Editorial

A New Paradigm on Drugs and Democracy: the debate is open

Some days ago the Latin American Commission on Drugs and Democracy Declaration was published, headed by the former presidents Fernando Henrique Cardoso, from Brazil, Ernesto Zedillo, from Mexico, and César Gaviria, from Colombia, and with the participation of 17 independent personalities from several Latin American countries. In this Declaration a new paradigm is proposed to understand and face the drug problem in Latin America. However, this new paradigm that promises – from its point of view – to be innovative and to solve the problem, shows several diffi culties that deserve attention and further discussion from the academic world.

•     The violence and the organized crime associated with drug traffi cking are increasing every year.

•     The results of the war on illicit drugs are poor compared to the high economical and social costs and the heavy loss of human lives.

•     The prohibitionist policies based on the eradication of production and the interdiction of traffi cking and distribution of drugs, as well as on the criminilization of consumption, have not yielded the expected results.

•     We are far from eradicating the illicit crops and the manufacturing of said drugs, as well as from curbing their disastrous social and economical consequences. On the contrary, Latin America is still the biggest exporter of cocaine and cannabis in the world, and it is producing increasingly more opium and heroin

•     Organized crime has increased, both by international traffi cking and by its control of domestic markets and cultivable territories.

•     There is an increased violence that is affecting the entire society, but particularly the poor and young people.

•     The organized delinquency has infi ltrated democratic institutions, leading to criminilization of politics and politicization of crime.

•     The corruption of government employees, of the judicial system, governments, political system and, especially, of the police forces in charge of keeping law and order.

According to the above points, the aim of the Declaration is breaking the taboo and the silence and opening up the debate, acknowledging the failure of current policies and proposing a new paradigm, with "safer, more effi cient and humane policies".

Below are some of the statements that may lead us to open up the debate:

"The challenge at hand is to drastically reduce the harm caused by illegal narcotics to people, societies and public institutions. To move in this direction, it is essential to differentiate between illicit substances according to the harm they infl ict on people's health and the social fabric".

"The search for more effi cient policies, rooted in the respect for human rights, implies taking into account the diversity of national situations and emphasizing prevention and treatment".

"The European Union policy focusing on the reduction of the damages caused by drugs as a matter of public health, through the provision of treatment to drug users, has proved more humane and effi cient. However, by not giving appropriate emphasis to the reduction of domestic consumption in the belief that the focus on harm reduction minimizes the social dimension of the problem, the policy of the European Union fails to curb the demand for illicit drugs that stimulates its production and exportation from other parts of the world".

Keeping in mind the above, the Commission proposes three guidelines for Latin America:

1.    Treating drug users as a matter of public health.

2.    Reducing drug consumption through information, education and prevention.

3.    Focusing repression on organized crime.

In this respect, the Commission adds: "Our approach does not imply any complacency in regard to the drug problem. We acknowledge that narcotics are harmful to people and societies. Treating drug users as a matter of public health and promoting the reduction of drug consumption are actually preconditions for focusing repressive action on two critical points: reduction of production and dismantling the networks of drug traffi cking".

To fulfi l this paradigm, the Commission proposes Latin America to take the following initiatives within the framework of public health:

1.    "Changing the status of addicts from ‘drug buyers in the illegal market' to that of ‘patients cared for in the public health system'. The enormous capacity of the narcotics trade for violence and corruption can only be effectively countered if its sources of income are substantially weakened. To accomplish this, the State must establish the laws, institutions and regulations enabling those who have become addicted to drugs to stop being buyers in an illegal market and to become patients of the health care system. This, combined with informational and educational campaigns, might have a signifi cant impact in terms of reducing the demand for illegal drugs, lowering its price and, as a consequence, undermining the economic foundations of this criminal business.

As regards this, we may ask ourselves:

-     How can we transform addicts into patients, when we are aware of all the reasons persons with a heavy degree of addiction put forward to justify their not wanting to be treated?

-      Whom do we call an "addict"? The individual with drug abuse or dependence, or the "occasional" consumer? Who of these two have the highest impact on drug demand? What do we know about this matter?

-     Would the occasional consumers – these are the most abundant and the ones showing the highest demand – accept being treated as patients? Should this be the case, which health care system would support this? In this regard, it is worth while to look into how this problems was addressed in Act 100, in which, due to lack of guarantees for this type of patients, many of the possibilities has been opened through writs of mandamus.

2.    "Evaluating from a public health approach and on the basis of the most advanced medical science the convenience of decriminalizing the possession of cannabis for personal use. Cannabis is by far the most widely used drug in Latin America. Its consumption has an adverse impact on the user's health, including mental health. But the available empirical evidence shows that the harm caused by this drug is similar to the harm caused by alcohol or tobacco. More importantly, most of the damage associated with cannabis use - from the indiscriminate arrest and incarceration of consumers to the violence and corruption that affect all of society – is the result of the current prohibitionist policies".

As regard this, we may ask ourselves:

-      Is it true, from the point of view of psychiatry, that the harm caused by cannabis is "similar" to the harm caused by alcohol

and tobacco? From what perspective is this asserted? As such, are an alcoholic cirrhosis, a tobacco-derived lung cancer, and an amotivational syndrome, or the family consequences derived from cannabis dependence all similar?

-      Would these similarities be medically or socioeconomically true?

-      Have the information and prevention policies been successful in preventing drug consumption? Which are the studies on this matter and what scientifi c evidence level do they contain?

-      Which clinical experiments or meta-analysis describe that this or that method has been successful in treating addiction to cannabis or other drugs?

"Reducing consumption through innovative information and prevention campaigns that can be understood and accepted, especially by young people, who accounts for the largest contingence of users".

"Drugs affect and undermine people's decision-making capacity. Statements by former addicts about these risks might have greater power to infl uence behaviour than the threat of repression or virtuous exhortations no to use drugs. The social and cultural changes that have led to amazing reductions in tobacco consumption show the effectiveness of information and prevention campaigns based on clear language and arguments that are consistent with the experience of those they try to reach".

"Most of the current prevention campaigns implemented in the world have failed. There is much to be learned from the experiences carried out by European countries, such as the United Kingdom, the Netherlands and Switzerland and it is necessary to explore experiences in other regions".

As regard this, we may ask ourselves:

-      Is a campaign against tobacco similar to that against illegal drugs, and does it have the same effect? Has this been proven anywhere? Is the effect of tobacco similar to that of cannabis or any other illegal drug? Would this be like stating that, as one campaign is successful against cirrhosis secondary to infectious hepatitis, the same strategy would also work for alcoholic cirrhosis? In terms of prevention it is important to study the vector and the effects on the host. Are tobacco and cannabis interchangeable?

-     What effects would allowing consumption of one drug have on the consumption of other illegal drugs – in this case cannabis, which

repeatedly have been shown to be a gateway to other drugs? Is this solution viable from the point of view of public health or from a socioeconomic perspective? Would alleviating one perspective harm the other? What is the cost/benefi t of this exchange?

-     As regards the learning that may be obtained from the experiences in other countries, it is not clear whether this is in the positive or the negative sense. If it is in the positive sense, there is wide medical evidence refuting, or at least disproving, the success of the experiences in said countries. If it is in the negative sense – i.e. poor experiences – we have to dedicate some time to study and discover what has lead over the years to such poor or null answers.

-     Furthermore, it must be taken into account that, as stated by the Commission in another paragraph: "the simple decriminalizing of consumption, if not accompanied by information and prevention policies, could have the contrary effect of worsening the addiction problems." Is there an effective prevention strategy seriously studied somewhere in the world and on which we can rely? And what's more, are there any Colombian or Latin American studies in this respect when the Commission declares that we must have answers based on our culture?

Finally, the Commission states: "Latin America's active participation in the global debate would mark its transition from a problem-region to a pioneering-region in the implementation of innovative solutions for the drug problem".

In conclusion, we believe that the Latin American Commission on Drugs and Democracy Declaration is a document worth to be studied and discussed in depth, out of which many more questions will emerge.

Likewise, we invite to a deeper refl ection on the benefi ts of the medical science in treating this problem and to avoid "taking refuge in not very realistic successes in treatment and prevention", which may induce us to make wrong decisions. As such, we suggest the academic body and the Asociación Colombiana de Psiquiatría to cautiously study this proposal and to start the suggested debate based on scientifi c evidence and which may serve to clarify this diffi cult matter.

Carlos Gómez-Restrepo
Director-Editor
Revista Colombiana de Psiquiatría