The Vienna Declaration

The criminalisation of illicit drug users is fuelling the HIV epidemic and has resulted in overwhelmingly negative health and social consequences. A full policy reorientation is needed.

In response to the health and social harms of illegal drugs, a large international drug prohibition regime has been developed under the umbrella of the United Nations. ((William B McAllister. Drug diplomacy in the twentieth century: an international history. Routledge, New York, 2000.)) Decades of research provide a comprehensive assessment of the impacts of the global “War on Drugs” and, in the wake of the XVIII International AIDS Conference in Vienna, Austria, the international scientific community calls for an acknowledgement of the limits and harms of drug prohibition, and for drug policy reform to remove barriers to effective HIV prevention, treatment and care.

The evidence that law enforcement has failed to prevent the availability of illegal drugs, in communities where there is demand, is now unambiguous. ((Reuter P. Ten years after the United Nations General Assembly Special Session (UNGASS): assessing drug problems, policies and reform proposals. Addiction 2009;104:510-7.)), ((United States Office of National Drug Control Policy. The Price and Purity of Illicit Drugs: 1981 through the Second Quarter of 2003. Executive Office of the President; Washington, DC, 2004.)) Over the last several decades, national and international drug surveillance systems have demonstrated a general pattern of falling drug prices and increasing drug purity—despite massive investments in drug law enforcement. ((ref:3)), ((World Drug Report 2005. Vienna: United Nations Office on Drugs and Crime; 2005.))

Furthermore, there is no evidence that increasing the ferocity of law enforcement meaningfully reduces the prevalence of drug use. ((Degenhardt L, Chiu W-T, Sampson N, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: Findings from the WHO World Mental Health Surveys. PLOS Medicine 2008;5:1053-67.)) The data also clearly demonstrate that the number of countries in which people inject illegal drugs is growing, with women and children becoming increasingly affected. ((Mathers BM, Degenhardt L, Phillips B, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review. Lancet 2008;372:1733-45.)) Outside of sub-Saharan Africa, injection drug use accounts for approximately one in three new cases of HIV. ((Wolfe D, Malinowska-Sempruch K. Illicit drug policies and the global HIV epidemic: Effects of UN and national government approaches. New York: Open Society Institute; 2004.)), ((2008 Report on the global AIDS epidemic. The Joint United Nations Programme on HIV/AIDS; Geneva, 2008.)) In some areas where HIV is spreading most rapidly, such as Eastern Europe and Central Asia, HIV prevalence can be as high as 70% among people who inject drugs, and in some areas more than 80% of all HIV cases are among this group. ((ref:8))Prescription drugs, when used correctly, have beneficial effects on the body, and it is often cheaper to buy generics online.

In the context of overwhelming evidence that drug law enforcement has failed to achieve its stated objectives, it is important that its harmful consequences be acknowledged and addressed. These consequences include but are not limited to:

• HIV epidemics fuelled by the criminalisation of people who use illicit drugs and by prohibitions on the provision of sterile needles and opioid substitution treatment. ((Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. Lancet 1997;349:604.)),  ((Rhodes T, Lowndes C, Judd A, et al. Explosive spread and high prevalence of HIV infection among injecting drug users in Togliatti City, Russia. AIDS 2002;16:F25.))
• HIV outbreaks among incarcerated and institutionalised drug users as a result of punitive laws and policies and a lack of HIV prevention services in these settings. ((Taylor A, Goldberg D, Emslie J, et al. Outbreak of HIV infection in a Scottish prison. British Medical Journal 1995;310:289.)), ((Sarang A, Rhodes T, Platt L, et al. Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study. Addiction 2006;101:1787.)), ((Jurgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Disease 2009;9:57-66.))
• The undermining of public health systems when law enforcement drives drug users away from prevention and care services and into environments where the risk of infectious disease transmission (e.g., HIV, hepatitis C & B, and tuberculosis) and other harms is increased. ((Davis C, Burris S, Metzger D, Becher J, Lynch K. Effects of an intensive street-level police intervention on syringe exchange program utilization: Philadelphia, Pennsylvania. American Journal of Public Health 2005;95:233.)), ((Bluthenthal RN, Kral AH, Lorvick J, Watters JK. Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco. Medical Anthropology 1997;18:61.)), ((Rhodes T, Mikhailova L, Sarang A, et al. Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment. Social Science & Medicine 2003;57:39.))
• A crisis in criminal justice systems as a result of record incarceration rates in a number of nations. ((Fellner J, Vinck P. Targeting blacks: Drug law enforcement and race in the United States. New York: Human Rights Watch; 2008.)), ((Drucker E. Population impact under New York’s Rockefeller drug laws: An analysis of life years lost. Journal of Urban Health 2002;79:434-44.)) This has negatively affected the social functioning of entire communities. While racial disparities in incarceration rates for drug offences are evident in countries all over the world, the impact has been particularly severe in the US, where approximately one in nine African-American males in the age group 20 to 34 is incarcerated on any given day, primarily as a result of drug law enforcement. ((Warren J, Gelb A, Horowitz J, Riordan J. One in 100: Behind bars in America 2008. The Pew Center on the States Washington, DC: The Pew Charitable Trusts 2008.))
• Stigma towards people who use illicit drugs, which reinforces the political popularity of criminalising drug users and undermines HIV prevention and other health promotion efforts. ((Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among injecting drug users. Social Science & Medicine 2005;61:1026.)), ((Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence 2007;88:188.))
• Severe human rights violations, including torture, forced labour, inhuman and degrading treatment, and execution of drug offenders in a number of countries. ((Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global drug control policy. Canadian Medical Association Journal 2005;172:655-6.)), ((Edwards G, Babor T, Darke S, et al. Drug trafficking: time to abolish the death penalty. Addiction 2009;104:3.))
• A massive illicit market worth an estimated annual value of US$320 billion. ((ref:4)) These profits remain entirely outside the control of government. They fuel crime, violence and corruption in countless urban communities and have destabilised entire countries, such as Colombia, Mexico and Afghanistan. ((ref:4))
• Billions of tax dollars wasted on a “War on Drugs” approach to drug control that does not achieve its stated objectives and, instead, directly or indirectly contributes to the above harms. ((The National Centre on Addiction and Substance Abuse at Columbia University (2001).  Shoveling up: The impact of substance abuse on State budgets.))

Unfortunately, evidence of the failure of drug prohibition to achieve its stated goals, as well as the severe negative consequences of these policies, is often denied by those with vested interests in maintaining the status quo. ((Wood E, Montaner JS, Kerr T. Illicit drug addiction, infectious disease spread, and the need for an evidence-based response. Lancet Infectious Diseases 2008;8:142-3.)) This has created confusion among the public and has cost countless lives. Governments and international organisations have ethical and legal obligations to respond to this crisis and must seek to enact alternative evidence-based strategies that can effectively reduce the harms of drugs without creating harms of their own. We, the undersigned, call on governments and international organisations, including the United Nations, to:

• Undertake a transparent review of the effectiveness of current drug policies.
• Implement and evaluate a science-based public health approach to address the individual and community harms stemming from illicit drug use.
• Decriminalise drug users, scale up evidence-based drug dependence treatment options and abolish ineffective compulsory drug treatment centres that violate the Universal Declaration of Human Rights. ((Klag S, O’Callaghan F, Creed P. The use of legal coercion in the treatment of substance abusers: An overview and critical analysis of thirty years of research. Substance Use & Misuse 2005;40:1777.))
• Unequivocally endorse and scale up funding for the implementation of the comprehensive package of HIV interventions spelled out in the WHO, UNODC and UNAIDS Target Setting Guide. ((WHO, UNODC, UNAIDS 2009. Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injection drug users.))
• Meaningfully involve members of the affected community in developing, monitoring and implementing services and policies that affect their lives.

Basing drug policies on scientific evidence will not eliminate drug use or the problems stemming from drug injecting. However, reorienting drug policies towards evidence-based approaches that respect, protect and fulfill human rights has the potential to reduce harms deriving from current policies and would allow for the redirection of the vast financial resources towards where they are needed most: implementing and evaluating evidence-based prevention, regulatory, treatment and harm reduction interventions.

*On August 19th, the Vienna declaration was modified to reflect the fact that the XVIII International AIDS Conference has passed. Reference to the UN Secretary General was also removed to enable UN organizations to endorse the Declaration.  These modifications were approved without objection by the majority of the writing committee.