9

The Consensus Crumbles

Afew days before the special UN session of 1998, an open letter landed on Kofi Annan’s desk. A long list of academics, journalists, diplomats, legislators and cabinet ministers from countries belonging to the six continents had had enough. ‘We believe that the global war on drugs is now causing more harm than drug abuse itself.’¹

Prohibition, they wrote, had only empowered organized crime, helped corrupt governments, stimulated violence and distorted both commercial markets and moral compasses. The UN had an essential role to play in combating the harm from drugs, but only if it was willing to face tough questions about past efforts. A fresh response was required, focused on health, education and development rather than on yet more interdiction efforts. ‘Realistic proposals to reduce drug-related crime, disease and death are abandoned in favour of rhetorical proposals to create drug-free societies,’ the letter complained. ‘Mr. Secretary-general, we appeal to you to initiate a truly open and honest dialogue regarding the future of global drug control policies – one in which fear, prejudice and punitive prohibitions yield to common sense, science, public health and human rights.’²

For ten years or so already, public challenges to the drug-control order had been gathering. Drug prohibition had always had its critics: politicians who found its characterizations excessive, doctors who resented the misappropriation of addiction theory, artists who complained of the constraints on their creativity. The failures of the war on drugs in its post-Nixon phase, from the 1980s onwards, now encouraged a large number of people to speak out for the first time. The first protests emerged in the USA, the country most actively and visibly committed to the fight. As the 1998 address confirmed, however, challengers to the consensus were by then arising everywhere.

Historically, there was no lack of alternative models to drug prohibition. The alternative best known to contemporaries was the free-for-all that had prevailed in the United States and Britain in the nineteenth century and into the early twentieth. But even the nineteenth century offered other precedents: the regulatory regime reliant on pharmacy laws long prevalent in France, Germany and a number of other European countries, for example. What one might call the Franco-German or the Continental model neither punished nor explicitly outlawed recreational use, permitting drugs to be sold only in pharmacies and on prescription. (This model had witnessed far lower rates of opiate use than in the USA or UK.) The apparatus of prohibition consists of an overlay of punitive legislation – national and international – over a set of pharmacy laws. Remove the punitive superstructure and there remains a system by which drugs are legally limited to the medical sphere, albeit one that shows far fewer teeth in punishing contraband and infringement. It might be called prohibition lite. Under it, drugs revert to what they were originally – medicines – and are treated as such at every step.

A third paradigm available for historical comparison is offered by the Southeast Asian opium monopolies of the interwar period. This consisted of government monopolies of varying geometry, sometimes encompassing cultivation and/or production, sometimes the retail trade, and always imports and exports. Under the regime that became most typical of the end of that period, consumers were registered, with the effect that the supply of drugs was limited to established users and closed to new applicants. The idea was that user numbers would trend down, but the same mechanisms could be deployed to manage the pains of a stable or growing population. The principle was that of another model for dealing with drugs of addiction: the British system as it emerged in the wake of the 1926 Rolleston Report.

The post-Rolleston drug regime was the product of a classically British compromise. It existed in practice more than in the law, and it may even be described as encompassing two conflicting systems, one run by doctors and the other by the Home Office, coexisting in a state of mutual respect. When this balance was lost, in the late 1960s, the system shrivelled without the intervention of any fundamental legal change. Yet the so-called British system was important because, even as it entered the end of its life, it became a point of reference for those seeking alternatives to the war on drugs, especially in the USA. Its central feature was also destined to become a key weapon in the armoury of drug-control challengers elsewhere: drug maintenance.

At the initiative of Sir Malcolm Delevingne, under-secretary at the Home Office responsible for drugs, Britain had during the First World War passed the anti-narcotics directive known as DORA Regulation 40b. This was formalized and extended in the first major piece of British anti-narcotics legislation: the Dangerous Drugs Acts of 1920. Delevingne, who also became the chief drug-fighter on the League of Nations’ Opium Advisory Committee, was for ‘stamping out addiction’ as the Americans were doing.³ The law, however, specified that listed drugs were allowed for legitimate medical purposes. Delevingne felt compelled to turn to the Ministry of Health in order to establish what exactly this meant. At stake was whether prescribing to addicts on the grounds that they could not do without their drug – a practice known as maintenance – constituted a legitimate medical purpose.

The task of investigating the matter was given to a Departmental Committee on Morphine and Heroin Addiction, chaired by Sir Humphrey Rolleston. All the Rolleston committee members were medical men, though one was also an analyst at the Home Office. While the committee did not quite speak with one voice, its key members, including Rolleston himself, were convinced of the need to protect the addict from the ravages of penal law. The result was an official statement that the long-term prescription of drugs to patients to treat their addiction was legitimate medical practice. Addiction was a private matter that belonged nowhere else but in the relationship between patient and medical practitioner. The Home Office need not be notified, let alone allowed to punish either doctor or patient.⁴

The report, published in 1926, did not have the force of law, but its recommendations were written up in a memorandum distributed among the medical- and dental-care professions. The medical world would decide who deserved to receive morphine, heroin or cocaine. Anyone who dealt in or took drugs outside it remained at the mercy of law enforcement. (That there were few addicts and that they were predominantly middle-class people viewed as respectable helped cement the compromise.) Tribunals were established to decide, in borderline cases, whether there were ‘sufficient medical grounds for the administration of the drugs by the doctor concerned’, leaving the Home Office the last word under this delicate balancing act.⁵

In the USA maintenance had briefly survived the passage of the first great piece of anti-narcotics legislation, the 1914 Harrison Act. A number of outpatient clinics dispensing heroin and cocaine preexisted the Act, and many more were set up after its passage.⁶ The new law permitted a doctor or druggist to dispense drugs ‘in the course of his professional practice only’. Whether this included maintenance was no clearer than under Britain’s Dangerous Drugs Act. The difference was that the question was resolved, in the USA, in the courts. The issue was probed by the Supreme Court in the 1920 case of a Pittsburgh physician, Jin Fuey Moy, who had been selling morphine prescriptions to addicts for the purpose of maintaining their habit. Moy was condemned for providing or selling prescriptions to persons who were not his usual patients and ‘for the mere purpose . . . of enabling such persons to continue the use of the drug’. The defendant was a known ‘dope doctor’, and the precedent was therefore not entirely clear-cut. United States vs. Behrman, dated 1922, laid all remaining doubts to rest: Behrman, a doctor, had given prescriptions for grains of heroin, morphine and cocaine to a patient named Willie King, yet ‘King did not require the administration of either morphine, heroin, or cocaine by reason of any disease other than such addiction.’⁷ The court condemned Behrman. Maintenance, the jurisprudence now said, was illegal.

The American maintenance clinics swiftly closed. Anslinger would liken them to ‘stations to spread leprosy and smallpox’.⁸ Maintenance was rejected in favour of the search for a cure. In order to keep addicts out of prison, the Public Health Service opened two institutions known as narcotic farms, located in Lexington, Kentucky, and Fort Worth, Texas. The farms, which opened in the 1930s, provided a three-phase treatment: a thirty-day profiling phase that began with ten days of detoxification, a phase of several months employed in farm work or crafts, and a final phase of preparation for the return to the outside world.⁹ The Lexington facility also ran an addiction research centre. Where exactly the farms fitted within the penalization of drug use was ambiguous. Their original reason for existence was to separate those convicted on possession charges from traffickers. But attendance was usually compulsory, and a secondary aim was to keep addicts under confinement while they were being rehabilitated. For this reason and for their forbidding aspect, they were sometimes called ‘prison farms’.¹⁰ The author of Junky, William S. Burroughs, provides his own unique take on them: ‘There was nothing wrong with the accommodations, but the inmates were a sorry-looking lot. In my section, there were a bunch of old bums with the spit running out of their mouths. You are allowed seven days to rest in population after medication stops. Then you have to choose a job and go to work. Lexington has a complete farm and dairy.’ After these seven days, Burroughs, sick from withdrawal, absconded in search of drugs with a group of inmates.¹¹

Apart from this option of dubious worth, the American drug user, if caught by law enforcement, faced the harsh penalties of incarceration. As sentencing toughened in the 1950s, prominent organizations such as the American Bar Association and the American Medical Association became alarmed. Having failed to derail the legislation which, in that decade, enshrined the ever harder penalization of drug users, they turned to the British system for a potential way out.¹² If the addict could discreetly be maintained on his or her drugs by a doctor, perhaps he or she could be kept out of Anslinger’s clutches in the first place. Maintenance, though not quite an alternative form of legalization, can if generalized become tantamount to user decriminalization, albeit under medical supervision. Prominent writers on drugs of addiction came to vaunt the British system, notably Alfred Lindesmith, a long-time critic of the nexus between addiction theory and punitive drug laws, and Lawrence Kolb, an addiction researcher and the Lexington farm’s first director.¹³ Into the 1970s two major research institutions, one private (the Drug Abuse Council) and one public (the National Institute on Drug Abuse) would be conducting major studies of the history of British drug policy.¹⁴

The paradox was that just as it was being rediscovered across the Atlantic, the British system came under attack at home. In the next twenty years, it was Britain who ended up adopting America’s harsher model, not vice versa.

Ostensibly the Rolleston compromise collapsed because a handful of gullible doctors were discovered to be prescribing heroin pills to addicts who were obviously reselling them on the black market. In the background stood official distress at the seeming glorification of drugs in 1960s youth culture and rises in drug use. The Home Office checked on the proper functioning of the Rolleston norms through an interdepartmental committee: this reported in 1961 that all was well. Such was not the conclusion of the second report of the Brain committee, named after its chairman Sir Russell Brain, published in 1964. A few doctors were making large prescriptions to patients who could only be reselling the pills. Indeed, the case narrowed down to that of one London doctor, Lady Isabella Frankau, whose philosophy was that addicts should never be denied what they asked for: ‘In 1962 one doctor alone prescribed almost 600,000 tablets of heroin (i.e. 6 kilogrammes) for addicts. The same doctor, on one occasion, prescribed 900 tablets of heroin (9 grammes) to one addict and, three days later, prescribed for the same patient another 600 tablets (6 grammes) “to replace pills lost in an accident”.’¹⁵

The committee’s solution was, first, to raise supervision one notch by asking doctors to notify addicts to a central authority and, second, to restrict the right to prescribe dangerous drugs to authorized treatment centres.¹⁶ Nothing changed in the law. On paper, the Rolleston system was modified even less fundamentally than the Brain committee recommended: theoretically individual doctors continued to be allowed to prescribe heroin or cocaine, provided they obtained a licence to do so. From 1968, nevertheless, practices changed, causing the old system to wilt. The Home Office had taken control, breaking the balance that had prevailed for forty years. It issued more than five hundred licences, but almost all of them went to psychiatrists, all hospital-based.¹⁷

The psychiatrists decided that addicts could and should be cured through abstinence. Clinics or ‘drug-dependency units’ could theoretically still dispense drugs for addict maintenance but, endowed with fresh ambition and matching support staff (doctors, nurses, social workers, psychologists), they adopted the loftier goal of full rehabilitation. The drug-dependency units moved away from prescribing heroin except as a bridging measure: between 1971 and 1978, just as British opiate use began to boom, the amount of heroin they prescribed fell by 40 per cent. Most clinics had by the mid-1970s adopted a strict withdrawal programme in lieu of long-term prescribing.¹⁸

Just as it was attracting increasing interest abroad, then, the long-prevalent British practice of drug maintenance was coming into disuse. More than the rectification of a prescribing particularity, this was a shift away from drug liberalism: if addicts are able to obtain drugs at will, at least for private consumption, from doctors rather than street dealers, their habit is effectively decriminalized and the black market sidelined. At the same time, since the shift in the British system did not rely on legal change, it could be reversed again. This is what happened in the 1990s when, partly as a result of pressure from the mounting aids epidemic, some of the drug-dependency units picked up heroin maintenance anew. By then, however, a lively debate over the merits of drug prohibition in general had taken hold both at home and beyond British shores.

The United States and other developed countries were pouring significant means into supply suppression in Latin America and Southeast Asia. So far they had little to show for it. The war on drugs was not leading to falls in user numbers. This was the first trigger for contestation. The second was the aids epidemic. People who injected drugs were dying from aids and they were passing the disease around. Illegality was helping neither tracking nor prevention. Both factors, emerging in the second half of the 1980s, gave vent to the first systematic challenge to prohibition in at least half a century.

The signatories to the 1998 letter included a number of political figures nationally known in their home countries alongside jurists, diplomats and personalities from journalism and the arts. Prominent American figures involved in the fight included the mayor of Baltimore Kurt Schmoke and ex-Secretary of State George Shultz. Ten years earlier, Schmoke had been one of the very first to call for a national drug-policy overhaul. His proposal – to legalize all drugs, whether marijuana, heroin or crack cocaine – had attracted significant media attention at the time and acted as a catalyst for the nascent drug debate.¹⁹ George Shultz had been Secretary of State under Reagan and was as such one of the architects of the conflict’s late militarization. His support for a change of tack spoke loudly as to suppression’s supposed successes in Latin America.

Equally important were the academics – sociologists, historians and, in particular, criminologists – who fed the debate with data and questioned its assumptions. Key contributors included the criminologist Arnold Trebach and the political scientist Ethan Nadelmann. Nadelmann’s Lindesmith Center, founded in 1994, coordinated the open letter to Kofi Annan. It would merge in 2000 with Trebach’s Drug Policy Foundation, founded in 1987, to form the Drug Policy Alliance (DPA). In the twenty-first century the DPA would go on to play a key role in the legalization of marijuana in multiple American states. Significant debate participants otherwise included the historian David Courtwright, the sociologist James Inciardi and, in Europe, the French sociologist Anne Coppel and the Dutch criminologist Tim Boekhout van Solinge, to name but a few.

The star of liberal economics Milton Friedman was another 1998 signatory. Though Friedman was not a regular drug commentator, his involvement was important because it stood for the philosophical argument for liberalization. The University of Chicago economist had made the case against drug prohibition as early as 1972. In a Newsweek opinion piece, just as Nixon was beginning to take down the French Connection, Friedman had warned: ‘We cannot end the drug traffic. We may be able to cut off opium from Turkey – but there are innumerable other places where the opium poppy grows. With French cooperation, we may be able to make Marseilles an unhealthy place to manufacture heroin – but there are innumerable other places where the simple manufacturing operations involved can be carried out. So long as large sums of money are involved – and they are bound to be if drugs are illegal – it is literally hopeless to expect to end the traffic or even to reduce seriously its scope.’²⁰

Friedman’s argument was a return to Mill’s ideas on liberty and the sanctity of individual choice: ‘On ethical grounds, do we have the right to use the machinery of government to prevent an individual from becoming an alcoholic or a drug addict? For children, almost everyone would answer at least a qualified yes. But for responsible adults, I, for one, would answer no. Reason with the potential addict, yes. Tell him the consequences, yes. Pray for and with him, yes. But I believe that we have no right to use force, directly or indirectly, to prevent a fellow man from committing suicide, let alone from drinking alcohol or taking drugs.’²¹ For his follower Thomas Szasz, a professor of psychiatry, the right to use drugs was ‘more basic than the right to vote’, a matter of sovereignty over one’s own body.²² Szasz rejected equally the notion that habitual drug use constituted either a crime or a disease, denying any validity to the theory that the drug addict was by nature unfree.²³ Prohibition, in the libertarian view, violated the individual’s right to freedom from coercion. The state had no authority to impose treatment, let alone a prison term, on the user: ‘An ill person generally has the right to refuse medical treatment even when such treatment is necessary to preserve that person’s life. Individuals have the right to refuse treatment because the value of controlling one’s own destiny outweighs the economic, social and emotional costs of a premature death.’²⁴

The libertarian argument was important because it tended to be made by right-wing commentators who might otherwise have sided with hard-line prohibition. As such, it would play a key role in the twenty-first-century legalization of marijuana. Libertarian legalizers, nevertheless, were few. Even the war on drugs’ vocal critics tended to be wary of grand legalization proposals. The debate principally ran along utilitarian, not ideological, lines. Even after legalization, it was pointed out, sales to minors would presumably still attract penalties, so drug-related incarceration would not entirely end. If drugs, like alcohol, were taxed, they would likely continue to generate smuggling.²⁵ Proposals to change the system, then, ranged widely. Some wished to legalize certain drugs only, typically marijuana but in some cases also psychotropics such as LSD. Others merely sought to remove the criminal penalties on drugs, especially on possession – an alternative to decriminalization being depenalization, a policy by which offenders were not prosecuted or at any rate not jailed, but continued to carry a criminal record. Continued prohibition, finally, could be tempered with ‘medicalization’, in various permutations akin to the British system in its post-Rolleston days.²⁶

Liberalizing criticism of prohibition likewise came to rely on three main practical arguments. First, prohibition threatened public health by forcing users to resort to unsafe practices. Second, the war on drugs enriched gangs and fostered violence. Third, the means deployed in policing and incarceration were wasted and better used in treatment. To this was added, in the USA specifically, a fourth point: that the war on drugs fell predominantly on African Americans and was inherently racist.

‘The unintended victims of drug prohibition policies’, argued Nadelmann, ‘are the 30 million Americans who use illegal drugs, thereby risking loss of their jobs, imprisonment, and the damage done to health by ingesting illegally produced drugs; viewed broadly, they are all Americans, who pay the substantial costs of our present ill-considered policies, both as taxpayers and as the potential victims of crime.’²⁷ Consumers of injected drugs bought from the street pumped adulterated substances into their bodies, sometimes comprising materials more dangerous than the drugs themselves. Bootleg pills sold as LSD or Ecstasy might well be deadly alternatives, and the youth who bought them undercover on a night out had little way of knowing. Black-market purchases, the fear of asking for treatment because it might attract criminal sanction: such were the results of prohibition, and they put lives at risk. The AIDS epidemic made the danger yet more imminent. ‘AIDS is a greater threat to our survival than all of the drugs combined,’ warned Trebach. ‘Properly designed drug maintenance (even those providing for medical heroin and other feared drugs) and needle-exchange programmes should be advocated as essential elements in all AIDS-control strategies and bills.’²⁸ AIDS was not even the only danger. In 2017 UNODC estimated that 585,000 people died worldwide as a consequence of drug use; among these deaths, 50 per cent were from hepatitis C and another 10 per cent from AIDS, both of which can be contracted through unsafe injecting practices.²⁹

Anti-narcotics enforcers had long argued that drugs fostered crime. The trope had been a favourite of Anslinger, who used it to scare legislators into toughening drug laws. The Swedish minister of health, Margot Wallström, speaking at the UN, complained of girls ‘falling in love with an older boy with drug problems, then dropping out of school, and then turning to crime’.³⁰ Crime, the liberalizers countered, was the product of prohibition, not of the drugs themselves. Perhaps the worry should not be imaginary marijuana-fuelled axe murderers, but the thousands of victims of a Pablo Escobar empowered by smuggling riches. Kurt Schmoke, in his initial call for a debate, had argued that legalization would cut the grass from under the dealers’ feet and drastically reduce violent crime.³¹ Prohibition itself boosted criminal statistics by making drug dealing or using an offence. ‘Producing, selling, buying, and consuming strictly controlled and banned substances is itself a crime that occurs billions of times each year in the United States alone. In the absence of drug prohibition laws, these activities would obviously cease to be crimes,’ began Nadelmann.³² Perhaps users also committed crimes such as robberies or muggings to feed their habit; but illegality, by making drugs more expensive, only made such infractions more common. Legalization, on the contrary, would reduce drug-related violence, especially by criminal gangs: ‘Legalization of the drug market would drive the drug-dealing business off the streets and out of the apartment buildings, and into legal, government-regulated, tax-paying stores. It would also force many of the gun-toting dealers out of business.’³³

Related to crime was the question of law enforcement, incarceration, the associated budgets and whether they were well spent. During the Californian campaign for marijuana legalization, the former San José police chief Joseph McNamara would be quoted as saying: ‘I know from thirty-five years in law enforcement. Today, it’s easier for a teenager to buy pot than beer. Proposition 19 will tax and control marijuana just like alcohol. It will generate billions of dollars for local communities, allow police to focus on violent crimes, and put drug cartels out of business.’³⁴ It was not just the billions spent overseas in eradication programmes or the hunt for elusive drug lords. Pursuing addicts and street dealers cost police time and money, reformers argued. Incarceration itself was expensive. A German study dated 1981 estimated the costs of drug repression, including that of keeping 5,000 people in jail, at a minimum of DM 2.5 billion (€1.25 billon) annually.³⁵ Would this not be better spent on anti-overdosing pills or job creation in poor areas? The funds freed from incarceration could be used to subsidize social programmes, treatment and prevention.³⁶

Added to this bill was the racial bias which drug prohibition evinced and perpetuated, reformers believed. The American statistics were stark. As of the mid-1990s 78 per cent of American marijuana users were white, as well as 71 per cent of cocaine users and 41 per cent of heroin users, yet 74 per cent of federal prisoners on drug offenses were Black and 16 per cent Hispanic.³⁷ This could not be explained by the higher penalties on drug dealing, had relatively more dealers been Black. Actually, a survey from the same period found that Blacks represented no more than 16 per cent of dealers and whites 82 per cent.³⁸ Penalties fell more heavily on minority populations, especially those who were Black, feeding a cycle of ghetto lawlessness and repression. This bias had been fed by the passage of tough laws against crack cocaine, whose use was more prevalent among deprived African American communities. In 1986 Congress had introduced mandatory sentences of five to ten years on offences involving as little as 5 grams of crack – by comparison to a threshold of 500 grams for powder cocaine. Though tough laws on crack played well to Republican electoral agendas, they were, moreover, a bipartisan effort, betraying institutional bias. President Bill Clinton failed to overturn the blatant discrepancy between sentencing on crack and powder cocaine when he got the chance.³⁹ Racial disparity was growing with incarceration rates, regardless of the party in power: between 1976 and 1996 white drug arrests climbed by 86 per cent, while Black drug arrests increased 400 per cent.⁴⁰ That the war on drugs perpetuated racism was a key libertarian argument; it would feature in the legalization of marijuana and in its preparatory campaigns in the 2010s.⁴¹

The argument in favour of prohibition was rarely articulated. It benefited, rather, from simple inertia and the public’s belief that if something was illegal, there had to be good reasons. The case was nevertheless advanced formally by James Wilson, who had been Nixon’s chairman of the National Advisory Council for Drug Abuse Prevention, in the review Commentary in 1990. Wilson ridiculed Friedman and the liberalizers. He rightly praised the Nixon administration’s success in the fight against the French Connection. His statistics, and his chronology, were more questionable. In the ensuing two decades, rates of heroin use had remained approximately flat, Wilson contended, whereas they would have risen had the drug been legalized. The point would have been statistically more valid on marijuana, and it rather ignored exponential rises in amphetamines and cocaine, including crack cocaine use. Wilson also criticized the British system, which in his opinion had led to skyrocketing opiate use; he seemed unaware that the heroin wave he was describing had actually coincided with the system’s relinquishment. But Nixon’s former council chairman only really made one main point. The war on drugs was being neither won nor lost: the problem was contained. Prohibition kept user numbers down. Were it relaxed, they would skyrocket.⁴²

Ultimately, the entire debate hinged on that question. It did not matter that prohibition placed the lives of injecting users at risk or that incarceration cost money if one accepted that it kept drug use down drastically. The prospect of creating tens of millions of new addicts dwarfed the disappointments of floundering supply suppression overseas. Nor were reformers able to offer a firm rebuttal. Researchers consulted the decriminalization of marijuana in certain Australian states in the 1980s and ’90s and the ‘coffee-shop’ policy of cannabis toleration practised in the Netherlands. Neither data set was conclusive. Cannabis use had increased in the Australian states concerned, but the rise was not significant. Dutch marijuana consumption had remained broadly stable for years, then doubled between 1984 and 1996 – but similar trends could be observed in countries that had not liberalized, such as Canada, Norway or the UK.⁴³ A weakness of the reforming camp was that it tended to concede implicitly that legal availability would lead to higher rates of use by at least some margin.⁴⁴ From historical example, this is far from clear. Past surges in drug use have obeyed sociocultural trends often irrespective of availability. It suffices to compare nineteenth-century India to China, or twentieth-century Turkey to Iran. There remained the unknowable question: would a relaxation of the rules cause drug use to shoot upwards?

Pointing at the injustice of the war on drugs was not enough. Perhaps it was costly and ineffective: to convince a sceptical or an apathetic public, reformers needed to prove that legalization was safe. Because it involved assessing a leap into the unknown, this was, in turn, an impossible task. The emergence of an active, multi-sided debate was an important development to the course of the long war on drugs, but for now it was insufficient to force a reversal. Would attitudes about drugs and the risks they involved themselves change? There was the possibility that they might with yet another shift in the forever fraught concept that was addiction.

The popular meaning of the term ‘addiction’ has changed in the past couple of decades. The word is proudly displayed in Dior perfume advertisements. Video games are vaunted as addictive in their own marketing material. Routinely, everything and anything is described as addictive, from coffee to shopping or from jogging to social media. Negative connotations have disappeared, or they have been downgraded so much that the concept has lost its teeth. Yet somehow drug addiction remains in its own category. Ask someone why drugs should remain illegal and the knee-jerk response is: they are addictive.

In the aftermath of the who’s abandonment of the word ‘addiction’ in favour of ‘dependence’, medical organizations were deserting the concept – the American Psychiatric Association, for example, dropped it in favour of ‘substance use disorder’.⁴⁵ Yet while the terms changed, at heart remained the age-old question: did drugs make the user sufficiently unfree to justify his or her punishment or forcible confinement by the state?⁴⁶ Historically, addiction theory had been born of medical observation. The problem was that such observation centred on patients, failing to take into account casual or healthy users. A more complete picture started to emerge after the Second World War and especially from the 1960s as sociologists became involved – Alfred Lindesmith was a forerunner – as psychiatrists took a second look, and as governmental and other healthcare institutions began to produce more systematic data.

The first thing this research confirmed was that many people took drugs, even opiates, without becoming addicted. Contracting a habit, it showed, did not automatically follow from experimenting with drugs. One piece of evidence concerned returning veterans from the Vietnam war, who were systematically subjected to drug tests. GI urinalysis tests showed that 5.5 per cent used heroin. The actual proportion was likely higher, as soldiers faked the test because they needed to pass it to be discharged: the rate has been estimated at between 11 and 19 per cent. One study found that 95 per cent of them were clean of opiates a year after their return; within three years, only 2 per cent of returning GIS had continued to use the drug with any regularity.⁴⁷ Context was everything: once removed from the horrors of war, the need for the drug disappeared, however hooked many of these GIS had become.

More robust data are produced by the American Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA has been estimating, based on surveys, the nationwide number of users for an array of intoxicants. The data are compiled both in past-year and past-month format: that is, SAMHSA estimates how many people have been using each drug at least once a month and, separately, once or more in the last year. In 1995 there were 428,000 past-year but only 196,000 past-month heroin users. The difference, 232,000 people, had taken the drug that year yet were not sufficiently addicted to have used it at least once a month. For cocaine, including crack, the past-year total was 4,682,000 and past-month 1,873,000.⁴⁸ For both drugs, this suggested, the majority of users were casual, prepared to take the drug occasionally but not dependent enough to use it once a month, let alone every day.

The psychiatrist Norman Zinberg, a National Institute on Drug Abuse researcher, found concrete examples of such casual or controlled use. One of his interviewees was a forty-year-old carpenter, a man who had been married for sixteen years and had three children. The man had been using heroin for ten years at weekends only. Exceptionally he had used heroin midweek, but not in the last five years.⁴⁹ When asked how he avoided becoming an addict, another interviewee replied: ‘Well, I have responsibilities, you know, and I keep my use down. If I wasn’t married and I didn’t have my son or my business, then I think my chances of becoming an addict would be very strong.’⁵⁰ Zinberg’s research focused on opiates. Over a long period, 23 per cent had used less than once per month on average, 36 per cent monthly and 41 per cent weekly.⁵¹ Zinberg remarked: ‘The argument [for prohibition] implies a straight-line arithmetical relationship between use and misuse, which does not exist . . . It is likely that current social policy is discouraging primarily those who use drugs only moderately, while heavy users, to whom the substance is more vital, are flouting the law in order to make their “buys”.’⁵²

Alongside compulsive users whose existence was undeniable, there existed others for whom a subculture of controlled consumption kept addiction at bay. Several subjects reported engaging in daily activities while high, such as taking their children to a sporting event, washing the floor, talking with people, working or playing the piano.⁵³ These users developed their own rules, often enforced through peer pressure: special sanctions such as ‘do not use every day’ or limiting use to weekends, confining it to safe physical or social settings, or rituals to prevent it from invading their personal life.⁵⁴ Controlled users tended to shun addicts. One might chastise another for manifesting junkie-like behaviour: being dirty or disorderly, being unable to master the drug’s effects, spending too much on drugs, cheating others and so on.⁵⁵ Nineteenth-century China, too, had developed social codes differentiating respectable and excessive opium smoking, reserving it to specific classes, settings or occasions.

More recently, researchers have sought to rate addiction mathematically, or at least to place the various intoxicants on a single scale. One study asked experts to rank eighteen substances on how easily they ‘hooked’ people and how difficult they were to quit. Marijuana ranked fourteenth in its addictiveness, behind nicotine (first), alcohol (eighth) and caffeine (twelfth). Hallucinogens (Ecstasy, LSD and psilocybin), ranked yet further down the list.⁵⁶ Sliding away from addiction, another attempt at ranking intoxicants looked at the risk of overdose, defined as the ratio between a lethal dose and the most commonly taken, regular dose. The lower the ratio, the more dangerous the drug. Heroin had a tenuous safety ratio of 5, alcohol was at 10, cocaine at 15 and marijuana over 1,000.⁵⁷

Such comparisons have not always helped probe the addiction– prohibition paradigm. On the contrary, they can easily drift into a vaguer labelling whereby intoxicants are generally seen as harmful, implicitly or explicitly making the case for control. One such approach sought to develop a ‘rational’ scale for assessing the overall harm from intoxicants. Harm was defined as including physical and social harm (defined as cost to society and family, to healthcare systems, social care and law enforcement), and the risk of dependence. Dependence itself was made to include three parameters: intensity of pleasure, psychological dependence and physical dependence. The scoring, performed by the members of a panel, was equally arbitrary.⁵⁸ (Heroin came first and alcohol fifth, with marijuana and the psychotropics once again towards the bottom.) Another, EU-sponsored study renounced addiction in favour of what might be termed the social-democratic definition of dependence: ‘heavy use over time’. The concept, the authors found, ‘fits better with models of public health, bringing in health and social consequences over and above the criteria currently derived from medical classifications’.⁵⁹ The need to regard the addict as unfree was circumvented altogether, individual freedom being in any case ‘subsidiary’ to the ‘common good’. Drugs were bad according to how much they burdened the social-security system – though here, too, alcohol struggled to look good.⁶⁰

Still more problematic was that addiction simultaneously enjoyed a fresh lease of life with the development of brain science. In 1973–4 a group of Stanford University and Johns Hopkins academics had discovered that the brain contains receptors capable of bonding with morphine molecules. It was later shown that these receptors interacted with a multiplicity of endogenous chemicals whose function it was to relieve the stresses of danger or pain. The discovery paved the way for a revival of addiction as a measurable, relapsing brain disease.⁶¹

How the interaction of morphine or other intoxicants with neuronal receptors constituted or caused addiction was not explained, but another invention came to the researcher’s rescue: the brain scan. Scans allow researchers to show what parts of the brain react to drug intake, lighting them up. They show that some of these areas change in volume over time, including the right amygdala, a section believed to be active in processing emotions and memory.⁶² A key finding has been that this impact is particularly strong during adolescence and until the age of 21, when the brain remains more plastic, potentially causing long-term alterations.⁶³

Brain imaging does not explain how these potentially durable alterations create a habit mechanism. It is purely descriptive. Scans also show that the brain returns to normal after periods of abstinence of varying length – fourteen months, for example, for a meth user.⁶⁴ Research based on scans has, moreover, been drug-specific, again primarily centred on opiates. If anything, differences highlighted by brain imaging have proved that lumping illicit drugs together as addictive is questionable from a scientific point of view.⁶⁵ The problem was fixed with yet another discovery: dopamine. The release of dopamine, an organic chemical involved in the brain’s pleasure and reward mechanisms, is common to a multiplicity of intoxicants and to all drugs of abuse. As researchers explain: ‘At the receptor level, these increases elicit a reward signal that triggers associative learning or conditioning. In this type of Pavlovian learning, repeated experiences of reward become associated with the environmental stimuli that precede them.’⁶⁶ The attenuated release of dopamine over time from the repeated use of drugs could even explain tolerance, smaller increases in dopamine being observable among tolerant subjects.⁶⁷

Dopamine’s involvement in withdrawal mechanisms is more difficult to pinpoint.⁶⁸ Dopamine, moreover, can be shown to be involved in the mental rewards from much more than just drugs. Alcohol, too, triggers dopamine rushes, in addition to acting on its own identifiable receptors. That these rewards abate with repetition is nothing new: the law of diminishing returns applies to all pleasurable activities, whether jumping into cool water on a hot day or eating chocolate.⁶⁹

Brain science has nevertheless helped drug addiction make a comeback as something grounded in biological fact verifiable by science. Healthcare and drug-control organizations highlight brain theory in their pamphlets, even while their documents concede that genetic, psychological and environmental factors (‘lack of parental supervision’, ‘community poverty’) remain important in circumscribing addiction.⁷⁰ The American National Institute on Drug Abuse explains: ‘Our brains are wired to increase the odds that we will repeat pleasurable activities. The neurotransmitter dopamine is central to this. Whenever the reward circuit is activated by a healthy, pleasurable experience, a burst of dopamine signals that something important is happening that needs to be remembered. This dopamine signal causes changes in neural connectivity that make it easier to repeat the activity again and again without thinking about it, leading to the formation of habits.’⁷¹

In lay parlance, the idea of the ‘hijacked brain’ has taken the place of the nineteenth-century ‘disease of the will’.⁷² Just as sociological and psychiatric data were becoming available to nuance received wisdom, inventions such as the brain scan intervened. For all the graphic precision, brain mapping does not interact with knowledge about the neurochemistry of drug use to produce a theory of addiction. It is very unlikely that cellular analysis can ever explain the complex social behaviours involved in the habitual recourse to any of the illicit drugs, let alone to all of them as a group. The illusion that it does, however, reinforced the drug-debate stalemate, cementing the inertia protecting the drug-control system from its challengers.

At a CND session on the drug treaties, the American representative rebuffed calls for reform on the grounds that ‘addiction is a disease of the brain.’⁷³ Opinions on drugs and drug control were too hard to budge. Neither public views on drug control nor views on addiction and on the drugs themselves were liable to shift materially. The reformers simultaneously understood that they needed to change tack. Rather than seek to dismantle the system, they would turn to altering it from the inside. The result was a credo known as harm reduction.

Harm reduction is a broad church, and it has enjoyed some overlap with the legalization movement. Harm reductionists have included the historian David Courtwright, who rejected liberalization for its over-ambition and lack of detail, but also on occasion the Drug Policy Alliance, the creation of the key liberalizing critics of the war on drugs Arnold Trebach and Ethan Nadelmann. The DPA’S website writes: ‘Our mission is to advance those policies and attitudes that best reduce the harms of both drug use and drug prohibition, and to promote the sovereignty of individuals over their minds and bodies.’⁷⁴ Europe-based harm-reductionist lobby groups have included the Beckley Foundation, the Transnational Institute and the British association Release, to name but a few. The Beckley Foundation, the creation of the British heiress Amanda Feilding, informally succeeded Timothy Leary, without the theatrics, in the defence of LSD and other psychotropics. The Transnational Institute, left-leaning and less bold on drug reform, has taken up harm reduction as one of several social causes. Release is distinguished by its consultative status with the powerful Economic and Social Council of the UN, a body ranking above UNODC.⁷⁵

Harm reduction focuses on practical reforms to health and legal systems, a number of which were tested in various countries in the 1980s and ’90s. Outside the devotion of greater means for treatment, it has involved three chief policies. The first and most basic has consisted of needle and syringe exchange programmes, occasionally extending to safe injection rooms. The second has included opiate maintenance provision, generally on substitute opiates but sometimes on heroin itself. The third has involved the removal of penalties on possession, whether on marijuana only or on all drugs.

The first needle exchange programme opened in Amsterdam in 1984, with the aim of preventing the spread of hepatitis B. The idea was that if multiple users avoided sharing the same needle, they would not spread intravenously transmittable diseases. The policy soon received a significant impulse as health services everywhere woke up to the existence and implications of AIDS. Programmes opened in one European country after another, and they had spread throughout the EU by 1993. Syringe exchange programmes also opened, more haltingly, in a variety of American states, having met significant opposition at the federal level and been denied funding.⁷⁶

Going one step further were supervised injection rooms, also known as drug consumption rooms. Here the user is provided with not just a clean syringe but an environment where he or she can be free from the depredations of street consumption. Crucially, the rooms are overseen by personnel equipped to intervene in case of an overdose, especially by administering the inhibitor Naloxone. Injection rooms first opened in the 1990s in Switzerland, followed by Germany, the Netherlands and Australia. Later adopters have included Canada, Luxembourg, Norway, Spain and France, and such rooms are under consideration in a few more jurisdictions.⁷⁷ In the context of prohibition, supervised injection rooms have been more controversial than syringe exchange programmes. They more explicitly condone drug injecting and require the police to turn a blind eye. Still more controversial, nevertheless, has been drug maintenance.

In the 1930s a group of German scientists developed a synthetic opiate named methadone, destined to serve during the Second World War to relieve Germany’s morphine shortage. One among many such derivates, it initially attracted little attention, though the Lexington farm took it up as a tool to palliate withdrawal symptoms during the inmates’ initial weaning phase. Then, in 1962, the New York City Health Research Council asked the Rockefeller University academic Vincent Dole to assemble a team to research heroin addiction. While reading up, Dole came across a book by a young Harlem psychiatrist, Marie Nyswander, entitled The Drug Addict as Patient. He convinced her to join. Dole and Nyswander experimented on various substitutes, including codeine and morphine. They eventually picked methadone, which Nyswander knew from work in Lexington.⁷⁸

Methadone produces, in tolerant users, longer-lasting effects than other opiates without triggering a euphoric high. It has the power both to block the high produced by heroin (an effect labelled the ‘narcotic blockade’) and to eliminate withdrawal pains. It can also be administered orally. Dole and Nyswander introduced it to maintenance, and the results were spectacular: more than 90 per cent retention in treatment and the virtual cessation of heroin use. The two researchers were rewarded with the prestigious Lasker Prize. A few years later, Nixon seized on their results to create a Special Action Office for Drug Abuse Prevention, with the maintenance convert Jerome Jaffe in charge. By 1975 the United States possessed over four hundred methadone programmes, serving more than 75,000 patients.⁷⁹

Ironically, methadone maintenance soon petered out in the USA while it bloomed in other countries, where it had initially been greeted with scepticism. Methadone, after all, even if it is not heroin, is also a scheduled drug. Drug warriors consider methadone maintenance a form of surrender. Quitting it can be also difficult – clinical studies have shown relapse rates of 50 to 70 per cent after it was discontinued.⁸⁰ Though methadone has continued to be available throughout most of the USA, its accessibility became patchier, often limited to clinics, with more use for detoxification and less under maintenance programmes.⁸¹ By contrast, in the 1980s, methadone use began expanding in other developed countries. Australia, for example, produced national methadone guidelines in 1985. These make the drug available from general practitioners, and users pick up their prescriptions in pharmacies.⁸² Methadone maintenance has likewise become established in a number of European countries, though in some, such as Sweden and France, the synthetic opiate buprenorphine has become the alternative of choice.⁸³

Heroin maintenance made its own return around the same time. The British drug-dependency units that had been created to substitute for the old, post-Rolleston system were struggling to cope as opiate use spread. The arrival of AIDS threatened to take a heavy toll. A clinic in Merseyside, in the neighbourhood of Liverpool, initiated one of the first syringe exchange programmes. Local police agreed they ‘wouldn’t hang around outside and target clients’.⁸⁴ Emboldened, the Merseyside staff decided to expand the service to include heroin maintenance, for which it was already licensed. The programme was rounded out with counselling, plus employment and housing assistance. The Merseyside project, though it at first made waves, brought about a revival of British heroin maintenance, including among licensed general practitioners.⁸⁵

Switzerland, which was afflicted with one of the highest rates of opiate use in Europe, took a similarly bold step shortly thereafter. The programme enlisted 1,000 volunteer heroin addicts, launching at first experimentally in 1994. Later expanded and having been vetted by referendum in 1997, it is still running. The Netherlands launched a heroin maintenance trial next, in 1996, and Denmark in 2009. Canada initiated a similar programme in 2005 named the North American Opiate Medication Initiative (NAOMI).⁸⁶ Heroin is provided to patients at one clinic: the Providence Crosstown clinic in Vancouver. The total number of patients treated has remained small, in the low hundreds. None has died under the clinic’s supervision, however, which also relies on a safe injection room. A reporter describes the results as follows:

John Pinkney can trace his drug use back to the age of 6, when he was first prescribed Ritalin. By his 20s, he was using heroin and other street drugs. Now in his late 50s, he says his life is in a much better place. He has a part-time job. He brags about owning a television and furniture – the kinds of things others might take for granted, but were hard-fought for someone struggling with drug addiction. ‘I have a two-bedroom apartment,’ Pinkney said. ‘I have things. I got my TV and my pet and living room furniture and bedroom furniture. You know, it’s like I got my life back.’⁸⁷

Yet the most radical harm-reduction initiative was its third and final tier: user decriminalization. The best-known exercise in the field has probably been the Dutch cannabis ‘coffee-shop’ regime. A 1960s public debate on marijuana had led to the formation of another commission of inquiry: the Baan commission, named after its chairman Pieter Baan, chief inspector of mental health. The Baan report, published in 1972, was noncommittal: it was divided on the health effects of marijuana, and it raised the problem of the Dutch commitments under the international treaties. But Dutch heroin use was rising, and the government wished to prioritize law enforcement against hard drugs. In 1976 a new Opium Act (as the Dutch drug laws continued to be called) drew a distinction between cannabis products and drugs believed to present greater risks, including heroin, cocaine, amphetamines and LSD. Penalties for dealing in hard drugs were raised. The possession of marijuana and hashish in amounts up to 30 grams (1 oz) was conversely downgraded to a misdemeanour.⁸⁸

The government shrank from full legalization out of respect for its treaty obligations. Decriminalization, as a result, was a compromise measure. The Dutch regime was left with the contradiction that the sale or possession of small quantities was tolerated, including in coffee shops, but cultivation and wholesale handling remained fully criminalized.⁸⁹ In the early 1990s the government again considered legalization, or at least extending toleration to local cultivation and wholesale activities. This met with direct opposition from the French president Jacques Chirac, who attacked the proposal in the name of cooperation against crime and the ‘harmonization’ of EU drug policy. The Dutch authorities backtracked, lowering the permitted amount of coffee-shop sales to boot.⁹⁰ The number of coffee shops has declined since then, falling below 1,000 after the turn of the century.⁹¹

Yet bolder and higher-profile has been the decriminalization experiment that took place in Portugal from 2001. There, it was not just the possession of cannabis that was decriminalized, but all illicit drugs.

Portugal stood in the midst of a heroin epidemic, with accompanying infectious diseases and AIDS. Its per capita heroin use was the highest in Europe. The government, wishing to make changes, appointed an expert commission whose key figure was João Goulão, a doctor and founder of the country’s network of drug-abuse treatment centres. Goulão knew the pitfalls of criminalization at first hand: the justice system further isolated users, worsening their prospects. He believed that treating or ending addiction was best done in situ within communities, not in jails or compulsory centres. For this to be made possible, drug possession first needed to be decriminalized.⁹²

The reform he recommended was enacted in July 2001. (Goulão would go on to become Portugal’s ‘drug tsar’ through multiple administrations, and he would become an international ambassador for harm reduction.) The possession of drugs below certain thresholds ceased to be a criminal offence in Portugal. Users were now referred to a district-level commission for the dissuasion of drug addiction made up of three people: a lawyer, a social worker and a medical professional. The commissions were empowered to impose a fine, psychological counselling and/or other minor sanctions or, if the user was (or is) judged addicted, referral to an education programme. Trafficking has remained punishable in Portugal, quite severely.⁹³

Several European countries have since then decriminalized the possession of some or all drugs. Though Portugal has tended to overshadow them in terms of public attention, actually Italy and Spain decriminalized drug possession before it. Spain reformed its drug laws in 1983. A new provision distinguished soft from hard drugs, with two different ranges of penalties for trafficking and none for possession. Though there have been borderline cases and ambiguities, such as relating to gratuitous transfer, drug possession has remained exempt from punishment (other than through a fine if practised in a public place) since then.⁹⁴ Italy passed a new drug law in 1975 that redefined chronic drug use as an illness. Personal use and the possession of small quantities were downgraded to administrative offences. The system underwent a brief hiatus between 1990 and 1993, when the possibility of prison for possession was reintroduced – although only with short sentences and in repeat cases – and when the offence was reinstated as criminal. Since then, though drug users may be subject to penalties such as the temporary suspension of their drivers’ licence, drug possession has ceased to be a crime in Italy.⁹⁵ Estonia, in 2002, was the next country to decriminalize after Portugal. Other European countries to have decriminalized the possession of all drugs in later years include Bulgaria, Croatia, the Czech Republic, Latvia and Slovenia.⁹⁶

None of this, unsurprisingly, went unnoticed. Harm reduction pushed ever more insistently at prohibition’s boundaries. Criticism of the war on drugs, willy-nilly, was translating into practice. In an increasing number of countries, the authorities were becoming less willing to stick to the script. Their policies were beginning, from the turn of the century, to make a nasty dent in the shiny coachwork of drug control. It would have been surprising if the anti-narcotics system had not fought back. As the 1990s closed and as harm reduction began to make visible progress in various jurisdictions, it began to attract pushback.

Harm reduction works, its partisans protested. The epidemiological evidence has been that needle or syringe exchange programmes save lives. Supervised injection rooms help distribute information about safe injecting and put users in touch with social and medical services. They prevent overdoses from becoming lethal, and do not appear to encourage a greater number of people to inject drugs.⁹⁷

The Portuguese decriminalization, though sometimes contested, is generally considered to have produced good results. Total drug use continued to increase in the years following the reform, but the data are distorted by the large share taken by cannabis. Both drug use by youths and drug injecting fell.⁹⁸ A few years later, Portugal’s rates of opiate, cocaine and amphetamine use stood no higher than in a typical European country, and far lower than in the United States.⁹⁹ By 2015 its incidence of injected drug use, principally heroin, had dropped significantly compared with 2000.¹⁰⁰ Critics have complained that the number of people imprisoned for drug possession was already low before the reform, and that the total of arrests plus administrative citations remained high afterwards.¹⁰¹ The effects on crime and incarceration were nevertheless notable. The proportion and number of offenders sitting in Portuguese prisons for drug-related offences – including offences committed under the influence or to pay for drug purchases – both fell sharply. Prison overcrowding ended.¹⁰² More generally, the main decriminalizing countries have not stood out for increased levels of drug use. The data are patchy, but whether for opiates, cocaine or amphetamines, country rates merely vary, with no discernibly higher rates for the countries that have decriminalized possession compared to those that have not.¹⁰³

None of this prevented harm reduction from coming under strenuous criticism as it began to make headway. In 1998 the American drug tsar Barry McCaffrey labelled harm reduction ‘a hijacked concept that has become a euphemism for drug legalization’.¹⁰⁴ The hijacked concept met a stubborn resistance both institutionally and diplomatically. Prohibitionist stalwarts included Japan and Russia. In Europe France was long a hold-out, later replaced by Sweden.¹⁰⁵ Hard-fought discussions took place at the CND over needle exchange programmes, with EU countries leading the charge against opposition from the USA, Brazil, Japan and Russia, among others.¹⁰⁶ In 2000, for example, at the CND: ‘Concern was expressed about the policy of some Governments that permitted the establishment of drug-injection rooms for drug abusers or the provision of heroin to them. Some felt that such a practice ignored the extent of the problem. One considered that it amounted to abandoning drug abusers.’¹⁰⁷ The clash continued into 2008, with the 1998 action plan for achieving a ‘drug-free world’ coming up for review, when a group of 26 countries publicly expressed their frustration at the failure to agree on a harm-reduction mandate.¹⁰⁸

The competing concept the UN institutions and anti-narcotics forces promoted was demand reduction. But while this may sound similar to harm reduction, the two philosophies overlap only in a limited way, in the general sense that they both approve of treatment measures. Demand reduction focuses on the hope that information and propaganda will dissuade potential users from experimenting with drugs. On the contrary, harm reductionists begin from the assumption that such efforts have long been proven to be futile, and it is best to focus on damage limitation. While demand and harm reduction both involve treatment, moreover, they differ radically in the type of care they offer. Demand reduction essentially envisages treatment as an exhortation to abstinence. Its central feature is rehabilitation, with at best a short-term role for substitutes such as methadone. Maintenance is anathema because it is perceived to perpetuate drug use. As to user criminalization, at least implicit in demand reduction is the notion that the higher the penalty, the more strongly will anyone be dissuaded from using drugs. This is in straight contradiction to harm reduction.

The 1980 CND report, as an illustration, listed a number of demand-reduction initiatives. These included the opening of rehabilitation centres in Mexico, American education programmes on the risks of marijuana, an Italian ministerial decree curtailing methadone distribution, and precursor-chemical controls in the German Democratic Republic.¹⁰⁹ Such was not the style of measures likely to appeal to harm reductionists. The best compromise that could be found, in 1998, was to declare that to the existing goal of preventing the use of drugs should be added that of ‘reducing the adverse consequences of drug abuse’. This, though, was little more than papering over the cracks: ‘While China, Japan, the Russian Federation, the United States and several other countries are in favour of traditional demand reduction efforts (prevention) in order to reduce demand, most European countries, as well as Australia and Canada, tend to support policies that also contain elements of harm reduction (such as needle-exchange programmes) so as to reduce drug use-related HIV/AIDS rates and/or keep them low.’ Meanwhile: ‘Harm reduction programmes should not be carried out at the expense of, or be considered substitutes for, activities designed to reduce the demand for illicit drugs.’¹¹⁰

International bodies are first and foremost diplomatic forums. Their position is only as good as that of their member states, or what consensus their member states are able to muster. The CND’S views only reflected such politics. Yet the INCB, part of whose role it is to oversee the due implementation of the conventions, also stepped in. In 1999 it wrote that any state that permitted supervised injection rooms ‘could be considered in contravention of the international drug control treaties’. Subsequent reports followed a similar line, singling out Australia, Canada, Germany, the Netherlands, Norway, Spain and Switzerland.¹¹¹ In parallel, the board suddenly challenged the Dutch coffee-shop system, calling it an incitement in its annual reports. (The Dutch replied that their Opium Act remained in compliance with the treaties, which impose the demand that each participant criminalize possession only ‘subject to its constitutional limitations’. The objection is less valid, however, when it comes to penalizing the traffic itself: Dutch tolerance also turns a blind eye to cannabis sales, which may have been what attracted the INCB’S ire.¹¹²)

If harm reduction made progress around the world it was surreptitiously, country by country. China was long a key opponent of reform. After several decades of having been rid or almost rid of drugs, its government had discovered at the end of the 1980s that narcotics use was making a comeback. It used the 150th anniversary of the First Opium War in 1990 to conduct a patriotic education campaign. The message was that, starting from that war, China had experienced a series of defeats and humiliations at the hands of Western imperialists, a situation that had only been rectified after the Communists took power. Being soft on drugs was unthinkable.¹¹³ On the contrary, a new get-tough strategy became the order of the day. A 1990 law introduced fresh jail sentences up to life imprisonment or, in severe cases, the death penalty for those convicted of smuggling, trafficking or manufacturing.¹¹⁴ From 2000, nevertheless, China began to embrace measures for reducing the vulnerability of injecting drug users to AIDS. It established its own methadone programmes: soon, it would have more than five hundred methadone clinics. By 2009 thirteen Asian states were prescribing methadone or buprenorphine, including Cambodia, Bangladesh and Thailand, though the practice has remained illegal in Russia.¹¹⁵

Separately, a 2002 report by the legal affairs section of UNODC ruled that substitution and maintenance treatments as well as druginjection rooms were compatible with the drug treaties.¹¹⁶ UNODC may be junior to the CND and INCB, but it is also filled with experts inclined more towards practical solutions than to member-state politics. It was an important change when it began supporting alternatives to incarceration, a euphemism for the decriminalization of possession: ‘Where appropriate, governments should consider providing treatment and rehabilitation to drug abusing offenders, either as an alternative or in addition to conviction or punishment.’¹¹⁷ The INCB, finally, had been critical of the Portuguese decriminalization before the fact. Perhaps mindful of the disastrous political fallout if it came out with a formal condemnation, following a mission to the country in 2004 it concluded that Portugal remained in compliance with the treaties.¹¹⁸

Harm reduction, with each inroad, was chipping at the drug-control consensus. Its policies, by the turn of the twenty-first century, were enjoying piecemeal adoption around the world. Institutional sniping notwithstanding, their proponents were often able to squeeze under the UN agencies’ radar. If such initiatives as user decriminalization and maintenance came to make headway, moreover, they stood to make a fundamental, practical difference to the drug-control order.

Such achievements nevertheless remained local and fragile. For all the subterranean change, as the twenty-first century dawned, prohibition remained paramount. The apparatus of narcotics suppression survived, and even thrived. The treaties retained, in their strictest expression, the support of powerful states, and the UN institutions were not standing idly by. In a sense, furthermore, harm reduction represented a step back from the legalizing challenge that had arisen alongside it. Harm reduction sought to mitigate rather than end prohibition. With it, legalization, the idea that the war on drugs was failing and required a redesign, had given way to a more modest compromise approach. The debate that had sprung up in the 1980s, however, was not over. Three developments would impart a new dynamic to calls for reform: the opioid epidemic that was beginning to spread throughout the United States, sudden progress in the legalization of marijuana, and continued violence in Latin America.