Global commission on drug policies misses the mark

Language influences perception

On 9 January 2018, the Global Commission on Drug Policy (GCDP) launched the report The world drug (perception) problem, countering prejudices about people who use drugs (Global Commission on Drug Policies, 2018). The GCDP was established in 2011. It consists of

twelve former heads of State or Government, a former Secretary-General of the United Nations, as well as other experienced and well-known leaders from the political, economic and cultural arenas who feel, that they must advocate for drug policies based on scientific evidence, human rights, public health and safety, for all segments of the population.

However, the GCDP report uses many terms that belong to the category of ‘biased, pejorative, judgemental, ill- or undefined, or disrespectful language’ (as opposite to neutral, precise and respectful language). The frequent occurrence of imprecise terms in particular is problematic and reveals a limited understanding of several linguistic and medical aspects of the topic. As a result, the report rather reinforces certain aspects of irrational attitudes.

Examples of problematic terms

The word ‘drug’ is ambiguous and, especially if used in the sense of ‘medication’, the use of this term does not contribute to adequate access to medicines; instead, medication or medicine should be used as unambiguous term.

The report advises not to use ‘opioid replacement therapy’ and offered an equally bad synonym as an alternative: opioid substitution therapy, suggestive for this therapy ‘replacing street drugs by state drugs’. Hence, the proposed alternative is equally problematic; instead, opioid agonist therapy should be used.

The report uses the term ‘medication assisted therapy’ at one place when referring to the USA, where this term is frequently used. It suggests that the medication is only assisting a non-pharmacological therapy, which is not true: the medication is its mainstay. This hampers access to medicines when judges or politicians consider it to be an unimportant part of the therapy and then deny access to the medicines people need. It seems that the GDCP is aware of the problematic aspect of this term, but it is unclear why it was used in the report without a further comment.

The word ‘addiction’ used in the report is not part of any international system of definitions. It is considered by the WHO Expert Committee on Drug Dependence as pejorative, and moreover, it is suggestive for people subjecting themselves to slavery (Scholten et al., 2017b; World Health Organization, 2012). Precise alternatives which are internationally defined are dependence, or, as it is called in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), substance use disorder.

In addition, the report presents an incorrect definition of ‘dependence’ essentially saying that a person who will have withdrawal symptoms upon cessation of a medicine is dependent. The International Classification of Diseases-10 (ICD-10) and DSM-5 both categorize withdrawal as a distinct disorder and the presence of withdrawal is neither necessary nor sufficient to define a substance use disorder. The ICD-10 definition of dependence requires at least three symptoms, out of six, occurring at some time during the previous year. Two of the symptoms could be tolerance and withdrawal, but the four other symptoms are all psychological (the ‘four Cs’: Craving, loss of Control, Compulsion to use and despite of the Consequences) (World Health Organization, s.a.).

People discontinuing medication for pain, depression, anxiety and other disorders, as well as neonates born from mothers taking opioids may experience withdrawal and may require treatment but do not meet criteria for a substance use disorder. Therefore, withdrawal or tolerance alone is neither necessary nor sufficient to diagnose dependence. Moreover, many other medications not associated with substance use disorder can provoke tolerance or withdrawal syndromes.

It becomes even more confusing when the report claims that ‘[f]rom a medical perspective, only those with problematic drug use or dependence need treatment’. This may be true if the GCDP had defined dependence correctly, but a person with dependence as defined by the GCDP does not need any treatment. In case of a wish or need for cessation, a gradual tapering of the medicine will be sufficient.

Elsewhere, the report refers incorrectly to withdrawal syndrome as ‘physical dependence’, a condition that does not exist. After years of searching for a definition that stands, the WHO Expert Committee on Drug Dependence decided in 1992 that it is impossible to define physical dependence (World Health Organization, 1993). It recommended that the names of the two composing elements, withdrawal syndrome and tolerance, should be used instead. Physical dependence does not meet the ICD-10 criteria for dependence. Tolerance and withdrawal, unlike dependence, are two common phenomena when treating moderate and severe pain with opioids (Noble et al., 2008; Minozzi et al., 2013). Hence, the use of this term is highly suggestive for people with pain on opioid analgesics as being dependent. Referring to any person as being physically dependent is therefore stigmatizing and will easily lead to an unjustified denial of pain medication to people with moderate and severe pain.

More explanation of these problematic terms as well as more terms to avoid can be found in the recent article on terminology mentioned above (Scholten et al., 2017b).

Non-medical body making treatment recommendations

Unfortunately, it is not the first time that the GCDP publishes a report with flaws potentially harmful for people who need controlled medicines. In a recent policy paper on the opioid crisis in the United States, the GCDP recommends ‘[..] not [to] cut the supply of prescription opioids without first putting supporting measures in place. This includes sufficient treatment options for people with addiction and viable alternatives for pain patients’ (Global Commission on Drug Policies, 2017). Obviously, this is a treatment recommendation. However, for many moderate and severe pain conditions, there are no effective non-pharmacological treatment options and ‘supportive’ measures are not a sufficient replacement. Moreover, it is unclear which supporting measures these would be. Elsewhere in the report this recommendation is mitigated, inter alia by mentioning that ‘chronic pain patients and people at the end of life should not be made to suffer because others misuse these medications’. In a reaction to me, the GDCP stated that it in fact does not recommend cutting the supply of prescription opioids to pain patients. However, by putting the recommendation in a text box prominently, the harm has been done already.

A recommendation which is suggestive that people with moderate and severe pain will find effective non-pharmacological treatment is irreal in most cases, and it promotes that people with moderate and severe pain will be refused their pain medicines. Indeed, due to this and similar recommendations, social media are now full of complaints by desperate Americans having unbearable pain, some of them even considering suicide. Obviously, inaccurate policy analyses by American authorities and health insurers have led to unjust policies and inhuman and degrading treatment in the USA (Scholten and Henningfield, 2016).

Conclusion

Unintendedly, the two GCDP publications mentioned above are not helpful for people who need controlled medicines for the treatment of their condition. In individual cases, these publications will lead to severe suffering. In future reports, the GCDP should refrain from biased, pejorative, judgemental, ill- or undefined, or disrespectful language and also from making treatment recommendations.

By using neutral, precise and respectful language, the Commissioners will better contribute to a factual perception of the consumption of psychoactive substances, and, not having medical expertise, by refraining from medical recommendations they will follow a WHO guideline that decisions which are ordinarily medical in nature should be taken by health professionals (World Health Organization, 2011).