ISSUES IN MEDICINE
Beyond the rhetoric: Towards a more effective and humane drug policy framework in South Africa
The March 2011 Anti-Substance Abuse Summit in Durban continued the outdated approach to policy around illicit drugs in South Africa. It missed opportunities for discussing how to impact significantly on the health and social harms associated with problematic drug use and reduce the burden of drug-related cases in the criminal justice system. The government needs to move away from the political rhetoric of a ‘drug-free society’ and start the real work of formulating and implementing an evidence-based drug policy that learns from the experiences of other countries around decriminalising drug use; takes into account differences in the harms resulting from different classes of drugs; adopts a rights-based, public health approach to policy; and identifies a single (accountable) agency that has the authority to oversee policy implementation. In addition, consensus is needed on the short-, medium- and long-term priorities for drug policy implementation. The 17 evidence-based drug policy strategies identified by Babor et al. may serve as a useful starting point for policy development.
S Afr Med J 2011;101:704-706.
In March 2011 the Department of Social Development and the Central Drug Authority (CDA) hosted the 2nd Biennial Anti-Substance Abuse Summit in Durban with the theme ‘An Integrated Approach: Towards a Drug-free Society’. Some of the country’s top politicians, including the President and eight cabinet members, were participants. The main emphasis was on alcohol, and where illicit drugs were referred to the emphasis was on the link between drugs and crime, drug supply, and the need for treating people with alcohol or drug dependence. Little distinction was made between the harm caused by different types of drugs, and no distinction was made between persons who use and persons who are dependent on drugs.1
This continued focus on the drugs-crime nexus, and the emphasis on controlling and containing people with drug-related problems, is a concern as it reflects an outdated approach to drug policy that has been shown to be ineffective and inhumane internationally.2 , 3 Supply-orientated policies have had adverse consequences for people who use drugs, including missed opportunities to reduce the personal and social harms associated with problematic drug use.3 We contend that to be effective, South African drug policy needs urgent reworking. While there are common issues relating to policy around alcohol and illicit drugs, the country would be served best by separating policy development in these two areas and then investigating whether there can be synergies between the two during implementation. This paper focuses on policy around illicit drug use.
What is the status of drug policy development and implementation in South Africa?
Policy development around illicit drug use is being driven by various government departments and ministries, the CDA, and since late 2010 the Inter-ministerial Committee on Substance Abuse (IMC). The second National Drug Master Plan (NDMP; 2006 - 2011)4 provides the policy framework for addressing drug use in the country and the legislative framework is provided by the Prevention and Treatment of Substance Abuse Act 70 of 2008.5 The NDMP’s major limitation is that it does not translate generic policy statements into clear recommendations for action. This is left in the hands of various national departments and is mostly devolved to the provinces. Devolving this function to the level of the province has resulted in major differences in drug policy between the provinces, both in terms of the stage of policy development and position on various issues. Some provinces, such as the Western Cape, have a coherent and relatively forward-thinking policy framework that drives resource allocation; others either lack a framework or still focus predominantly on law enforcement. This fragmentation makes it difficult to develop and implement an evidence-based national drug policy framework. Another challenge is the lack of leadership on drug-related issues, both at national and provincial levels.6 This has hampered progress as no single person (or authority) has been responsible for driving the implementation of policies or accountable for the successes and failures of policies. In theory this was the CDA and provincial substance abuse forums, but in practice they have lacked the authority and resources to take this on.6
Although the NDMP is being revised, there is no reason to believe that there will be any major shifts from the current conservative focus which still calls for a ‘drug-free’ society. Among the various international policy options, South Africa’s policies have a strong focus on supply reduction through law enforcement and policing, despite rhetoric about having a developmental approach to drug use.4 These policies are not particularly humane, as people who use drugs are still imprisoned for drug possession and have limited access to evidence-based interventions. They also have had unintended adverse consequences for individuals and society, including overburdening the criminal justice system with drug-related offences, overcrowding prisons, and exposing imprisoned drug users to hardened criminals and further harms.2 Furthermore, the high prices of illicit drugs are often the direct consequence of the war that is waged against drug trafficking and often fuel drug selling and other drug-related crimes.7 This law enforcement focus also has limited investment in and access to the broad range of evidence-based interventions for drug-related problems, apart from a few urban-based high-threshold treatment services required to contain the most problematic types of drug users.
What is required to make drug policy in South Africa more effective and humane?
To make progress in the drug policy arena, the South African government needs to reach consensus on several issues. The first is how it views different drugs of abuse. A study8 into the overall harms associated with 20 different substances (including alcohol and tobacco) across 16 different dimensions (including drug-related mortality, drug-related morbidity, dependence, environmental harms, and harms to families and communities) found that heroin, crack cocaine and methamphetamine held the most harms for people who use drugs, and alcohol, heroin and crack cocaine were the substances most harmful to others. Overall, alcohol was rated the most harmful substance, followed by heroin and crack cocaine. Tobacco was ranked the 6th most harmful substance, and cannabis was ranked 8th. However, in many countries, including South Africa, policy responses to drugs are not logical or based on evidence of the harmful nature of substances, as they criminalise the use of drugs such as cannabis that are less harmful than both tobacco and alcohol, which are legal substances. In line with Babor et al.,9 we contend that the risk of harm associated with drug use varies according to the nature of the substance being used and the pattern of use (i.e. frequency and quantity of use, and route of administration), and that drug policy should take such differences into account.
The second key issue is where South Africa’s drug policy should relate to international drug policy, and specifically where the country should orient itself in relation to law-enforcement and punitive drug policies versus public health-orientated policies (focused primarily on preventing and reducing the harms associated with drug use).2 Our position is that a rights-based, public health approach to drug policy that fosters the implementation of evidence-based interventions for drug prevention and treatment is the most effective and realistic approach to regulating drug use.3 This is in keeping with recent shifts in global thinking about drug policy, including within UN agencies that previously strongly supported law enforcement approaches. These policy shifts are based on evidence that the war on drugs has failed and has exposed people who use drugs to more health and social harms.2 , 10 Based on this global policy shift, we support calls for South African drug policy to move towards decriminalising drug use9 and adopting a rights-based, public health approach to drug policy focused on preventing and reducing the harms associated with drug use. It must be made clear that this is not the same as legalising the manufacture or growing of drugs or their distribution. This approach also does not view drugs such as cannabis as harmless. Our view is that by decriminalising the personal use of drugs, funds spent on policing otherwise harmless people who use drugs could be redirected to preventing drug use as well as on public health interventions focused on problems such as driving while under the influence of drugs or aimed at users at high risk for harm or with patterns of use that are harmful.11
The third key issue relates to leadership, and specifically who should direct the development and implementation of policy in this area. A single agency should have overall authority to oversee the implementation of drug policy and must be fully accountable to the citizens of South Africa and report to Parliament on action taken and progress made. Our position is that this should be driven at a senior level of government through a body such as the IMC, but with input from technical experts within government and civil society and the support of a strengthened CDA. While it is important to consider local conditions when formulating and implementing a national drug strategy, much can be learned from international experience. For instance, Portugal has decriminalised possession of illicit drugs for a decade and a recent study found that Portugal has experienced reductions in problematic drug use, drug-related harms and criminal justice overcrowding.12
Finally, consensus must be reached on the short-, medium- and long-term priorities for policy. A good starting point is Babor et al.’s review of 43 commonly used drug policy interventions, of which 17 show evidence of effectiveness in at least one country.9 Several comprise evidence-based interventions for people who use opiates, including opioid substitution treatment, heroin prescribing, and needle and syringe programmes for people who inject drugs. They also report benefits for psychosocial treatments and self-help organisations for people who use drugs. Some evidence was found for the effectiveness of regulatory interventions in the pharmaceutical area, including increasing the prices of certain medications, restricting certain over-the-counter (OTC) sales, requiring prescriptions (versus OTC availability), having prescription restrictions with registers, and monitoring of medicines with a high potential for harm.9
Regarding supply and control interventions, there is some evidence for the effectiveness of precursor chemical controls and interdiction, but that once drugs are made illegal there is a point beyond which increases in incarceration yield little added benefit.9 In fact, several studies show that shifting between conventional criminal penalties and some other form of penalty had modest or no effect on cannabis use, but reduced the adverse consequences for the person who used drugs. Interestingly, the review also listed several (commonly supported) drug polices for which there was no evidence of effectiveness, including use of mass media for prevention messaging, preventive interventions that merely involved giving information about the dangers of drugs, programmes where police give talks to children in classrooms, and drug testing in schools.9
In conclusion, we call for a move away from the political rhetoric of a ‘drug-free society’ and challenge government to start the real work of formulating and implementing an evidence-based drug policy. To achieve this, policymakers must engage with evidence about what works, and learn from the mistakes of other countries. This will require leadership and an investment in developing a workforce that can implement the policy. To ensure a return on this investment, policy evaluation processes should form an integral part of the new drug policy framework.
1. Department of Social Development. Ethekwini resolution on Second Biennial Substance Abuse Summit, 25 March 2011. http://www.dsd.gov.za/index.php?option=com_content&task=view&id=307&Itemid=106 (accessed 8 August 2011).
2. Greenfield VA, Paoli L. If supply-oriented drug policy is broken, can harm reduction help fix it? Melding disciplines and methods to advance international drug-control policy. Int J Drug Policy (in press).
3. Stevens A. Drug policy, harm and human rights: A rationalist approach. Int J Drug Policy 2011;22:233-238.
4. South African Department of Social Development. National Drug Master Plan 2006-2011. Pretoria: Department of Social Development, 2007.
5. South African Government. Prevention and Treatment of Substance Abuse Act 70 of 2008. Government Gazette 32150, 21 April 2009. http://www.info.gov.za/view/DownloadFileAction?id=99550 (accessed 9 August 2011).
6. Myers B, Louw J, Fakier N. Alcohol and drug abuse: removing structural barriers to treatment for historically disadvantaged communities in Cape Town. Int J Soc Welf 2008;17:156-165.
7. Van Niekerk JP. Time to decriminalise drugs. S Afr Med J 2011;101:79-80.
8. Nutt D, King LA, Phillips LD Drug harms in the UK: a multicriteria decision analysis. Lancet 2010;376:1558-1565.
9. Babor T, Caulkins J, Edwards G, et al. Drug Policy and the Public Good. New York: Oxford University Press, 2010.
10. Global Commission on Drug Policy. War on Drugs. Report on the Global Commission of Drug Policy June 2011. http://www.globalcommissionondrugs.org/Report (accessed 11 August 2011).
11. Parry CDH. Critical issues in the debate on decriminalization or legalisation of cannabis in South Africa. S Afr Med J 2002;92:696-697.
12. Hughes CE, Stevens A. What can we learn from the Portuguese decriminalization of illicit drugs. Br J Criminol 2010;50:999-1022.
Accepted 16 August 2011.
Charles Parry is Director of the Alcohol & Drug Abuse Research Unit (ADARU) at the Medical Research Council (MRC) and an Extraordinary Professor in the Department of Psychiatry at Stellenbosch University. His interests include substance abuse epidemiology, alcohol and drug policy, and the effect of substance abuse on HIV and AIDS. Bronwyn Myers is a Specialist Scientist in the ADARU and an Honorary Associate Professor in the Department of Psychiatry & Mental Health at the University of Cape Town. Her interests include alcohol and drug intervention and services research and also drug policy. The authors indicate no conflicts of interest.
Corresponding author: C Parry (email@example.com)
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