Therefore, APHA:

• Urges Congress, the administration, and federal health agencies to convene relevant experts and stakeholders in the fields of public health, drug treatment, medicine, harm reduction, education and prevention, social work, and law enforcement, as well as people who currently use (or formerly used) drugs and affected communities, to critically review the effectiveness of current drug policies; to examine the potential public health gains of a range of new drug policies, including the decriminalization of personal drug possession and use; to open a public debate about regulatory alternatives to drug prohibition in order to address the public health and safety harms of illicit drug markets; and to produce a policy environment that will be most conducive to significantly expanding US treatment, education, and harm reduction programs.
• Urges federal, state, and local elected officials and agency staff to implement evidence-based and culturally appropriate prevention, regulatory, treatment, and harm reduction interventions, including (but not limited to):
o Expanding proven, life-saving public health interventions and harm reduction and treatment programs, including medication-assisted treatment, and strengthening professional preparation and training in these interventions for health care providers, CHWs, and public health, allied health, health education, and health communication professionals.
o Investigating (and, if results are favorable, implementing) new innovative agonist and partial agonist replacement treatments and medically supervised injection facilities, which have demonstrated their safety and efficacy in several countries around the world but have not yet been attempted in the United States.
o Increasing funding for existing treatment modalities and ensuring they are available to all people who need them, including those who are incarcerated or under criminal justice supervision.
o Deprioritizing the use (and funding) of non-health agencies—such as drug courts and other court-based diversion programs—to deal with people who use drugs and redirecting resources from criminal justice programs toward public health interventions to improve the health of such individuals.
• Calls on Congress to permanently repeal the federal ban on syringe access funding, to fund such programs to the maximum extent possible, and to remove other detrimental barriers to proven interventions.
• Encourages state governments to leverage resources potentially available through the Affordable Care Act toward effective community-based drug treatment, harm reduction, and physical and mental health services.
• Urges Congress and state governments to eliminate federal and state criminal penalties and collateral sanctions for personal drug use and possession offenses and to avoid unduly harsh administrative penalties, such as civil asset forfeiture, and acknowledges that proportionate criminal penalties may be appropriate—consistent with principles of public health and human rights—for behavior that occurs in conjunction with drug use if that behavior causes or seriously risks harm to others, such as driving under the influence; however, such penalties should not be imposed solely for personal drug possession and use.

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