- About HHR
Naomi Burke-Shyne, Joanne Csete, Duncan Wilson, Edward Fox, Daniel Wolfe, and Jennifer J. K. Rasanathan
Drug conventions serve as the cornerstone for domestic drug laws and impose a dual obligation upon states to prevent the misuse of controlled substances while ensuring their adequate availability for medical and scientific purposes. Despite the mandate that these obligations be enforced equally, the dominant paradigm enshrined in the drug conventions is an enforcement-heavy criminal justice response to controlled substances that prohibits and penalizes their misuse. Prioritizing restrictive control is to the detriment of ensuring adequate availability of and access to controlled medicines, thereby violating the rights of people who need them. This paper argues that the drug conventions’ prioritization of criminal justice measures—including efforts to prevent non-medical use of controlled substances—undermines access to medicines and infringes upon the right to health and the right to enjoy the benefits of scientific progress. While the effects of criminalization under drug policy limit the right to health in multiple ways, we draw on research and documented examples to highlight the impact of drug control and criminalization on access to medicines. The prioritization and protection of human rights—specifically the right to health and the right to enjoy the benefits of scientific progress—are critical to rebalancing drug policy.
The international drug control conventions and controlled substances
The international drug control conventions (hereinafter “the drug conventions”) impose varying levels of control on a range of substances based, in theory, on their perceived risk of misuse and medicinal value. Substances are listed in four separate “schedules,” with each schedule determining the requisite level of control for the substance listed within it. The drug conventions serve as the cornerstone for domestic drug laws and impose a dual obligation upon states: to prevent the misuse of controlled substances while ensuring their adequate availability for medical and scientific purposes.1 The drug conventions further explicitly provide that controlled substances are indispensable for medical and scientific purposes. Indeed, the World Health Organization’s (WHO) Model List of Essential Medicines includes 12 medicines that contain internationally controlled substances, such as morphine, methadone, buprenorphine, diazepam, and phenobarbital.2 Essential controlled medicines are used across the spectrum of health care, from childbirth, surgical anesthesia, and pain relief in palliative care (such as for people with end-stage AIDS or terminal cancer), to mental health treatment, drug dependence treatment, and neurological care.
Many controlled substances embody the duality in the drug conventions—that is, they have both licit (medical) uses and uses defined as illegal in some jurisdictions. For example, benzodiazepines, when prescribed by a licensed professional, are used to treat a range of ailments such as insomnia, obsessive-compulsive disorder, and seizures. Outside of this medical context, however, their use is illicit due to the perceived risk of misuse that they carry, and they are included in the drug conventions’ schedules. Despite the mandate that these two obligations be enforced equally, the dominant paradigm—in both the text of the drug conventions and their implementation—is an enforcement-heavy criminal justice response to controlled substances that centers on preventing what is deemed in law to be their misuse. This prioritization of restrictive control is to the detriment of ensuring adequate availability of and access to controlled medicines and infringes upon the rights of people who need them.
Balancing the medical merits of substances with their likelihood for non-medical use is, in theory, a matter of scientific judgment, and the drug conventions provide that the scheduling of controlled medicines should be based on WHO recommendations.3 To this end, WHO convenes an Expert Committee on Drug Dependence (WHO Expert Committee) to study controlled substances and make recommendations on the level of risk of harm and the therapeutic utility of a substance, which should subsequently be reflected in the substances’ scheduling under the drug conventions.4 On several occasions, however, the UN Commission on Narcotic Drugs (CND) rejected the recommendation of the WHO Expert Committee, particularly when it comes to recognizing the potential therapeutic benefits of certain cannabinoids that are controlled (as is discussed below). Independent addiction experts and clinicians repeatedly assert that some controlled substances, including cannabis and 3,4-Methylenedioxymethamphetamine (MDMA), are wrongly placed in the drug conventions’ most restrictive schedules.5 Others have concluded that the WHO Expert Committee does not evaluate some substances frequently enough and would benefit from emulating the best practices of some national-level evaluators.6
Indeed, not all international scheduling determinations are replicated nationally. For instance, heroin is classified in the Single Convention on Narcotic Drugs, 1961 (the Single Convention) as a Schedule I and Schedule IV substance, the most restrictive classifications, or “particularly liable to abuse and to produce ill effects…not offset by substantial therapeutic benefits.” This judgment is embodied in most national drug laws.7 However, a number of countries—including Switzerland, the Netherlands, the UK, and Germany—have, through law or public health regulations, established a licit use for heroin in treating well-defined cases of opiate dependence.8 Of note, cannabis and cannabis resin are similarly classified in Schedules I and IV of the Single Convention—that is, they are seen to be liable to abuse and without redeeming medical benefit. As with heroin, a number of countries have set policies legalizing and enabling access to cannabis for medical purposes, including for pain relief.
The Single Convention codifies the obligation on States parties to make adequate provision to ensure the availability of controlled substances for medical and scientific purposes, and stipulates three minimum criteria to which countries must adhere in national regulations: (a) individuals must be authorized to dispense substances controlled under the Single Convention by license (license to practice medicine or special license); (b) controlled substances may be transported only between institutions or individuals authorized under national law; and, (c) a medical prescription is required for the dispensation of controlled substances. However, the Single Convention also provides that states may impose stricter rules or controls if deemed necessary, and many countries opt to implement additional requirements. The Convention on Psychotropic Substances, 1971, sets out a more limited obligation, requiring that access to psychotropic substances for medical purposes not be unduly restricted.9
Surprisingly, there is no provision in the drug conventions to manage the interaction between states’ drug control obligations and their responsibility to ensure access to controlled medicines. The focus on drug control and punitive sanctions creates a frame that is heavily oriented toward criminal justice and policing, which can have profound effects even for medicines not currently controlled under the drug conventions. For example, against the advice of WHO, China attempted in 2015 to bring ketamine under international control, which would have severely limited access to a vital anesthetic in developing countries.10
WHO recognizes the bias of drug policy implementation in preference of control, as does the International Narcotics Control Board (INCB), which first highlighted the challenge as far back as 1989:
legislators sometimes enact laws which not only deal with the illicit traffic itself, but also impinge on some aspects of licit trade and use, without first having adequately assessed the impact of the new laws on such licit activity. Heightened concern with the possibility of abuse may also lead to the adoption of overly restrictive regulations which have the practical effect of reducing availability for licit purposes.11
That said, the INCB itself has been as much a part of the problem as its solution, often saluting restrictive drug control regimes imposed by governments without paying sufficient attention to the consequences of those regimes on access to medicines.12
This paper aims to demonstrate that the prioritization of criminal justice and the desire to prevent non-medical use of controlled substances under the drug conventions undermine access to controlled medicines, and in doing so, infringes upon the right to health and the right to enjoy the benefits of scientific progress (right to science). The impact of drug control will be examined, from the text of the law to the de facto extension of criminalization beyond the scheduling of substances to the health sector, where patients and individuals seeking treatment, health service providers, and researchers are adversely affected. We draw on documented examples to show the interaction between drug control, criminalization, and these rights. The paper concludes that the prioritization and protection of human rights—specifically the rights to health and to science —are critical to rebalancing drug policy.
Access to controlled medicines and the international human rights framework
The right to the highest attainable standard of physical and mental health (hereinafter “the right to health”) has been guaranteed in international law since the Universal Declaration of Human Rights in 1948 (UDHR).13 It is now protected in a range of conventions, notably in Article 12 of the International Covenant on Economic, Social and Cultural Rights, 1966 (ICESCR), and Article 24 of the Convention on the Rights of the Child (ratified by every country in the world except the United States of America).14 Under this right, access to essential medicines, as defined by WHO, is accorded the highest priority.15 The ICESCR construction of the right to health expands on the narrower mention in the UDHR of the right to medical services and “security” for people who are ill.16 Access to essential controlled medicines encompasses not only their availability, accessibility, acceptability, and receipt via high quality health services, but also includes access to information about the function and use of those medicines. Hence, realization of a core component of the right to health is, in practice, impeded by legal, regulatory, and attitudinal barriers (among others) which result from the restrictive manner in which the drug conventions have been interpreted. In reviewing states’ compliance with the right to health, UN treaty bodies have, for example, recommended steps to address barriers and increase access to medication-assisted treatment in Belarus, Georgia, Indonesia, Lithuania, Russia, Ukraine, and Uzbekistan.17 In a case currently pending before the European Court of Human Rights, applicants have challenged the Russian ban on opiate substitution therapy (also known as medication-assisted treatment) on the grounds of freedom from cruel, inhumane, and degrading treatment, the right to family life and privacy, and the prohibition of discrimination under the European Convention on Human Rights (ECHR).18
The right to science has similarly been guaranteed since the adoption of the UDHR (Article 27). It is further elaborated in Article 15(1)(b) of the ICESCR, which guarantees the right to enjoy the benefits of scientific progress and its applications.19 This right includes not only the right to knowledge and information generated from investigation, but also freedom of inquiry, the latter indispensable to scientific research. Despite these provisions—and the fact that independent scientific research is critical to an understanding of a substance, its properties, potential for harm and potential medical use—research into controlled substances is significantly hampered by onerous bureaucratic requirements and undue criminalization.20
Paul Hunt, the former UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (hereinafter “the Special Rapporteur on the right to health”), has commented on the “scant regard” of drug control for international human rights law and the generally disjointed interaction of the two legal frameworks.21 This disregard for human rights persists despite their place in the UN Charter, and supremacy of the obligations of UN member states under the charter over any other international agreement.22
The importance of respecting, protecting, and fulfilling human rights in the context of drug control has been affirmed in a plethora of international commitments and resolutions. As the UN General Assembly agreed in a 2007 resolution and reiterated in the outcome document of the UN General Assembly Special Session (UNGASS) on drugs in 2016, states have a legal obligation to carry out drug control “in full conformity with the purposes and principles of the Charter of the United Nations, international law and the Universal Declaration of Human Rights, with full respect for the sovereignty and territorial integrity of States, the principle of non-intervention in the internal affairs of States, all human rights, fundamental freedoms, [and] the inherent dignity of all individuals .”23 Similarly, Barrett observes:
Human rights in international drug control have … traditionally been absent, and are viewed as a nuisance by many governments and UN agencies … [T]he system consciously avoids addressing important but controversial issues in order to preserve the appearance of international consensus.”24
In the context of access to controlled medicines for pain relief, Lohman et al. argue that excessive over-regulation by governments and ignorance of health care providers conspire to create a vicious cycle of under-treatment, and conclude that poor prioritization of controlled medicines for pain relief is not a result of the low prevalence of pain but of the invisibility of its sufferers.25
The observations of Hunt, Barrett, and Lohman et al point to the normative gap between the human rights and drug policy frameworks, and the relative power imbalance between those promoting health and rights, and those with a criminal justice agenda.
Drug policy undermines access to controlled medicines and infringes upon the right to health
Where drug policy disproportionately emphasizes preventing diversion and non-medical use of controlled substances over ensuring their availability and access for medical and research purposes, it risks violating the right to health.26 Independent bodies charged with overseeing the aforementioned treaties have authoritatively interpreted the normative content of the right to health and related obligations. The Committee on Economic, Social and Cultural Rights (CESCR), for example, considers access to essential medicines, as defined by WHO, to be a core obligation within the right to health, meaning that access should be immediately prioritized by all state parties and not just added along the way toward progressive realization.27
Further, CESCR has clarified that the right includes both freedoms and entitlements, as well as immediate and progressive obligations to ensure healthcare facilities, goods and services are available, accessible, acceptable and of sufficient quality.28 Accessibility includes affordability as well as non-discrimination, such that “health facilities, goods and services must be accessible to all, including the most vulnerable or marginalized sections of the population, in law and in fact.”29 The right to health additionally includes obligations to take steps to prevent, treat, and control diseases, and to avoid policies that are likely to result in unnecessary morbidity.30 Consequently, UN treaty bodies have expressed concern at the Russian ban on opiate substitution therapy, and have called on a range of other countries to take steps to ensure access to such therapy.31
The global state of access to controlled medicines for pain relief illustrates the detrimental impact restrictive drug controls have on realizing the right to health. The INCB estimates that 5.5 billion people have limited or no access to these medicines, with 92% of the world’s morphine consumed in countries that constitute just 17% of the global population.32 While there are myriad reasons for this, including economic barriers, prescriber regulations, and marketing practices, it is difficult to overlook the role of overly burdensome regulatory frameworks, which have their roots in emphasis on restrictive control in the regulation of controlled medicines. Indeed, when we consider the effects of the drug conventions on the right to health, we see an incursion of the restrictive control and criminal justice mindset into the medical realm.
De facto criminalization
Punitive sanctions arising from the drug conventions (related to production, supply, and/or possession), efforts to prevent the diversion and misuse of controlled substances, and heavily politicized drug policy have collectively given rise to criminalization over and above the letter of the law. The result is the de facto criminalization not only of controlled substances and those who use them, regardless of their licit use or status, but also of those who prescribe them.
De jure and de facto criminalization weigh heavily upon the work of health professionals. In many jurisdictions, health professionals face disproportionate penalties for errors in the handling or prescribing of controlled medicines; are burdened by onerous security-related storage requirements; and are often subject to law enforcement oversight beyond what is prescribed in law or regulation.33 Twenty-one countries participating in a 2014 INCB survey indicated that the fear of sanctions or prosecution represented a barrier to the availability of controlled medicines in their country, while a total of 81 countries reported implementing penalties for the inadequate recordkeeping of controlled medicines, varying from fines and license revocation to prison sentences.34 This incursion of criminalization into the sphere of health undermines professionals in the delivery of ethical health care, poses a considerable disincentive to the therapeutic use of controlled substances, and creates an environment of constant, implicit accusation that health professionals are on the verge of misconduct.35
The negative impact of de facto criminalization reaches beyond health professionals: it is evident in the mistreatment of people who use drugs and people in medical need of controlled substances in non-judicial settings that nonetheless bear the imprint of the law. In the case of people who seek treatment for opioid dependence, the deforming influence of criminalization means that patients in need—like the controlled substance itself —become something to be contained and controlled.36 For example, people may be subjected to humiliating requirements such as having to collect their medicines at a police station, undergoing mandatory urine testing to assess non-medical substance use, being shifted from weekly methadone collection to daily supervision, and not being permitted to touch their medicine (which can only be administered by a physician or nurse).37
Where opioids are used in drug dependence treatment, doctors are required to maintain a degree of control over not only the controlled substances, but the patient’s behavior, suggesting a policy that not only pre-empts diversion, but hints that patients and even doctors are not to be trusted. Many countries require patients to attend a clinic on a daily basis for their dose of methadone, rather than making take-home doses available as is the case for most medicines. And, while a number of treatment options for opiate overdose or dependency exist (such as medicines that block intoxication like buprenorphine and medium-term control options such as injectable extended-release naltrexone), treatment choices are often guided by overly punitive and restrictive policies and provider prejudice rather than medical need.38 In the United States, for example, drug courts—meant to offer treatment as an alternative to imprisonment—frequently require that patients pursue treatment with opioid blockers, naltrexone, or enter drug-free treatment rather than using methadone or buprenorphine, two medicines with demonstrated beneficial effect (and psychoactive properties).39 In the UK, Release, the UK center of expertise on drugs and drug law, reports similarly restrictive or punitive measures including withdrawal of a methadone prescription where a client is deemed to have exhibited behavioral issues (a measure in breach of national guidelines); coerced reduction of methadone or buprenorphine dosage; and conditional methadone prescription, such as requiring patient engagement with other interventions. Release argues that these measures fall short of the UK’s commitments under ICESCR and points out, “In no other area of treatment would we see the choice of the individual to be able to access a widely available and evidenced treatment at the expense of political ideology.”40
The overemphasis on regulating controlled medicines and patients who need them extends beyond those seeking drug dependence treatment. Use of morphine and other opioids for pain relief, for example, is heavily stigmatized in Armenia, Kenya, and many other low- and middle-income countries.41 Patients may be denied the appropriate medicine, prescribed an inadequate amount to control their pain, or permitted to take home only a small supply of medicine.42
These medicines are mythologized for their capacity to cause dependence. The implication is that a patient becomes criminal should dependence occur, though technically, a patient only becomes a criminal when denied a legal source of controlled substances. Rigid laws also mean that overbearing efforts are made to prevent the diversion of controlled medicines to illicit markets, even when there is a lack of evidence about diversion or the development of dependence in those to whom these medicines are prescribed. A systematic review demonstrates that, among patients with no history of substance misuse who were treated with opioid analgesics, only 0.43% misused their medication, while just 0.05% developed dependence.43 There is little justification, therefore, for restricting prescriptions for controlled medicines or denying their availability. Indeed, such measures undermine the right to health, not only by impeding access to essential controlled medicines, but because they fly in the face of the notion of health as a fundamental constituent of human dignity.44
The following case studies further highlight the de facto criminalization of patients and healthcare professionals, in violation of the right to health.
Case study 1
A 2015 Human Rights Watch report on palliative care and access to pain relief in Armenia found that fewer than 3% of those in need of morphine had access to it. Oral morphine is not available, and outpatient (out of hospital) access to injectable opioids is available in limited doses to cancer patients only (as prescribed by an oncologist). In flagrant violation of patient confidentiality, oncologists reported being required to provide written monthly reports to the police disclosing details of patients who receive opioid pain relief, including their names, addresses, and ID numbers.45 Human Rights Watch observed that police oversight and control, along with participation in the regular destruction of morphine ampules at health facilities generate “a sense of trepidation among oncologists and pharmacists.”
While steps to reform oncologist reporting practices were initiated in 2016, the de facto criminalization of patients, caregivers, and health professionals continues via excessive regulatory requirements. For example, oncologist prescriptions must be approved by a standing commission of multiple doctors and bear four different stamps of authorization. Patients or their caregivers are also required to return the empty ampules before a new prescription is issued.46 These requirements, among others, inculcate a significant degree of stigma around opioid analgesic use and require thousands of people in severe pain to wait for effective pain medication or simply go without it. These barriers unnecessarily limit access to medicines for pain relief, in violation of both the right to health and the prohibition of cruel, inhuman, or degrading treatment.47 They additionally indicate disproportionate interference with the right to respect for private and family life.48
Case study 2
The overreach of restrictive control into the realm of health also plays out at the international level. While WHO’s health expertise is enshrined in the drug control treaties, it has often been resisted in the CND and opposed by the INCB. Cannabis and cannabinoids are examples. Delta-9-tetrahydrocannabinol (Δ9-THC), a formulation of the main psychoactive ingredient in cannabis, has been reviewed several times by the WHO Expert Committee.49 One of the chemical variants of Δ9-THC, dronabinol, has been available by prescription in many countries for some years.50 In 1989, the WHO Expert Committee recommended that dronabinol be reclassified under the 1971 Convention to a schedule that recognized both its potential for abuse and therapeutic value due to its effectiveness in reducing nausea secondary to chemotherapy.51 This recommendation was rejected by the CND the first time it was considered, though was eventually approved by the CND in 1991.52
In a later report, the WHO Expert Committee concluded that dronabinol was useful for the treatment of chronic pain, multiple sclerosis, neuropathic disorders, arthritis, and AIDS-associated anorexia, and that other medical uses were likely to be found.53 It therefore recommended that dronabinol be reclassified to a schedule that reflected a greater balance in favor of therapeutic importance relative to potential for harm. The CND declined to vote on the recommendation, deciding instead to request a further review by the WHO Expert Committee.54 When it comes to the medical value of cannabinoids as judged in UN mechanisms, it has been difficult for health experts to overcome the politicization of drug control, and the consequent undue restrictions put on access to controlled substances with potentially great medicinal value. Hence, overly restrictive drug control can impede research into the medical benefits of controlled substances, thus infringing also on the right to science, as discussed below. Fortunately, in 2016 the WHO Expert Committee outlined its intention to conduct a pre-review within the following 18 months on whether or not to consider re-scheduling cannabis under the conventions, a move which could influence domestic legal regimes.55
Case study 3
Since 2000, the United States has seen a nearly fourfold increase in opioid overdose deaths, in which both drug control policy and a confluence of other factors have played a part. 56 There is no single agreed explanation for this phenomenon. In at least some parts of the country, it seems that periods of increased legitimate prescription of opioids for pain relief, perhaps with inadequate monitoring of these prescriptions, led to crackdowns on prescription opioids, which in turn led to the wider use of heroin and other street opioids, of which the purity and toxicity are unknown.57 Overly restrictive controls on opioid prescribing, however, are rarely sufficient to tackle misuse, and indeed can unduly limit access to pain relief medications.
Overly restrictive drug control policy may promote overdose deaths in several ways.58 First, methadone and buprenorphine maintenance treatment, which reduces additional narcotic usage, remain heavily restricted, not integrated into primary health care, and not sufficiently available in many parts of the country.59 Second, most jurisdictions still do not have policies that encourage the ready availability of naloxone for overdose reversal to people who use drugs, their families and friends, as well as first responders.60 Third, in spite of its excellent results elsewhere, the US has not adopted heroin-assisted treatment, which could be useful in cases where other treatment has not succeeded, which are, by definition, cases at high risk of overdose. Various human rights bodies have interpreted a requirement to ensure access to medication-assisted treatment under the right to health.61
Case study 4
In Russia, as mentioned above, methadone and buprenorphine for treatment of addiction are illegal: police can arrest those in possession of the medicines, and prosecutors threaten those who distribute information about these medications with violation of laws prohibiting propaganda about illegal drugs—criminalization which impedes deeply into the sphere of health.62 This is despite the fact that WHO categorizes both methadone and buprenorphine as essential medicines. They are among the best-studied and most effective treatments for opioid dependence and have demonstrable benefit in reducing HIV risk via injecting, which accounts for the largest share of Russia’s HIV epidemic. The ban on these medicines is a clear violation of the right to health, and equating education about the medicines with propaganda further violates the right to information. Despite the stance of their government, Russian representatives have served for years on the INCB, sponsor UNODC’s informal working group on science, and participate actively in debates on drug dependence treatment and other measures at the CND.
Drug policy undermines access to controlled medicines and impedes the right to enjoy the benefits of scientific progress
The right to health and the right to enjoy the benefits of scientific progress are interrelated and interdependent. The right to science is “sometimes considered a prerequisite for the realization of a number of other human rights” and is explicitly linked to rights to health, the rights of older persons, and development.63 As yet, CESCR has not made a detailed interpretation of the right to science as it has the right to health. The right to enjoy the benefits of scientific progress is enshrined under Article 27 of the UDHR (“Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits”) and Article 15(1)(b) of ICESCR, as well as regional standards in Africa, the Americas, and Europe. Under ICESCR, the right is supplemented by a negative obligation under Article 15(3), which provides that states must respect the freedom indispensable for scientific research. This has been interpreted to mean the state is obliged not to interfere with choices and priorities decided by scientists and not to impose a certain topic or method of research on the academic community.64
The right to science is broadly acknowledged to be of great significance in the context of globalization, the communication revolution, and the accelerated pace of scientific and technological development; and yet, it is poorly implemented to the extent it was referred to as a right at “vanishing point” by Schabas in 2007.65 In 2009, recognizing the increasing relevance and continued neglect of the right to science and its applications, UNESCO convened a series of discussions designed to clarify the normative content of the right and enhance its implementation. The conclusions and proposals for the normative framing of the right, captured in the Venice Statement, emphasized freedom of inquiry as a vital element in the development of science, access to the benefits of scientific progress, and the “creation of an enabling and participatory environment for the conservation, development and diffusion of science and technology” as core components of the right to science.66 The right to science has since been the subject of increased attention.67
The Special Rapporteur in the field of cultural rights stipulated that a prerequisite for implementing the right to science is “ensuring the necessary conditions for everyone to continuously engage in critical thinking about themselves and the world they inhabit, and to have the opportunity and wherewithal to interrogate, investigate and contribute new knowledge.”68 The Special Rapporteur also sets out the normative content of the right to science—to paraphrase: access to knowledge and to the benefits of science without discrimination; opportunities to contribute to the scientific enterprise and freedom indispensable for scientific research; information to enable informed decision-making “after considering both the possible improvements offered by scientific advances and their potential side effects or dangerous usages” as well as participatory decision-making in determining what constitutes “benefits” of scientific progress; and an enabling environment.69 The two normative conditions most pertinent in the context of drug policy are access and freedom of inquiry, specifically:
- In terms of access: the innovations “essential for a life with dignity should be accessible to everyone, in particular marginalized populations.”70 This non-discrimination obligation demands eliminating both de jure and de facto barriers.71
- In terms of freedom of inquiry: freedom of scientific research has been interpreted as “the right or freedom to assess and choose the preferred path of scientific and technological development.”72 The Special Rapporteur on cultural rights clarifies that freedom “means ensuring that the scientific enterprise remains free of political and other interference, while guaranteeing the highest standards of ethical safeguards” and explicitly notes that barriers to scientific research must be overcome.73
In the context of drug policy, the incursion of criminalization and overly restrictive control into research restricts the scope and implementation of scientific inquiry. This frequently occurs via heavy administrative and bureaucratic regulation of controlled substances under the auspices of anti-diversion measures, which effectively impede freedom of inquiry. Below, we argue that disproportionate bureaucratic, legal, or other restrictions may violate states’ obligations under Article 15(3) of ICESCR.
In a similar vein, the American Association for the Advancement of Science reported that scientists participating in its 2013 focus groups remarked that “over-regulation can have the cumulative effect of stifling the freedom indispensable for scientific research and creative activity” and that “[w]hile regulations individually may or may not be reasonable responses to concerns about national security [and] trade … an accretion of overlapping, vague and contradictory regulations can smother the scientific enterprise.”74 When researchers are able to initiate and demonstrate the medical value of a controlled substances—for example, prescription heroin in Canada—the de jure criminalization of controlled substances means access to medical treatment and related information may still be impeded.75 Even where law reform reflects scientific findings, de facto criminalization lends stigma and additional impediments to accessing the substance.
Furthermore, de facto criminalization engenders bias and tends to politicize issues related to controlled substances. This impacts judgment and decision-making from scientific review to funding. The Special Rapporteur on cultural rights commented on “the diminishing role played by the State in research and development and the concomitant extensive increase in the involvement of the private sector,” adding that the state should not rely entirely on the private sector and should make all efforts possible to ensure publicly funded research.76 We argue that de facto criminalization weakens access to science and its applications, and amounts to a violation of (often vulnerable or marginalized) individuals’ rights.
Finally, we recognize that scientific freedom is not absolute, “but centers on the nexus of freedom and responsibility.”77 Any restriction to the right to science must comply with the relevant legal standard. For example, Article 4 of ICESCR provides that rights in that covenant can only be restricted in a manner that is according to law, consistent with the nature of the right, pursuant to a legitimate aim (such as the protection of public health), and strictly necessary for the promotion of general welfare in a democratic society. CESCR has stated that “such limitations must be proportional, i.e. the least restrictive alternative must be adopted where several types of limitations are available.”78
The following case studies highlight the de facto criminalization of patients and researchers, in violation of the right to enjoy the benefits of scientific progress.
Case study 1
In the UK, researchers require a special license in order to hold Schedule 1 controlled substances (those subject to the most stringent level of control). Obtaining such a license may take up to one year, cost GBP3000 (plus an additional GBP2000 for security equipment and police checks), and furthermore may require additional import licenses, since most suppliers of controlled substances are located outside the UK. David Nutt, psychiatrist and neuropsychopharmacologist, estimates that overcoming these hurdles increases the cost of the research into controlled substances “by about 10-fold.”79 Consequently, just four hospitals in the UK hold a Schedule 1 dispensing license. As such, research into the medical value of Schedule 1 substances is effectively smothered, closing opportunities for discovery of therapeutic benefit (or harm).80 Despite initial case reports suggesting a medical value for MDMA analogues (similar in structure to MDMA) in alleviating dyskinesia (involuntary movements) associated with Parkinson’s disease, media hype around potential misuse of MDMA analogues resulted in their blanket classification as Schedule 1 substances.81 This effectively criminalized both the analogues and the research, as the sites conducting the research could not afford Schedule 1 licenses.82
Similarly, in Canada, it took a research group sponsored by the Multidisciplinary Association for Psychedelic Studies more than four years to be permitted to import MDMA from Switzerland under a special license, even though the group had already obtained approval from the federal department of health and a Canadian institutional review board to conduct research into the therapeutic use of MDMA in post-traumatic stress disorder.83 Nutt notes there are no known instances of diversion of Schedule 1 or Schedule 2 drugs from research labs, “So the law simply censors research rather than protects the public; indeed the limitation to clinical research produced by the regulations almost certainly has done much more harm than good to society by impeding medical progress.”84
Case study 2
The issue of access to cannabis for medical treatment received a high degree of attention in the US after a series of television documentaries on the beneficial effects of a cannabis derivative for children with Dravet syndrome, or treatment-resistant epilepsies, among other conditions.85 Dr. Sanjay Gupta, CNN’s chief medical correspondent, documented the story of more than 100 American families who moved to Colorado (which authorized patients and their caregivers to possess, cultivate, and use cannabis for medical purposes in 2000), in order to secure regular access to the substance for medical use for their children. As the law currently stands, these patients and families must stay in Colorado, because transporting their medicine (a non-psychoactive cannabis oil) puts them at risk of criminal prosecution.86 Previously, therapeutic benefits of the cannabis extract had not been scientifically evaluated. Critics of overregulation note that this was the result of restrictions on research with cannabis and its derivatives in the US, including licensing restrictions and refusal to reschedule cannabis by the Drug Enforcement Agency, which retained authority of the decision despite lack of health expertise. These restrictions violate both freedom of inquiry and the requirement for non-discriminatory access to the benefits of scientific progress.
Case study 3
LSD is another case in point. Notwithstanding accounts suggesting that LSD may have considerable therapeutic value for treating alcoholism in some patients, researching the medical value of LSD in Europe is made impossible by the fact that there is no approved source of LSD formulation for human clinical trials.87 In this case, marginalized members of European society—people in need of treatment for alcoholism—are denied access to the benefits of research.
Case study 4
In the US, researchers published multiple papers noting that MDMA caused dopaminergic brain damage. The finding was widely circulated, and retracted only after it was revealed that the researchers had mistakenly used methamphetamine—known to impair dopamine function—rather than MDMA, in the experiment. Widespread media coverage of the erroneous finding, along with a lack of appropriate scrutiny of results or interest in replicability, reflects the presumptive prejudice and bias toward detection of harm built into research on psychoactive substances.88
Restrictions on the exercise of the right to science such as these need to be carefully considered in light of the permissible limitations of rights outlined in Article 4 of ICESCR, outlined above. Specifically, they should be reviewed to consider whether they are the least restrictive measures in pursuit of a legitimate aim (protection of public health). Given, for example, that the risk of diversion from research laboratories is extremely low, the calculation of proportionality in assessing these restrictions on research should also consider the lost possibility for treatment and medical benefit resulting from drug restrictions. In these circumstances, we argue that draconian restrictions on the right to science, which have a potentially significant impact on the right to health and which seek to combat a small risk of diversion, are often disproportionate and therefore in violation of ICESCR.
Finally, the bias against psychoactive substances also requires attention to the questions not asked or comparisons not conducted in scientific research. For example, the trial used to approve long-acting naltrexone, an opioid blocker for addiction treatment, compared this medicine to placebo and counseling alone (shown to be inferior to existing treatments in multiple previous studies) rather than to opioids with known medical benefit (and psychoactive effect) used in addiction treatment.89 Since approved, the opioid blocker has become the treatment preferred by multiple actors in the US criminal justice system, with respondents from that sector reporting that they prefer it to the psychoactive treatments because of the medical evidence indicating superiority.90 This is striking, of course, because there has been no comparative study. Ethicists and researchers have flagged this lapse, and a genuine comparison is now underway between the opioid blocker and the medicines which comprise the gold standard of care.91 Scientific gaps caused by bias threaten the right to science by undermining the balance of freedom and responsibility in research.
As noted by the Johns Hopkins–Lancet Commission on Public Health and International Drug Policy, impediments to access to controlled medicines go hand in hand with other elements of overzealous drug control, such as mass incarceration for minor offenses, even if cloaked in the guise of health concerns. Both are fueled by the demonization of people who use drugs, and by unscientific notions of addiction that dominate the public mind, with health clinics and other non-judicial spaces bearing the imprint of criminal law through what we have referred to as de facto criminalization.92 The massive denial of opioids and other controlled medicines to people who desperately need them—which remains a quintessential example of global health inequity—is furthered by the difficulty faced by researchers whose work could explore the therapeutic benefits of controlled medicines but who cannot obtain controlled substances or official approval for their research.
The Johns Hopkins–Lancet Commission report suggests ways to emerge from the unscientific demonization of drugs and the futile pursuit of drug prohibition in favor of an approach based on the idea that the harm of psychoactive drugs, like the harms of tobacco, for example, can be controlled by pragmatic public health measures. A truly health-oriented drug policy requires openness by policy-makers, institutional review boards, health professionals, and society to the idea that controlled substances have benefits for human health and human dignity, and that their study and use to promote public health is a worthy enterprise. Indeed, their contributions to health and well-being are as essential to compliance with international law as the regulation of substances that can cause harm. States’ obligations related to the right to health extend to a duty to uphold that right through international cooperation and assistance. This means, for example, that they should respect, protect, and fulfill the right to health in their joint action in intergovernmental bodies such as the CND.
In regular sessions of the CND in recent years, as well as in the 2016 UNGASS on drugs, member states—including some with relatively repressive drug laws—pledged to adopt “public health approaches” to drug control policy that conform with human rights.93 The INCB ended its 2017 session with a press release urging vigilance and cooperation in addressing the world’s drug problems, but “in conformity with human rights.”94 In many cases, national level pledges took the form of commitments to treat people who use drugs as patients, not criminals.95 It remains to be seen if these commitments have any meaning, or if they will distract attention from unchanged health- and human rights-unfriendly policies under a different banner. If countries or international mechanisms are truly interested in a health-based approach to addressing drug problems, they must prioritize improving access to controlled medicines, thereby also meeting their obligations to respect, protect, and fulfill the rights to health and the benefits of scientific progress.
Naomi Burke-Shyne, LLB, Masters of International and Community Development, is a senior program officer with the Public Health Program, Open Society Foundations, London, UK.
Joanne Csete, PhD, MPH, is an adjunct associate professor at the Mailman School of Public Health, Columbia University, New York, USA.
Duncan Wilson, LLB (Hons), LLM, is a project director with the Public Health Program, Open Society Foundations, New York, USA.
Edward Fox is a Communications and Advocacy Senior Associate at Global Health Strategies New York, USA.
Daniel Wolfe, MPH, MPhil, is a director with the Public Health Program, Open Society Foundations, New York, USA.
Jennifer J. K. Rasanathan, MD, MPH, is a program officer with the Public Health Program, Open Society Foundations, New York, USA.
Please address correspondence to the authors c/o Naomi Burke-Shyne. Email: firstname.lastname@example.org.
Competing interests: None declared.
Copyright © 2017 Burke-Shyne, Csete, Wilson, Fox, Wolfe, and Rasanathan. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
- The conventions are complementary and mutually reinforcing, with the 1961 Single Convention on Narcotic Drugs, as amended by the 1972 Protocol and the 1971 Convention on Psychotropic Substances codifying the rules of international drug control for narcotic and synthetic psychotropic substances, respectively. The 1988 United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances strengthens State obligations to criminalize illicit production, possession and trafficking of drugs.
- WHO Model List of Essential Medicines, 2015. Available at http://www.who.int/medicines/publications/essentialmedicines/en/.
- United Nations General Assembly, 1972 Protocol Amending the Single Convention on Narcotic Drugs, 1961, December 9, 1975, A/RES/3444 (Single Convention), Article 3. Available at https://www.unodc.org/pdf/convention_1961_en.pdf.
- See World Health Organization, “WHO Expert Committee on Drug Dependence” (online introduction). Available at http://www.who.int/substance_abuse/right_committee/en/.
- J. van Amsterdam and D. Nutt, “European rating of drug harms,” Journal of Psychopharmacology 29/6 (2015), pp. 655-660; D. Nutt, L.A. King, and L.D. Phillips, Independent Scientific Committee on Drugs, “Drug harms in the UK: a multicriteria decision analysis,” Lancet 376 (2010), pp. 1558-1565.
- E. Danenberg, L.A. Sorge, W. Wieniawski et al., “Modernizing methodology for the WHO assessment of substances for the international drug control conventions,” Drug and Alcohol Dependence 131/3 (2013) pp. 175-181.
- Single Convention (see note 3), Article 3, paragraph 5.
- B. Fischer, E. Oviedo-Joekes, P. Blanken, et al., “Heroin-assisted treatment (HAT) a decade later: a brief update on science and politics.” Journal of Urban Health 84/4 (2007), pp. 552-562.
- UN General Assembly, 1971 Convention on Psychotropic Substances, December 9, 1975, UN Doc. No. A/RES/3443 (1971 Convention), preamble. Available at https://www.unodc.org/pdf/convention_1971_en.pdf.
- World Health Organization Expert Committee on Drug Dependence Thirty-sixth Meeting, Ketamine: Update Review Report (WHO, Geneva, 2014). Available at http://www.who.int/medicines/areas/quality_safety/6_2_Update.pdf.
- World Health Organization, Ensuring balance in national policies on controlled substances: Guidance for availability and accessibility of controlled medicines, (Geneva, WHO, 2011), p. 16. Available at http://apps.who.int/iris/bitstream/10665/44519/1/9789241564175_eng.pdf; International Narcotics Control Board, Report of the International Narcotics Control Board for 1989 (New York, 1989).
- J. Csete and D. Wolfe, Closed to reason: The international narcotics control board and HIV/AIDS. Canadian HIV/AIDS Legal Network and International Harm Reduction Development Program (IHRD) of the Open Society Institute (Toronto/New York, 2007).
- Universal Declaration of Human Rights (UDHR), G.A. Res. 217A (III) (1948), Art. 25. Available at http://www.un.org/Overview/rights.html.
- The right to health is also protected in a range of regional human rights conventions, including the African Charter on Human and Peoples’ Rights (1981), the Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights (1988), and the European Social Charter (1961, revised in 1996).
- Committee on Economic, Social and Cultural Rights, General Comment No. 14: The Right to the Highest Attainable Standard of Health, UN Doc. No. E/C.12/200/4 (2000), para 43 (d). Available at http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4slQ6QSmlBEDzFEovLCuW1AVC1NkPsgUedPlF1vfPMJ2c7ey6PAz2qaojTzDJmC0y%2b9t%2bsAtGDNzdEqA6SuP2r0w%2f6sVBGTpvTSCbiOr4XVFTqhQY65auTFbQRPWNDxL.
- Universal Declaration of Human Rights (see note 13), Article 25(1).
- See, for example UN Docs E/C.12/BLR/CO/4-6 (2013); CCPR/C/GEO/CO/4 (2014); E/C.12/IDN/CO/1 (2014); E/C.12/LTU/CO/2 (2014); E/C.12/RUS/CO/5 (2011); CEDAW/C/RUS/CO/8 (2015); E/C.12/UKR/CO/6 (2014); E/C.12/UZB/CO/2 (2014).
- The International Centre for Human Rights and Drug Policy and the Canadian HIV/AIDS Legal Network, Case Information Sheet: Kurmanayevskiy et al v Russia (May 2016). Available at http://www.hr-dp.org/european-court-of-human-rights-kurmanayevskiy-et-al-v-russia.
- It is further guaranteed in a range of other international and regional instruments. See Report of the Special Rapporteur in the field of cultural rights, Farida Shaheed, The right to enjoy the benefits of scientific progress and its applications, UN Doc. A/HRC/20/26 (2012).
- D. Nutt, “Illegal drugs laws: Clearing a 50-year-old obstacle to research,” PLoS Biology, 13(1) (2015), pp. 3-5.
- P. Hunt, “Human rights, health, and harm reduction – States’ amnesia and parallel universes” (keynote presentation at the 19th International Harm Reduction Conference, Barcelona, Spain, May 11, 2008).
- Articles 55 and 56 of the UN Charter enshrine human rights in the UN Charter, requiring all UN Member States to “take joint and separate action” to achieve “universal respect for, and observance of, human rights and fundamental freedoms,” while Article 103 of the UN Charter provides that States’ obligations under the Charter prevail over their obligations under any other international agreement.
- UN General Assembly Special Session on the World Drug Problem, G.A. Res A/RES/S-30/1, (2016) Annex. Available at https://www.incb.org/documents/PRECURSORS/Resolutions-Precursors/GA-UNGASS-Res_S-30-1_2016.pdf.; Declaration on International Cooperation against the World Drug Problem, G.A. Res 61/183 (2006), para. 1. Available at http://www.worldlii.org/int/other/UNGA/2006/238.pdf.Document1.
- D. Barrett, “Reflections on Human Rights and International Drug Control,” in J. Collins, (ed), “Governing the global drug wars,” London: LSE IDEAS, 2012, pp. 56-62.
- D. Lohman, R. Schleifer, J.J. Amon, “Access to pain treatment as a human right” BMC Medicine (2010), 8:8. Available at http://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-8-8.
- As the UN Committee on Economic, Social and Cultural Rights has clarified, violations of the right to health include both acts of commission and acts of omission. Acts of commission can include passing laws that interfere with the realization of the right (for example through limiting access to medicines necessary for the treatment of pain or drug dependence); and failing to take steps to redress inequality in access to healthcare, goods and services (for example failing to address the significant global inequality in access to controlled medicines). See General Comment 14 (see note 15), Part 3.
- General Comment 14 (see note 15), para 43(d).
- General Comment 14 (see note 15), para 12, 30; Committee on the Rights of the Child, General Comment No. 15: The Right of the Child to the Enjoyment of the Highest Attainable Standard of Health, UN Doc. CRC/C/GC/15, (2013), para. 25. Available at http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=6QkG1d%2FPPRiCAqhKb7yhsqIkirKQZLK2M58RF%2F5F0vHCIs1B9k1r3x0aA7FYrehlNUfw4dHmlOxmFtmhaiMOkH80ywS3uq6Q3bqZ3A3yQ0%2B4u6214CSatnrBlZT8nZmj
- General Comment 14 (see note 15), para 12(b).
- Article 12(2)(c) ICESCR; General Comment 14 (see note 15).
- See note 17. See also R. Douglas Bruce and R. A. Schleifer, “Ethical and human rights imperatives to ensure medication-assisted treatment for opioid dependence in prisons and pre-trial detention,” International Journal of Drug Policy (2008), 19/1, pp. 17–23.
- International Narcotics Control Board, Availability of Internationally Controlled Drugs: Ensuring Adequate Access for Medical and Scientific Purposes Indispensable, adequately available and not unduly restricted (Vienna: INCB, 2015), p. iii. Available at: http://www.incb.org/documents/Publications/AnnualReports/AR2015/English/Supplement-AR15_availability_English.pdf.
- S.V.S. Bandewar, “Access to controlled medicines for palliative care in India: Gains and challenges,” Indian Journal of Medical Ethics 12/2 (2015), pp. 77-82; M.J. Bojko, A. Mazhnaya, R. Marcus et al. “The future of opioid agonist therapies in Ukraine: A qualitative assessment of multilevel barriers and ways forward to promote retention in treatment.” Journal of Substance Abuse Treatment 66 (2016), pp. 37-47.
- International Narcotics Control Board (see note 32), para. 134. Available at http://www.incb.org/incb/en/documents/Publications/AnnualReports/AR2015/availability_2015.html
- D. Puras and J. Hannah, “Reasons for drug policy reform: Prohibition enables systemic human rights abuses and undermines public health,” British Medical Journal, (2017), 356:i6586.
- Methadone and buprenorphine are both widely used medicines in treating opioid dependence, and are contained in WHO’s Model List of Essential Medicines, WHO (see note 2).
- B. Reville and A.M. Foxwell, “The global state of palliative care—progress and challenges in cancer care,” Annals of Palliative Medicine, 3/3 (2014), pp. 129-138 2; Bojko et al (see note 33) pp. 37-47.
- D.S. Festinger, K.L. Dugosh, D.R. Gastfriend, and C. Sierka, “Attitudes and practices on the use of extended-release naltrexone in criminal justice settings [research abstract),” Drug and Alcohol Dependence, 171 (2017), pp. e62-e63; D. Wolfe, M.P. Carrieri, N. Dasgupta, et al., “Concerns about injectable naltrexone for opioid dependence,” The Lancet, 377/9776 (2011), pp. 1468-1470; European Monitoring Centre for Drugs and Drug Abuse, “Perspectives on drugs: strategies to prevent diversion of opioid substitution treatment medications,” Lisbon, 2016.
- J. Csete and D. Wolfe. “Seeing through the public health smoke-screen in drug policy” International Journal of Drug Policy (2017) 43, pp. 91-95. Available at http://dx.doi.org/10.1016/j.drugpo.2017.02.016.
- Release, Drugs, the Law and Human Rights, Drug Policy in the UK and its Intersection with International Human Rights: Submission to the Office of the High Commissioner for Human Rights from Release (London: Release, 2016). Available at http://www.release.org.uk/sites/default/files/pdf/publications/Release%20submision%20on%20drug%20policy%20in%20the%20UK%20-%20OHCHR%20final.pdf
- Human Rights Watch, All I Can Do Is Cry: Cancer and the Struggle for Palliative Care Armenia (New York, Human Rights Watch, 2015). Available at: https://www.hrw.org/report/2015/07/14/all-i-can-do-cry/cancer-and-struggle-palliative-care-armenia; Human Rights Watch, Needless Pain: Government Failure to Provide Palliative Care to Children in Kenya (New York, Human Rights Watch 2010). Available at: https://www.hrw.org/report/2010/09/09/needless-pain/government-failure-provide-palliative-care-children-kenya; Y-C. Kim, J.S. Ahn, M.M.P. Calimag, et al., “Current practices in cancer pain management in Asia: a survey of patients and physicians across 10 countries,” Cancer Medicine 4/8 (2015) pp. 1196-1204; J.H. Kwon JH, “Overcoming barriers in cancer pain management,” Journal of Clinical Oncology 32 (2014) pp. 1727–1733.
- Kim et al (see note 41); Human Rights Watch, Uncontrolled Pain Ukraine’s Obligation to Ensure Evidence-Based Palliative Care (New York, Human Rights Watch, 2011). Available at: https://www.hrw.org/report/2011/05/12/uncontrolled-pain/ukraines-obligation-ensure-evidence-based-palliative-care.
- M. Noble, S.J. Tregear, J.R. Treadwell and K. Schoelles, “Long-term opioid therapy for chronic non-cancer pain: a systematic review and meta-analysis of efficacy and safety,” Journal of Pain and Symptom Management, 35/2 (2008), pp. 214–228.
- General Comment 14 (see note 15) para. 17.
- Human Rights Watch (2015, see note 41).
- Lohman (see note 25); Open Society Foundations, Palliative Care as a Human Right: A Factsheet (2016) Available at https://www.opensocietyfoundations.org/publications/palliative-care-human-right-fact-sheet.
- Protected in a range of international and regional human rights treaties including the International Covenant on Civil and Political Rights (article 17) and the European Convention on Human Rights (Article 8).
- World Health Organization, WHO Expert Committee on Drug Dependence 35th report, WHO Technical Report Series 973 (Geneva: WHO, 2012).
- J.E. Joy, S.J. Watson Jr., and J.A. Benson Jr. Marijuana and medicine: Assessing the science base (Washington, DC: National Academies Press, 1999).
- World Health Organization, WHO Expert Committee on Drug Dependence 26th report, WHO Technical Report Series 787, (Geneva: WHO 1989).
- WHO (2012, see note 50).
- World Health Organization, WHO Expert Committee on Drug Dependence 34th report, WHO Technical Report Series 942, (Geneva: WHO, 2006).
- UN Commission on Narcotic Drugs, Scheduling Procedures (Vienna: CND). Available at: https://www.unodc.org/unodc/en/commissions/CND/Mandate_Functions/Mandate-and-Functions_Scheduling.html
- World Health Organization, WHO Expert Committee on Drug Dependence 38th Report (Unedited Draft), (WHO, Geneva, 2016). Available at: http://www.who.int/medicines/access/controlled-substances/ECDD_38th_Report_Unedited_version_13032017.pdf?ua=1
- Centers for Disease Control and Prevention, Wide-ranging Online Data for Epidemiologic Research (WONDER), Multiple-Cause-of-Death file, 2000–2014 (Atlanta: CDC, 2014). Available at: (http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf).
- See, e.g. A. Case and A. Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of Science 112/49 (2015), pp. 15078-86; B. Pardo, “Do more robust prescription monitoring programs reduce prescription opioid overdose?” Addiction (2016) doi: 10.1111/add.13741 (e-pub ahead of print).
- K. Miller, “LePage vetoes bill aimed at increasing access to overdose antidote,” Portland Press Herald, April 20, 2016.
- B. Nosyk, M. D. Anglin, S. Brissette, T. et al., “A call for evidence-based medical treatment of opioid dependence in the United States and Canada,” Health Affairs 32/8 (2013) pp. 1462-9.
- R.A. Rudd, P. Seth, F. David, and L. Scholl, “Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010-2015,” Morbidity and Mortality Weekly Report 65/5051 (2016):1445-1452.
- While the United States is not party to either the ICESCR, the CRC, or CEDAW, which have issued the bulk of recommendations in this regard, it is interesting to note that such an obligation has been found by the UN Human Rights Committee to exist under the International Covenant on Civil and Political Rights, to which the USA is party, on at least one occasion. See UN Human Rights Committee, concluding observations on Georgia, UN Doc. CCPR/C/GEO/CO/4 (2014).
- T. Parfitt, “Vladimir Mendelevich: Fighting for drug substitution treatment,” The Lancet, 368(9532) (2006),p. 279.
- Human Rights Council Resolution 11/8, Preventable maternal mortality and morbidity and human rights, UN Doc. No. A/HRC/11/37 (2009) para 2; Committee on Economic, Social and Cultural Rights, General Comment No. 6, The Economic, Social and Cultural Rights of Older Persons, UN Doc. No. E/1996/22 (1995), para. 42; Commission on Human Rights resolution 2003/71, Human Rights and the Environment as Part of Sustainable Development, UN Doc. No. E/CN.4/RES/2003/71 (2003), preamble.
- Y. Donders, “The right to benefit from scientific progress: in search of state obligations in relation to health,” Medicine, Health Care and Philosophy, 14 (2011), p. 376; Note also, that the travaux preparatoires show that in proposing the REBSP in 1951, the United Nations Educational, Scientific and Cultural Organization (UNESCO) placed significant emphasis on health and on the realization of other human rights, stating that “scientific discoveries in the theoretical field might lead, especially in the present era, to practical applications of cardinal importance for the improvement of human welfare, more particularly in health.” It added that, “[t]he right of everyone to enjoy his share of the benefits of science was to a great extent the determining factor for the exercise by mankind as a whole of many other rights.” Commission on Human Rights, Summary Record of the 228th Meeting held at the Palais Des Nations Geneva, UN Doc. No. E/CN.4/SR.228, (1951).
- UNESCO, the Amsterdam Center for International Law and the Irish Centre for Human Rights, “Introduction, Prof. William Schabas and Ms Maria Virginia Bras Gomes,” Report of the Experts Meeting on the Right to Enjoy the Benefit of Scientific Progress (Amsterdam, UNESCO, 2007) p. 5.
- The Venice Statement on the Right to Enjoy the Benefits of Scientific Progress and its Applications, adopted in July 2009 by a group of experts, para 13. Available at: https://www.aaas.org/sites/default/files/VeniceStatement_July2009.pdf.
- Farida Shaheed, UN Special Rapporteur in the Field of Cultural Rights, The Right to Enjoy the Benefits of Scientific Progress and its Applications, UN Doc. A/HRC/20/26 (2012); AAAS Science and Human Rights Coalition, Defining the Right to Enjoy the Benefits of Scientific Progress and its Applications: American Scientists’ Perspectives (New York, AAAS, 2013). Available at: http://www.aaas.org/sites/default/files/content_files/UNReportAAAS.pdf
- Shaheed, ibid, para. 18.
- Ibid, para. 18.
- Ibid, para. 29.
- Ibid, para. 31.
- Donders (see note 64), p. 373.
- Shaheed (see note 67), para 39; The Venice Statement (see note 66), para. 8 and para. 42.
- AAAS Science and Human Rights Coalition (see note 67), p. 15.
- E. Oviedo-Joekes, K. Marchand, K. Lock et al, “A chance to stop and breathe: participants’ experiences in the North American Opiate Medication Initiative clinical trial,” Addiction Science & Clinical Practice (2014) 9:21.
- Shaheed (see note 67), para. 70-71.
- AAAS Science and Human Rights Coalition (see note 67), p. 17; A. Chapman, “Towards an Understanding of the Right to Enjoy the Benefits of Scientific Progress and Its Applications,” Journal of Human Rights 8 (2009) p. 17.
- General Comment 14 (see note 15) para 28-29; see also Chapman (see note 77), p. 17.
- Nutt (2015, see note 20), p. 4.
- Ibid., p. 3.
- P.H. Huot, T.H. Johnston, K.D. Lewis et al., “Characterization of 3,4-Methylenedioxymethamphetamine (MDMA) Enantiomers In Vitro and in the MPTP-Lesioned Primate: R-MDMA Reduces Severity of Dyskinesia, Whereas S-MDMA Extends Duration of ON-Time,” Journal of Neuroscience, 31 (2011), pp. 7190–7198.
- D.J. Nutt, L.A. King, and D.E. Nichols, “New victims of current drug laws,” Nature Review Neuroscience, 14 (2013) p. 877.
- D.J. Nutt, L.A. King, and D.E. Nichols, “Effects of Schedule I drug laws on neuroscience research and treatment innovation,” Nature Reviews, Neuroscience, 14 (2013), p. 580. Available at: http://www.nature.com/nrn/journal/v14/n8/full/nrn3530.htm.
- Nutt (2015, see note 20), p. 5.
- S. Gupta, “I am doubling down on medical marijuana,” CNN International Edition (March 6, 2014). Available at: http://www.cnn.com/2014/03/05/health/gupta-medical-marijuana/; B.E. Porter and C. Jacobson, “Report of a parent survey of cannabidiol-enriched cannabis use in pediatric treatment-resistant epilepsy,” Epilepsy & Behavior, 29/3 2013, pp. 574–577.
- Gupta, see note 85.
- T. Krebs and P-Ø. Johansen, “Lysergic acid diethylamide (LSD) for alcoholism: a meta-analysis of controlled trials,” Journal of Psychopharmacology, 26 (2012), pp. 994–1002; Nutt (2015, see note 60), p. 3; Good Manufacturing Practice production, Regulation (EU) No. 536/2014 of the European Parliament and of the Council on clinical trials on medicinal products for human use and repealing Directive 2001/20/EC, 16 April 2014. Available at: http://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32014R0536&from=EN.
- G.A. Ricaurte, J. Yuan, G. Hatzidimitriou, et al., “Severe dopaminergic neurotoxicity in primates after a common recreational dose regimen of MDMA (ecstasy),” Science 297 (2002), pp. 2260–2263; retraction Science 301 (2003), p. 1479; Nutt (2013, see note 83) p. 583.
- Wolfe et al. (2011 see note 38) pp. 1468-1470.
- Festinger et al. (see note 38), pp. e62-e63.
- E.V. Nunes, J.D. Lee, D. Sisti, et al., “Ethical and clinical safety considerations in the design of an effectiveness trial: A comparison of buprenorphine versus naltrexone treatment for opioid dependence,” Contemporary Clinical Trials 51 (2016) pp. 34-43.
- J. Csete, A. Kamarulzaman, M. Kazatchkine et al., “Public health and international drug policy (Commission report),” Lancet 387/10026 (2016), pp. 1427-1480.
- UN General Assembly Special Session on the World Drug Problem (see note 23), para. 5(e) and (o).
- INCB, “INCB urges increased vigilance and international cooperation to effectively address the world drug problem in compliance with human rights.” Press Release (Vienna: Feb 17, 2017). Available at https://www.incb.org/incb/en/news/press-releases/2017/press_release20170203.html.
- UN General Assembly, General Assembly Special Session Adopts Resolution Recognizing Persisting Health, Safety, Well-Being Challenges Posed by World Drug Problem (April 2016). Available at http://www.un.org/press/en/2016/ga11773.doc.htm.
Letter to the Editor: The Rule of Law as a Social Determinant of Health
O.B. K. Dingake
Letter to the Editor: Refusal to Treat Patients Does Not Work in Any Country – Even if Misleadingly Labelled Conscientious Objection
Christian Fiala and Joyce H. Arthur
Letter to the Editor Response: Much to Debate about Conscientious Objection
Wendy Chavkin, Laurel Swerdlow, and Jocelyn Fifield
Papers in Press
The Cholera Epidemic in Zimbabwe, 2008-2009; A Review and Critique of the Evidence
C. Nicholas Cuneo, Richard Sollom, and Chris Beyrer
Letter to the Editor: Human Rights, TB, Legislation and Jurisprudence
O. B. K. Dingake
UNstoppable: How Advocates Persevered in the Fight for Justice for Haitian Cholera Victims
HIV Criminalization Laws and the Right to Health
Canada’s Mining Industry in Guatemala and the Right to Health of Indigenous Peoples