Real Change or Changing Rhetoric? Monitoring the Shift in US Drug Policy

Since President Obama's election, the Office of National Drug Control Policy (ONDCP) has been making noises about a shift in approach and priorities towards addressing drugs and drug problems -- as opposed to its previous "War on Drugs" approach, which criminalized what is primarily a public health issue. Last month's 53rd Commission on Narcotic Drugs (CND) meeting was a marker on how the US would present this much-ballyhooed new face to the international community.

But first a word of explanation about the CND to set the stage for understanding this year's events and its significance. The CND is the United Nations entity charged with setting global drug policy and passing it down to the UN Office on Drugs and Crime (UNODC). Each spring the CND has its yearly meeting at its headquarters in Vienna. Last year's CND (the infamous 52nd annual meeting) was a tempestuous event centering on the inclusion of the term "harm reduction" in the major Political Declaration intended to sum up the findings and recommendations of the meeting. Although CND is a consensus-driven event, 26 countries bolted at the close in protest when "harm reduction" was excluded from the Political Declaration. Remember, for other countries, harm reduction is the designated approach to addressing drug use. To exclude it is a denial of reality and a slap in the face of countries that have embraced it.

This CND looked to be different. For one, the new ONDCP political appointees named by the Obama administration were the first indicator of change. The ONDCP Director (or "Drug Czar," in common parlance) is Gil Kerlikowske. He may be a law enforcement appointee -- a top cop -- but his latter-day experience was as Chief of police in Seattle, a city with a large needle exchange program in a part of the country that has integrated a harm reduction approach into its drug strategy as well as hosting an active drug reform community. Kerlikowske's No. 2, the newly appointed ONDCP deputy director, is Tom McLellan, a well-known proponent for drug treatment. In a very early sign of the new administration's break from its predecessor, Kerlikowske declared the term "War on Drugs" an unhelpful appellation. (He also let it be known that changing the tack of the former strategy would be like altering the course of a massive oil tanker.)

Even before these ONDCP appointments, the U.S. under the Obama administration publicly reversed its position on syringe exchange by acknowledging that the science was indisputable: as an intervention for stemming the spread of HIV among drug injectors, syringe exchange works. This was a 180 degree turn from the previous administration. And yet, while the new ONDCP clearly embraces some of the tools and methods of the harm reduction approach to addressing drug problems, it still considers the term itself taboo.

Another hopeful sign: the new ONDCP shows some measured degree of openness to engaging members of the harm reduction community. We, like all other progressive change communities, never managed to have any real discussion or dialogue with ONDCP staff under the Bush administration. When, at last year's CND meeting, which took place just months after Obama's inauguration, several of us in the harm reduction camp left a hard-worked-for meeting with some ONDCP staff, a member of the latter remarked that this was the first time that the US delegation had been allowed to meet with "drug legalizers." (Within the ONDCP bubble, any group that challenges the prevailing drug war paradigm is labeled a "drug legalizer" -- a term in the U.S. propaganda clampdown that has nothing to do with regulating drug markets and everything to do with selling crack to 5th graders.) The so-called "drug legalizers" that talked to the delegation in Vienna last year included such organizations as the Harm Reduction Coalition, Human Rights Watch, and the Washington Office on Latin America -- all of whom have a serious critique of the failings of U.S. drug strategies but none of which actually work on drug legalization.

It's honestly hard to tell at this point whether the ONDCP's new approach is a cynical placation device or a more genuine but wary openness and curiosity. Consider the 45 minute conference call with Director Kerlikowske during which 10 or so drug reform groups were invited to make three or four points towards the development of ONDCP's new soon-to-be-released drug strategy. (Again it was all of the pigeon-holed "drug legalizers" on this one particular call.) On the one hand, inviting us was a tokenistic and nonsensical gesture; on the other, it was the first time that a diversity of input was considered.

But I digress. Back to last month's 53rd Commission on Narcotic Drugs, which promised to be less controversial than the tension-ridden 52nd and more of a convivial lovefest. We were watching to see how the U.S. presented itself to the world. Could it be a uniter or would it continue in its divisive approach? Things started looking up the very first day, with opening speeches from Kerlikowske and McLellan. Both men's presentations were eminently pragmatic, reasonable, knowledgeable -- and devoid of War on Drugs rhetoric. McLellan's approach was the treatment angle. Kerlikowske disappeared to trade war stories with the Russians but his Deputy stayed throughout and was a charm. "Is the glass becoming more than half full?" I wondered in my daily blog post.

In fact, as I note in my post from the first day, Commission on Narcotic Drugs: Progress Towards a Pain Free World? the U.S. sponsored a resolution that may allow more access to pain medication for chronically- or terminally- ill patients. This may not seem like a big deal here in the US, where patients in the last stages of illness are often provided with liberal amounts of pain medication. But we are, as a recent, excellent report from Human Rights Watch, notes, the exception: 150 countries have no access to medical opioids or other effective pain medication. No morphine, no Fentanyl -- no nothing. Since what the U.S. says often goes, global drug policy-wise, for both better and worse, this resolution could have a true positive impact on people's lives worldwide. It was refreshing to hear McLellan critique the shortcomings of the current U.S. drug treatment system. (Here is my full post, Reforming Drug Treatment in the US: Two Steps Forward, One Step Back.)

In contrast to the usual rhetoric, which places all the blame for failure on users and accredits all good news to the wonders of the current system, McLellan called for market-driven reforms -- reforms that take into account the needs of drug users.

But here's the rub. Despite McLellan's talk of a market-driven system, the US is still averse to the inclusion of the words "people who use drugs" in international resolutions and documents, and continues to actively work to have this language removed. And that clause usually appears in the context of having drug users at the table so that they can have input into policy and service development. If the US is serious about addressing stigma, exclusion, and discrimination against people who use drugs, shouldn't it come up with a plan to do so without stigmatizing, excluding and discriminating against them?

Finally, as I noted in my wrap-up post -- Most Improved (Drug Policy) Player: the USA -- the U.S. remains, despite its realigned approach to drug policy under the new administration, doggedly opposed to the actual use of the term "harm reduction" while simultaneously supporting many of the practices associated with it. For example, the U.S. statement regarding demand reduction reinforced this administration's support of needle exchange as well as every intervention that appears in the UNODC, WHO, UNAIDS Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. But it also made clear that the U.S. doesn't support harm reduction interventions that it doesn't consider geared toward decreasing drug use, such as safe injection sites.

It's too bad that this view -- so adamantly stated -- isn't based in fact. Take the research on Insite, the safe injection facility located in Vancouver, Canada that has a drug treatment facility within its premises. Research shows that clients of Insite increased their use of both its short-term detox and long-term drug treatment facilities. Add to that the fact that programs providing prescription heroin to users also appear to have been maligned: again, studies show that participants decrease their use of illicitly bought heroin and other drugs.

The public face of the U.S. at the 53rd meeting of the Commission on Narcotics Drugs was a reasonable one. I found myself more in agreement than disagreement with most of the statements and presentations. It was a middle ground. Less of an "eliminate all drug use" approach and a more health-centered approach. The next step in turning this boat around is action. The ONDCP strategic plan is out soon. Will there be some heft, money, and political clout behind the rhetoric? Will ONDCP step out of its comfort zone and move a little beyond an abstinence-based approach?