Promoting Healthy Drug Policies to Improve Health and Treatment

1. The need for doctors to promote healthy drug policies to improve health and improve drug treatment Dr Chris Ford, Holly Catania & Rebecca Murchie IDHDP Friday 9th November 2012

2. Purpose of paper • To understand the effect of drug policies on the health and drug treatment of people who inject drugs in a number of different countries • Explain the need for doctors to get involved in advocating for healthy drug policies www.idhdp.com

3. Is evidence important in practice? • How good are we at using it? • Is evidence important in drug policy? • Do we practice it? • Policy and practice needs to be evidence-imbued • To inspire or influence thoroughly; pervade “work imbued with the revolutionary spirit” www.idhdp.com

4. What is a drug policy? • Covers all activities related to illicit drugs • ‘A system of laws, regulatory measures, courses of action and funding priorities concerning (illicit) psychoactive drugs and promulgated by a governmental entity or its representatives’ adapted from Kilpatrick, 2000 www.idhdp.com

5. Does policy affect amount of drug use? • “Globally, drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones.” • Degenhard et al., World Health Organisation, 2008 ‘Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys’ http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050141 www.idhdp.com

6. Global Network • Aims to mobilize the voice and increase participation of doctors in drug policy reforms • We advocate building bridge from practice to policy by: • Promoting the treatment of people who use drugs with respect and evidence-based imbued treatment • Promoting harm reduction including OST, OD prevention • Promoting drug policies based on health, science, human rights and compassion • Preventing the spread of HIV, HCV and other blood borne diseases by providing sterile needles and syringes • Using our knowledge of what works in clinical practice to influence or change drug policies www.idhdp.com

7. Questionnaire how the medical treatment of people who use drugs was affected by their country’s drug policy • Results showed all countries’ drug treatment systems affected by their national drug policy, mostly in a negative way, particularly with regards to health and rates of HIV infection and against evidence-based medical treatment • Many countries reported similar issues: • Impact of stigma • Interference by law enforcement • Change in government interrupts progress in putting policy into practice www.idhdp.com

8. Damage on people if unhealthy drug policy • HIV prevalence is fueled by the war on drugs and the criminalization of people who inject drugs Global Commission on Drug Policy’s report, "The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic," June 2012. • In Russia 37% of the 1.8 million people who inject drugs are infected with HIV, NSP is severely limited and OST is illegal • In Central Asia, Latin America and Sub-Saharan Africa, OST coverage equates to less than one person for every 100 people who inject drugs Economic and Social Council Official Records (2009) Supplement No. 8 United Nations Commission on Narcotic Drugs Report on the Fifty-Second Session (14 March 2008 and 11–20 March 2009). New York: UN. www.idhdp.com

9. Impact of Drug Policies on Recent HIV prevalence Among People Who Inject Drugs Source: War on Drugs: Report of the Global Commission on Drug Policy June 2011 www.idhdp.com

10. Impact of Drug Policies on Recent HIV prevalence Among People Who Inject Drugs Source: War on Drugs: Report of the Global Commission on Drug Policy June 2011 www.idhdp.com

11. Impact of Drug Policies on Recent HIV prevalence Among People Who Inject Drugs Source: War on Drugs: Report of the Global Commission on Drug Policy June 2011 www.idhdp.com

12. Estimated HIV prevalence among different risk groups in Thailand Source: Thailand Bureau of Epidemiology, HIV Total Sentinel Surveillance. Ministry of Public Health (2011) www.idhdp.com

13. IDUs as share of total HIV cases and of patients receiving ART, 2008Data sources: number of IDUs infected with HIV,60 total HIV cases;68 IDUs on ART in Russia,69 China,14 Ukraine,70 Vietnam,12,68 and Malaysia.65 IDU=injecting drug user. ART=antiretroviral therapy. *Data are for 2009. HIV in people who use drugs “Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward .”Wolfe D et al., July Lancet 2010; 376: 35-366) www.idhdp.com

14. Figure 2. OST available to <2% of IDUs www.idhdp.com Source:The Lancet : HIV in people who use drugs “Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward.” Wolfe, D; Carriere, P; Shepard, D. The Lancet July 2010; 376:355-366

15. Figure 3. www.idhdp.com Source: The Lancet 2010; 376:355-366

16. Corporal punishment & drug offenses • A recent study by Harm Reduction International finds that over 40 states apply some type of judicial corporal punishment for drug and alcohol offences. • Drug detention in the name of treatment (no rights of appeal, forced labor, no treatment) www.idhdp.com

17. Decline in new HIV cases attributable to drug injecting in British Columbia coinciding with public health interventions www.idhdp.com Source: BC Centre for Disease Control and BC Centre for Excellence in HIV/AIDS

18. Effective HIV interventions Scaling up Combination HIV Interventions: Nairobi, Kenya www.idhdp.com

19. What makes a healthy drug policy? • Balanced and integrated whole system including: • Prevention • Supply • Treatment • System needs to meet needs and comply with the evidence rather than opinion • Needs to be subject to regular review and evaluation www.idhdp.com

20. Good evidence imbued treatment People at centre • Harm reduction • OST • Psychological interventions • Abstinence-based • Mutual aid groups • Rehabilitation and reintegration • General health care • Employment, social, housing and financial www.idhdp.com

21. Successful experiments in drug policy: 1. Four Pillar approach in Switzerland • Between 1991 and 2004, drug related deaths declined by more than 50% • Levels of new HIV infections divided by 8 within 10 years • 90% reduction of property crime committed by drug users • 70% of injectors are now in some kind of treatment www.idhdp.com

22. Successful experiments in drug policy2. Decriminalization in Portugal • No. of street overdoses fell from 400 to 290 annually • Reduced illicit drug use among most at-risk group (15-19 year olds) since 2003 • Reduced prevalence of HIV among IDUs; expansion in treatment Incidence of HIV and AIDS among drug users, 2000-2008 Source: Fátima Trigueiros, IDT Portugal, Alex Stevens, University of Kent, Caitlin Hughes, University of New South Wales www.idhdp.com

23. Case study: Portugal – treating, not punishing • Data since 2001 show that “decriminalisation has had no adverse effect on drug usage rates in Portugal” • Came after some rises in the 1990s • Numbers in treatment risen from 6,000 in 1999 to over 24,000 in 2008 • Reflects big rise in treatment but not in drug use • % used heroin increased from just 1% to 1.1%. • Most other drugs, the figures have fallen • Number injecting heroin fallen from 45% to 17% • IDU now only 20% of Portugal’s HIV cases, down from 56% before. www.idhdp.com

24. Manuel Cardoso, deputy director of the Institute for Drugs and Drug Addiction • “Before decriminalisation, addicts were afraid to seek treatment because they feared they would be denounced to the police and arrested,” • “Now they know they will be treated as patients with a problem and not stigmatised as criminals.” • “We no longer have to work under the paradox that exists in many countries of providing support and medical care to people the law considers criminals.” www.idhdp.com

25. Evidence is there • Good evidence-based treatment for people who use drugs set in a healthy integrated drug policy works • Hence should not be restricted by punitive, opinion-based national drug policies www.idhdp.com

26. UK • Preoccupied by the wrong things • Lurch from retention (rather than improvements) to completions (and out of treatment) • Distracted by cheapness rather than quality • Need to balance aspiration with caution • Need jointed up system www.idhdp.com

27. Drug policies that adversely affect access to quality medical care need to be challenged to improve drug treatment and reduce HIV rates in people who inject drugs • We as doctors need to be involved in drug policy reform to improve care of people who use drugs • IDHDP believes that healthcare professionals, especially medical doctors, need to actively engage in drug policy reform to promote harm reduction and reduce the spread of HIV/AIDS and other infectious diseases, and support humane and healthy drug policies based on science • Drug policy is particularly vulnerable to political influence that has little to do with evidence-based medicine, probably more so than any other area of health, and it is important to identify this and challenge where it is happening www.idhdp.com

28. Other priority areas of work • Criminalization of people who use drugs "We are losing the war against drugs.” Bush “War on drugs is a war on human beings. The politicians are formulating the drug problem as an issue of national security, but it is an issue of public health” Mexican poet, Javier Sicilia • HCV: Link between HCV and drug policy is not as clear as for HIV, and it needs greater investigation www.idhdp.com

29. Why not join us? Thank you Dr Chris Ford, Holly Catania and Rebecca Murchie IDHDP www.idhdp.com