The right medicine for World Drug Day.

Through the United Nations Office on Drugs and Crime (www.unodc.org), June 26 is the declared World Drug Day - the International Day Against Drug Abuse and Illicit Trafficking. Their credos include “We can all play a role in promoting health in our communities” as well as a call for “Global action for healthy communities without drugs”. As we strive in this cause for improved health and welfare of our fellow citizens by reducing the damage to humanity from drug abuse, advances in medicine and treatment are a call for hope. Reductions of drug abuse, however, will not just come about by identification and application of new medical interventions but also by revising education and public health policies, poverty reduction, anti-corruption efforts, and upgrading the politics of criminal justice and interdiction. It is essential to accept that any discussion of drug abuse must start with the two most dangerous substances of all: tobacco and alcohol. Tobacco is the leading preventable cause of death on this planet1. Tobacco kills more people worldwide than HIV, tuberculosis, and malaria combined with approximately 5.4 million deaths per year. Death from alcohol worldwide is some 2.5 million per year, which also far outpaces death from all other remaining drugs of abuse combined2. It is also important to understand that drug abuse is increased when the substance is stripped from its cultural/ritualistic purpose. Tobacco is, for example, revered by all Native peoples in the Western Hemisphere from Alaska all the way down to southern Chile: it is used as an offering and in prayer to the Creator. Soon after Columbus “discovered” the “New World” – tobacco was stripped from its spiritual context, and its misuse is an entrenched pandemic. This loss of ritual and context repeats across substances: sacramental alcohol in certain religions does not fuel alcohol dependence. The chewing of coca leaves in the high Andes does not promote cocaine abuse. Even the peyote cactus, which contains the hallucinogenic substance mescaline, is safely consumed by more than 500,000 American and Canadian Native peoples as an expression of their religious faith in the Native American Church: no one has ever identified such prayer services as fomenting a torrent of hallucinogen abusers. It is the pathological relationship with a drug that is the source for drug abuse and dependence: we must recognize that it is how drugs are consumed which leads to harm - and so it is open, honest drug education that includes what drugs do and not do, harm and not harm, that must champion the social advancement called for in a World Drug Day. There are important medications that help treat some forms of substance dependence. For alcoholism, disulfiram, accamprosate, and naltrexone help prevent or limit reuse of alcohol. For tobacco, nicotine replacement helps the user transition to abstinence, buproprion changes tobacco's flavour to something less appealing for many, and varenicline is a partial agonist at the same nicotinic acetylcholine receptors as tobacco. Opiate dependence can be interrupted by the agonist replacement methadone, the partial agonist/antagonist product buprenorphine/naloxone, or long-term depot injection of naltrexone. Vaccines are being developed for cocaine3, and other drugs, which may one day effectively extend abstinence in the early days after quitting. But we must not turn from any potential strategy that may lead to harm reduction and promotion of recovery from drug abuse. Having access to clean needles can reduce the transmission of HIV infection4. Perhaps even more surprising is that the best treatment for the committed, most serious category of opiate dependent patients is to provide heroin itself. This model has been piloted and expanded with great success in Switzerland5 and Germany6. New paradigms of public health must also help dismantle existing criminal justice systems that push drug abusers deeper into hiding their problems out of fear of censure, arrest, and imprisonment. It is hard to imagine this lofty goal of “healthy communities without drugs” when we can not even prevent alcohol from surreptitious manufacture in our prisons. Legalization may reassure more abusers to step forward for assistance. Legalization would also damage the huge profit incentive for criminal manufacture and distribution. Funds plowed into police and military tactics might be better spent for treatment, demand reduction education programmes, and improving access to medicines and other therapies. But whether we turn to legalization or expanding a more crushing form of Drug War, in either case it may be most practical to accept that we must move beyond goals that stifle the human spirit that sometimes even intentionally chooses the harmful path. When one sees firsthand the damage to the poorest and most vulnerable, it is hard to accept either the roadmap to legalization or to expanded criminalization as pointing to the solutions called for on an International Day Against Drug Abuse. Alcohol and tobacco are legal and criminalized but their abuse remains. Inhalants are legally available and then diverted for intoxication: what model of treatment or intervention will ever prevent all abuse except through social development, education, and compassion for the user? This is just as needed for Native peoples in Alaska7 as it is for those caught up in addiction in Punjab8. As we have compassion for so many rejected groups, it is my fervent hope that we will lead with our moral covenant to uphold and uplift life including those that suffer from all forms of drug abuse. An International Day Against Drug Abuse needs to be a year-round effort for much, much more. We cannot just dream these dreams: we must live these dreams. The drug abusers and drug dependent are our children, our siblings, our parents, our extended families and friends. Medical research will empower physicians with radically more potent tools against drug addiction, but our most potent treatment is nestled within our hearts. Lives are saved when we hold to such ideals.