HOW WELL DO INTERNATIONAL DRUG CONVENTIONS PROTECT PUBLIC
HEALTH?

Summary

The Single Convention on Narcotic Drugs in 1961 aimed to eliminate the
illicit production and non-medical use of cannabis, cocaine, and
opioids, an aim later extended to many pharmaceutical drugs.

Over the past 50 years international drug treaties have neither
prevented the globalisation of the illicit production and non-medical
use of these drugs, nor, outside of developed countries, made these
drugs adequately available for medical use. The system has also
arguably worsened the human health and wellbeing of drug users by
increasing the number of drug users imprisoned, discouraging effective
countermeasures to the spread of HIV by injecting drug users, and
creating an environment conducive to the violation of drug users'
human rights. The international system has belatedly accepted measures
to reduce the harm from injecting drug use, but national attempts to
reduce penalties for drug use while complying with the treaties have
often increased the number of drug users involved with the criminal
justice system.

The international treaties have also constrained national policy
experimentation because they require nation states to criminalise drug
use. The adoption of national policies that are more aligned with the
risks of different drugs and the effectiveness of controls will
require the amendment of existing treaties, the formulation of new
treaties, or withdrawal of states from existing treaties and
re-accession with reservations.

This is the third in a Series of three papers about
addiction

Introduction

2011 marked the 50th anniversary of the Single Convention on Narcotic
Drugs.1 This convention prohibited the production and use of narcotic
drugs""specifically cannabis, opioids, and cocaine""except for
medical and scientific purposes.

The primary policies pursued have been criminalisation of the
production, sale, and use of these drugs for non-medical purposes.
Subsequent international treaties have extended this approach to
synthetic pharmaceutical drugs, such as amphetamine-type stimulants
and benzodiazepines, and the chemical precursors used to manufacture
these agents.2, 3

Key messages

The international drug control system has not ensured adequate medical
supply of opioids, particularly in low-income and middle-income
countries, but also in some high-income countries.

The system has not effectively restricted the non-medical use of
controlled drugs, and illicit drug production, manufacture, and use is
now a global issue. Illicit drug use accounts for a substantial and
increasing global burden of disease.

The system's emphasis on criminalisation of drug use has contributed
to the spread of HIV, increased imprisonment for minor offences,
encouraged nation states to adopt punitive policies (including
executions, extra-judicial killings, imprisonment as a form of
treatment, and widespread violations of UN-recognised human rights of
drug users), and impaired the collection of data on the extent of use
and harm of illicit drugs, all of which have caused harm to drug users
and their families.

The international system precludes policies that are more aligned to
the risks of drug use and the adverse consequences of prohibition,
such as the regulation of producers, consumers, and the conditions
under which drugs are used.

Policy experimentation requires changes to the international treaties,
which are possible in principle but unlikely in practice.

Other options include renunciation of the treaties and re-accession
with reservations, or adoption of a new treaty.

We briefly describe how the international system has operated and
assess how well it has achieved its primary goals""namely, protection
of public health and wellbeing through reduced use of prohibited drugs
and expedited access to these drugs for medical use. We argue that the
international system's provisions have restricted policy
experimentation in national and local drug policies. We suggest ways
in which the international treaties could be modified to allow the
necessary policy experiments to develop more evidence-informed
practices that give priority to the protection of public health and
wellbeing.

Current international drug control system

The 1961 convention covered drugs derived from three plants: opioids
from the poppy (Papaver somniferum) and derivatives, cocaine from the
coca bush (Erythroxylum coca), and cannabis from the cannabis plant
(Cannabis sativa). A separate 1971 convention made the non-medical use
of a wide range of synthetic drugs a punishable offence, although
whether a criminal sanction was needed has been disputed.4 These drugs
were manufactured primarily by pharmaceutical companies in developed
countries whose economic power ensured that the treaty imposed less
strict controls on manufacture and trade than did the 1961
convention.2 A 1988 convention on trafficking consolidated the focus
of the control system on suppression of illicit markets by including
provisions to prevent money laundering and extending controls to
precursor chemicals (panel 1).5

Panel 1

International drug control treaties

1961 Single Convention on Narcotic Drugs

Required nations to make the non-medical use of cannabis, cocaine, and
opioids a criminal offence

Amended by a 1972 Protocol

1971 Convention on Psychotropic Substances

Extended the system to cover synthetic drugs""eg, amphetamines,
benzodiazepines, opioids, lysergic acid diethylamide (LSD)

1988 Convention Against Illicit Trafficking in Narcotics and
Psychotropic Substances

Focus on police suppression of illicit markets

Extended to cover drug precursor chemicals

The management and enforcement of the drug treaties are done by
several international agencies that have overlapping responsibilities
and different mandates and sometimes work at cross-purposes.6 The
international political body that governs drug issues is the
Commission on Narcotic Drugs, which operates under the remit of the UN
Economic and Social Council. The commission is composed of
representatives from 53 states chosen by the Economic and Social
Council on the basis of geography and interest, and it meets every
year in Vienna to negotiate, adopt resolutions, and approve the
system's budget.

The commission operates on a consensus basis, which makes change very
difficult.

The UN Office on Drugs and Crime (UNODC) is the specialised UN agency
on drug issues that serves as the secretariat for the Commission on
Narcotic Drugs. It advises governments on effective law enforcement
and treatment systems and methods of estimation of illicit drug
production and consumption. The UNODC's annual World Drug Report has
become an increasingly useful source of international statistics on
illicit drug use and markets.7 UNODC is a small agency (about 500
employees) whose work is largely influenced by the governments that
contribute most of its funding.

In 2009, UNODC's core funding was estimated at US$13A.1 million,
whereas funding earmarked by donor governments for particular purposes
was $197A.9 million.8

The International Narcotics Control Board comprises 13 experts elected
by the UN Economic and Social Council. The board is responsible for
overseeing the operation of the international drug treaties,
management of international markets in medicines controlled by the
treaties, and ensuring the supply of opioids for pain and other
medical uses. The board deems itself the guardian of the treaties and
often publishes interpretations of their provisions and names
countries judged to have violated treaty provisions.9

Under the 1961 and 1971 international drug conventions, WHO provides
medical and scientific advice on which drugs should be under
international control and to what extent.

According to the 1971 convention, WHO expert committees' assessments
"oeshall be determinative as to medical and scientific matters" . WHO
provides advice and nominates five candidates for membership of the
International Narcotics Control Board (from which the Economic and
Social Council chooses three), but the Commission on Narcotic Drugs
makes the final decisions about scheduling drugs, subject to review by
the council.

Aims and functioning of the international system

The international system has two aims: to suppress the production,
distribution, and use of all drugs under its control for all but
medical and scientific purposes; and to ensure that controlled drugs
(especially the opioids) are made available for medical purposes""eg,
pain control.

The first goal is intended to promote the health and welfare of
mankind by preventing addiction and misuse of drugs.

The preamble to the 1961 treaty characterised addiction to narcotic
drugs as "oea serious evil for the individual" that was "oefraught
with social and economic danger to mankind" and noted that
signatories had a "oeduty to prevent and combat this evil" .1

An analysis that tracked the various roles of 33 long-serving
functionaries described the international system fairly as a
gentlemen's club.1 The membership has since expanded substantially.
Although national governments are the main parties to the system,
representation of non-governmental organisations (NGOs) has increased.

NGO attendance at meetings of the Commission on Narcotic Drugs
increased10 from 81 in 2007, to over 300 in an NGO forum in 2009. Such
organisations cannot vote or contribute to debates; rather they seek
to influence the views of national representatives.

In the past, the few NGOs that attended mostly supported drug-free
approaches to treatment and agreed with the international treaties.

NGOs that now attend the meetings often have a drug reform agenda and
some include drug users as members.

These new organisations often campaign to increase funding for needle
and syringe programmes and opioid substitution treatment. Some11 have
advocated for policies that respect the human rights of drug users and
some want to change the international system.

The international drug control system has had to respond to a broad
range of views and growing critical scholarship.9, 12 So far, however,
the effects of civil society organisations in the drug control system
have been much less than in other areas of public health such as AIDS,
baby formula and breastfeeding, and tobacco control.8, 13 The upsurge
in international NGO activity is associated with substantial policy
changes in several countries, such as decriminalisation measures14 and
a ballot proposition to legalise cannabis in California. But people in
the official policy community""ie, on national delegations to the
Commission on Narcotic Drugs, or in international bureaucratic
positions""have a vested commitment to the existing system and have
kept civil society at bay.15

Informally, the USA has long had a leading role in the international
system.1, 6 The USA has strongly opposed harm reduction approaches to
illicit drug problems (eg, needle and syringe programmes, supervised
injecting centres, and heroin maintenance treatment), with support
from other nations such as Japan and Russia. The USA now accepts
needle and syringe programmes but still objects to use of harm
reduction wording in UN documents.8""10,16""18 UNODC used to share
this objection, but has become more accepting of measures such as
needle and syringe programmes.8

Since harm reduction is a core principle of public health,19 the
embargo on the use of this term is symbolic of the marginalisation of
the role of WHO in the UN drug control system.

At the end of the 1990s, WHO moved projects on reduction of HIV
infection among drug users to the UN agency on AIDS, which had some
protection from direct pressure from individual countries.20

WHO's advice has on occasion been ignored by the UNODC and the
Commission on Narcotic Drugs. In 2002, the WHO Director General, under
pressure from the UNODC,10 declined to transmit to Vienna a
recommendation by the 33rd expert committee that pharmaceutical
delta-9-tetrahydrocannabinol (the main psychoactive constituent of
cannabis) should be reclassified from schedule 2 to the lowest
schedule of the 1971 Convention. A similar recommendation by the 2006
expert committee was rejected by the Commission on Narcotic Drugs.10,
21

WHO and UNODC have resumed cooperation. In 2009, a UNODC and WHO
programme13 jointly produced drug treatment guidelines and a
discussion paper on the role of coercion in the treatment of
addiction.22 Nonetheless, the international system devotes more of its
resources (as shown in its budget allocations and the topics of
debates by the Commission on Narcotic Drugs) to suppression of illicit
drug markets than to direct protection of public health and wellbeing.

National drug policies

Despite the substantial uniformity in legal frameworks required by the
international drug control system, national drug policies differ in
priorities. Some nations (eg, China and the USA) treat drugs primarily
as a problem for law enforcement and so prioritise the suppression of
trafficking, whereas others (eg, the Netherlands and Portugal) focus
on help for drug users and reduction of the adverse consequences of
drug use. These variations show national attitudes towards drug use,
individual rights, and the role of government; the nature and history
of national drug problems; and the different ways in which drug use
affects a nation.6 For some nations, the drug problem is primarily a
domestic one, but for others (eg, Mexico and Nigeria) the greatest
damage to public health and safety arises from trafficking to the USA
and Europe. For example, in Mexico drug trafficking to the US market
has led to 35 000 homicides between 2007 and 2010.23 By contrast, much
less violence is associated with drug markets in many European countries.

Although these variations make it difficult to systematically compare
drug policy across all countries, some common features can be seen
among developed nations.24 Prevention programmes""primarily
school-based""attract modest funding.

Treatment for drug dependence is increasingly provided (eg, Australia,
the Netherlands, Switzerland, and the UK).6 Opioid substitution
therapy has become the mainstay of treatment for opioid addiction in
western Europe25 and in some developing countries (eg, Iran26). Other
countries with large numbers of heroin-dependent people refuse to
provide opioid substitution therapy, most notably Russia.27

Assessments of drug programmes have had a marginal role in the
formulation of policy even in developed countries that have heavily
invested in research (eg, Australia, Canada, the UK, and the USA). The
US National Institute on Drug Abuse dominates worldwide funding of
scientific research on drugs,28, 29 but does not fund research on drug
policy.

The greatest inconsistency between US policy and evidence is the mass
incarceration of drug offenders (about 500 000 individuals in 2005).30
A ten-times increase in the number of individuals imprisoned for drug
offences has occurred since 1980 despite declines in drug quantities
sold, in the number of drug users, and in estimated illicit
revenues.31 The evidence is clear that incarceration is an ineffective
way to increase the price and reduce the availability of drugs.32
National policy reforms within the international system

The international conventions severely restrict the ability of
national governments to experiment with alternative drug control
systems by requiring all signatories to criminalise non-medical drug
use. This constraint has had different effects on policies for
injected drugs like heroin and cocaine and policies for the most
widely used illicit drug, cannabis.

In the case of injected drugs, public health advocates in many
developed countries have successfully campaigned to provide clean
injecting equipment to prevent HIV transmission. Eight countries
(Australia, Canada, Germany, Luxembourg, the Netherlands, Norway,
Spain, and Switzerland) have provided supervised injecting centres to
reduce blood-borne virus transmission and overdose and to increase
drug users' contact with treatment services.27, 33 These changes,
which have largely been made without legislation to remove criminal
penalties for use, have been criticised by UNODC and the International
Narcotics Control Board as contrary to the treaties.

UNODC has now accepted that needle and syringe programmes and
treatment diversion programmes comply with the treaties, but the
International Narcotics Control Board continues to argue that the
status of supervised injection centres is unclear.34

In the case of cannabis, the main legislative experiments in the past
50 years have been to reduce or eliminate criminal penalties, or to
substitute civil penalties (eg, fines) for the use or possession of
the drug.14 This policy has been extended to all illicit drugs in
Brazil, Colombia, the Czech Republic, Mexico, and Portugal.14 Often a
statutory criminal penalty is retained to avoid conflict with the
international treaties.

The International Narcotics Control Board has argued that
decriminalisation of drug use and toleration of drug sales violates
the 1988 convention. Governments that have changed penalties and some
scholars35 disagree.

The UNODC has issued a discussion paper in which it argues that
diversion of illicit drug users into treatment is consistent with
international treaties,22 as long as criminal penalties are retained
in law.

No evidence is available on whether the presence or absence of
criminal penalties for use and possession of cannabis substantially
affects the prevalence of use or levels of health-related harm.6, 14
Criminal penalties are frequently enforced in a discriminatory way
against socially excluded minorities.14, 36 Therefore to justify the
criminalisation of cannabis use as a strategy to reduce use is difficult.

The reduction of penalties for cannabis possession and use while the
international treaties are complied with has often had the converse
consequence of so-called net widening.

Because the implementation of offences with reduced or non-criminal
penalties is not time-consuming for police, more young people might
receive police records for failure to pay fines than if criminal
penalties had been retained.14 Studies in North America and many
European countries show that arrests for cannabis use have risen
substantially in recent years, alongside reductions in the severity of
penalties for use.14

The Netherlands has moved the furthest away from criminal penalties by
de facto (but not de jure) legalising retail sales of small amounts of
cannabis in coffee shops.

Evidence that this form of legalisation has affected rates of use or
harm is scarce, although commercialisation could have done so.37 The
prevalence of cannabis use in the Netherlands is less than in
countries such as the UK, France, and the USA, which have retained
criminal penalties.14, 38

No developed nation has formally legalised cannabis supply to address
what is known in the Netherlands as the back door problem""ie, that
although front door sales of cannabis are de facto legal, the back
door supply of the drug is not. In parts of India, however, cannabis
shops operate under state government licences, a practice that has so
far escaped censure from the International Narcotics Control Board.14

The liberal definition of medical marijuana use in California is
arguably a form of de-facto legalisation of cannabis sales.

The Californian and local authorities have partly addressed the back
door issue by allowing non-profit cooperatives to supply cannabis to
medical dispensaries.39 To legally access medical marijuana, a patient
must have a doctor's letter specifying that he or she has a health
disorder that could benefit from cannabis use. Over 200 000 patients
are claimed to have such letters40 (8% of the estimated 2 500 000
past-month cannabis users in the state41). Doctors in California
advertise provision of these letters for under $100, often for
disorders (eg, anxiety, sleeplessness, and pain) for which evidence of
benefit from controlled trials is scarce.39

The table provides a summary of the outcomes of five major changes in
law with regard to criminalisation of cannabis use at the state or
national level, as well as an assessment of the limitations of the key
research studies.

TableTable:
http://www.thelancet.com/journals/lancet/article/PIIS0140673611614232/table?tableid=tbl1&tableidtype=table_id§ionType=green
Assessment of changes to laws about criminalisation of drug use

How successfully has the international system achieved its
goals?

Access to pain medication

The international system has ensured supplies of opioids for medical
need in developed countries, but WHO has estimated that 80% of the
world's population has either no or inadequate access to effective
pain medication.51 The International Narcotics Control Board
acknowledges that such difficulty with access "oecontinues to be a
matter of concern" .52 One factor seems to be that the international
system's emphasis on policing has encouraged nations to give a greater
priority to prevention of diversion of prescribed opioids to the black
market than to provision for pain control.6

Reduction of illicit markets

The system has failed to achieve its original goals of elimination of
illicit markets and the non-medical use of controlled drugs.

In 1998, the UN system set the more restricted but still ambitious
goal of "oeeliminating or significantly reducing the illicit
cultivation of coca bush, the cannabis plant, and the opium poppy by
the year 2008" . However, by 2009, this goal was as distant as it was
in 1998.53 Between 1998 and 2009, the production of synthetic drugs
such as 3,4-methylenedioxymethylamfetamine (MDMA) and metamfetamine
increased, as did domestic cannabis cultivation in many developed and
developing countries.54

According to the UNODC, between 172 million and 250 million people
worldwide were estimated to have used an illicit drug in 2007.55
Cannabis is the most commonly used prohibited drug and accounts for
nearly three-quarters of users. Mass markets for cocaine, heroin, and
some other prohibited drugs exist in many developed and some
low-income and middle-income countries. Injecting drug use has become
a worldwide issue that has contributed to the spread of HIV/AIDS.27
The non-medical use of prescription opioids, benzodiazepines, and
stimulant drugs has also increased since the early 2000s, particularly
in North America and Australasia.56""58

Health and wellbeing

The goal of increasing health and wellbeing by eliminating
drug-related harm has also not been met. Injecting drug use of heroin
and other opioids, amphetamines, and cocaine is the least common form
of drug use but harms the most users through fatal overdose, HIV
infection, and injury.

As discussed in detail in the first report in the Series,55 although
global health burden related to cannabis use has not been estimated,
estimates in countries with high rates of use (such as Australia and
Canada) suggest that cannabis accounts for a small part of the health
burden attributable to illicit drugs.59, 60 Diverted prescription
drugs have had a growing role in illicit drug use, although the global
burden has yet to be quantified.61

The spread of non-medical drug use has been accompanied by steady
reductions in illicit drug prices and increases in drug purity in many
countries.6 This situation has occurred despite increased expenditure
on law enforcement in most developed countries (most notably in the
USA, which has the best time series data on price and purity).62

Has the international system improved human health and
wellbeing?

Major challenges exist in assessment of the effects of the
international control system on human health and wellbeing.

First, to separate the effects of the treaties from the effects of the
national policies implemented in accordance with their provisions is
impossible. Second, criminalisation of the non-medical use of these
drugs ensures that we have poor data on the extent of and the harm
caused by their use.55

These challenges notwithstanding, to argue that the effects have been
beneficial is difficult.

Illicit drug use and the contribution of illicit drugs to the burden
of disease have increased worldwide over the past decade.55
Anti-trafficking efforts have harmed many nations where these drugs
are produced and through which they are transshipped. Criminalisation
of drug use has many adverse consequences for drug users and their
families.63 The system's emphasis on criminalisation has substantially
increased imprisonment, with drug offences accounting for a large
proportion of all imprisonments in most high-income countries.

Evidence that the adverse effects of imprisonment of drug offenders
can be justified by reductions in availability of illicit drugs or in
rates of use is absent.64

Extremely punitive national responses have also flourished under an
international system that has given greater priority to control of
drug markets than to human rights.

Iran, for example, might have executed as many as 10 000 drug
traffickers in the 1990s. A Thai crackdown in 2003, known as the Thai
war on drugs, resulted in 2275 extrajudicial killings in 3 months.6
These responses are not directly encouraged by the international drug
control system, but the system's vilification of drug trafficking and
criminalisation of drug users have created a moral environment that
legitimises these responses.65

The main defence provided for the international system is that illicit
production and drug use and harm would have been an even bigger
problem had the system not been in place.66 This claim is difficult to
assess for two main reasons.

First, to predict which national policies would replace the existing
system is impossible. Many nations would probably leave policies
unchanged. However, we believe that some nations would experiment with
reduction of criminalisation, at least with regard to use of illicit
drugs. If these innovations were successful, many nations might lower
criminalisation. Second, to estimate what rates of drug use and drug
harms would be under these new systems is a challenge.38 Research
summaries6 suggest that the effects of increased criminalisation on
prevalence of drug use is negligible. The proposition that the
international drug control system has had a positive effect on human
health and wellbeing is difficult to defend, even if precise
accounting for the system's aggregate effects is impossible.

Moving towards risk-based drug control systems

Options within the international system to improve the wellbeing of
drug users are few. Research33 lends support to harm reduction
services for problem drug users (eg, opioid substitution treatment,
needle and syringe programmes, antiretroviral treatment, and other
psychosocial interventions), most of which the international system
now supports.

These developments in harm reduction are welcome, but a more radical
overhaul of the international system is needed to attune it to
differences in the risks posed by different prohibited drugs.

Four main models of drug control exist (panel 2); control systems
under these models differ in how much they limit or structure the free
choices of adults, in how severely they punish individuals who
contravene the rules, and in how effective they are at minimising
rates of use and drug-related harm.38

Panel 2

Models of drug control

Prohibition

Prescription systems, in which a licensed health practitioner controls
access to the drug

Market regulation, in which the state distributes or licenses
producers and retailers to sell the drug under various conditions
(often includes contexts of use)

Regulation of consumers""eg, by setting age limits, requiring ration
cards, or prohibiting certain behaviours, such as driving after drug
use14, 67, 68

A rational and evidence-based system of drug control that aims to
improve public health should differentiate between psychoactive
substances (and the circumstances of their use) on the basis of the
risks of each drug to users and others.

Such a system would also take account of the harm that could arise
from the social policies (such as criminalisation of use) introduced
to reduce drug use.63, 69

The necessary evidence for such a risk-based approach is accumulating.
The comparative risk analysis of the global burden of disease
estimates for 2000 found that, on the basis of patterns of use at that
time, alcohol and tobacco were about equally harmful to users in terms
of the total disability-adjusted life-years lost worldwide.

Illicit drugs (mainly opioids) accounted for about one-fifth as much
harm as did alcohol and tobacco.70 Evidence has also been accumulating
on the effectiveness of different policies that aim to minimise harm
from psychoactive substances.6, 14, 71

Neither international nor national systems of drug control are based
on estimations of risks from drug use, or on the consequences of
different control mechanisms. Conspicuously, few international
controls are in place on the two most harmful substances in the
comparative risk analysis of global burden of disease: alcohol and
tobacco.

No international agreement exists for alcohol and the provisions of
the Framework Convention on Tobacco Control are far weaker than those
of the international drug treaties.72 Prohibition of the non-medical
use of substances covered by the treaties precludes regulation via
market and availability controls.

That which is prohibited cannot easily be regulated.14

Cannabis is the drug whose inclusion in the international system is
most often seen as anomalous because it is widely used by young adults
in many countries, and its health effects are much less harmful than
those of the opioids and stimulants.46, 73 However, the treaties
prevent any experimentation with alternative policies for reduction of
harm associated with this drug.

Amending the treaties

The international drug conventions allow for their amendment, but the
conditions that have to be met to do so make change difficult.

Nonetheless, without amendment, other ways for a country, or group of
countries, to move forward are possible in principle.

The least disruptive way would be for countries to reassert their
authority to adopt a regulatory rather than prohibitory system
domestically for one or more drugs, while continuing to meet their
obligations under the treaties to control international trade in drugs.14

The most feasible way for an individual country to do so would be to
withdraw from one or more of the treaties and then re-accede with
specified reservations.74, 75 For example, Switzerland and the
Netherlands ratified the 1988 treaty with a reservation against the
provision that required the criminalisation of use and possession.
Bolivia is using the strategy of withdrawal and re-accession to allow
internal legalisation of coca leaf chewing.76

Alternatively, a group of like-minded countries could agree on a new
international treaty which would then take precedence with respect to
their internal markets and their dealings with each other.

Panel 3 sets out the options, for instance, for a group of nations
that proposed a move to a regulated cannabis market.

Panel 3

How to move to a regulated market in cannabis without conflicting with
the international control system?

Any system that allowed the regulated availability of controlled
substances for non-medical use would contravene the international drug
conventions. Hence, any government that wished to experiment with such
a system for cannabis must either ignore international legal
obligations or go beyond the conventions in one of the following ways:14

Countries such as the USA with a constitution in which national law
has equal status with international law could pass a new national law
that conflicted with the treaties.

Under the constitution, this new law would take precedence. A country
that adopted this option would have to withstand substantial
international opprobrium.

A nation wishing to establish a regulated cannabis system could
withdraw from the applicable conventions and then re-accede with
specific reservations.14, 74, 75 This procedure is recognised in
international law. A group of nations could adopt a new treaty in
conflict with the existing treaties; under international law this
treaty would take precedence between the signatory nations.

A framework convention on cannabis control has been drafted along
these lines, modelled on the Framework Convention on Tobacco Control.14

Conclusions

During the time that international drug control treaties have been in
place, the stringency and complexity of the international system and
the number of substances controlled have substantially increased.

No evidence suggests that illicit drug production or use have
lessened, but the system has had many adverse effects on human health
and wellbeing.

National experimentation in approaches to prevention and reduction of
drug-related harm should be allowed.

The international drug treaties in their present form seriously
constrain governments' capacities to engage in such policy
experiments. They have restricted the freedom of action to change
penalties for personal use, with the result that reduction in
penalties has sometimes counterproductively increased the numbers of
young people penalised for drug offences.

Countries that wish to experiment with different ways of regulating
drug use and reducing drug-related harm will need to consider opting
out of provisions of the existing drug control treaties.

The cultural positions of different drugs vary enough to preclude
universal policies on how to deal with all illicit or indeed licit
drugs.

From the perspective of public health, we need to move towards a
control system that is more aligned with the risks that different
drugs pose to users and shows an understanding of the effects of
different regulatory approaches on drug use and harm.

Contributors

Both authors contributed equally to the writing and review of this
report.

Conflicts of interest

RR has been provided with support for travel by the Beckley Foundation
for drug policy research project meetings and reports.

RR's professorship is supported by the Victorian Department of Health
and the Foundation for Alcohol Research and Education (FARE), and his
research by FARE and government research grants.

PR has been provided with travel support and honoraria by the Beckley
Foundation for drug policy research project meetings and reports.

Acknowledgments

We are grateful to Louisa Degenhardt, David Bewley-Taylor, John
Strang, and Keith Humphreys for their comments and suggestions, to
Sarah Yeates for her help in referencing and formatting, and
particularly to Wayne Hall for his advice and help.

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a Centre for Alcohol Policy Research, Turning Point Alcohol and Drug
Centre and School of Population Health, University of Melbourne,
Melbourne, VIC, Australia

b School of Public Policy and Department of Criminology, University of
Maryland, College Park, MD, USA

Correspondence to: Prof Robin Room, Centre for Alcohol Policy
Research, Turning Point Alcohol and Drug Centre and School of
Population Health, University of Melbourne, 54""62 Gertrude Street,
Fitzroy, Melbourne VIC 3065, Australia