EDITORIALS
Arguments against the compulsory treatment of opioid dependence
Ruth Birgin on behalf of the Asian Network of People Who Use Drugs*
c/o 1 Hamilton Place, Bowen Hills, Qld., 4006, Australia
The Asian Network of People Who Use Drugs finds a recent attempt to advocate for compulsory "rehabilitation" centres1 founded on faulty arguments and dubious research that, if heeded, poses a direct threat to the human rights of people who use drugs and the dignity of society at large.
Wu's round table article claims to refute the rationale behind the recent call made by 12 UN agencies "... to close compulsory detention and rehabilitation centres and implement voluntary, evidence-informed and rights-based health and social services in the community".2 In countries with compulsory centres, the detention of people who use drugs often occurs without sufficient due process, legal safeguards or judicial review, and there are frequent reports of physical and sexual violence, forced labour, sub-standard conditions, denial of health care, and other violations of human rights in such state-sanctioned centres.3 Yet Wu claims "... there is no evidence that people in such centres are at higher risk of opioid-related medical complications, infectious diseases or death, than those not living in compulsory treatment centres". A 2010 report - one of many exposés - on compulsory drug treatment and forced labour shows that such centres deny access to treatment, put inmates at risk of physical abuse and forced labour.4 To imply that such unacceptable conditions may also exist in the community is the weakest possible defence for favouring compulsory centres.
The article suggests that we "... must take into account both the human rights of the opioid-dependent individuals and those of the people who live in their communities", omitting the fact that deprivation of liberty without due process is always an unacceptable violation of human rights.5 When the rights of drug-using individuals have been compromised for community well-being, these measures have both failed to improve communities and forced people who use drugs further underground, encouraging needle-sharing and other risky behaviours.6,7 State-sanctioned violence always reflects badly on society as a whole, not least in Asian countries that identify as community-oriented.
Wu proposes - and the discussants disagree - that compulsory centres make the community safer from violent criminals. Yet studies show that "... many dependent drug users do not commit any crimes other than drug use/possession, where it is criminalized".8 Evidence also shows that low threshold treatments such as methadone maintenance programmes reduce involvement in crime.9
Wu proposes that: "Compulsory treatment centres should be part of a broader harm reduction strategy." The UN system has recommended nine essential services for people who inject drugs, all of which have a strong evidence base and none of which sanction compulsory treatment.10 Compulsory drug rehabilitation centres have not shown to be effective in preventing relapse and they pose considerable risks to the well-being of detainees.11,12
The UN Special Rapporteur has reported on abuse, torture, cruel and inhumane treatment and degrading punishment in health-care settings. With regard to mandatory drug treatment, the report states: "... State drug policies intentionally subject large groups of people to severe physical pain, suffering and humiliation, effectively punishing them for using drugs and trying to coerce them into abstinence, in complete disregard of the chronic nature of dependency and of the scientific evidence pointing to the ineffectiveness of punitive measures."13 The UN office for Drugs and Crime further reminds us that: "Many countries provide long-term residential treatment for drug dependence without the consent of the patient that is in reality a type of low security imprisonment. Evidence of the therapeutic effect of this approach is lacking, compared to traditional imprisonment and community based involuntary drug treatment. It is expensive, not cost-effective, and neither benefits the individual nor the community."14
We argue that compulsory drug centres fail in their stated aim of achieving abstinence and that the points made in favour of the centres do not amount to any rational excuse for keeping them open. The Asian Network of People who Use Drugs reaffirm our call for relevant states to close down compulsory drug detention centres, and for the UN system to rigorously discourage their continuation. We also offer our network as a resource for governments wishing to implement services that have been proven to reduce crime as well as improving health and human rights for people who use drugs. ■
Competing interests: None declared.
References
Available at: http://www.who.int/bulletin/volumes/91/4/13-120238
1. Wu Z. Arguments in favour of compulsory treatment of opioid dependence. Bull World Health Organ 2013;91:142 - 5. doi:10.2471/BLT.12.108860
2. International Labour Organisation; Office of the High Commissioner for Human Rights; United Nations Development Programme; United Nations Educational, Scientific and Cultural Organisation; United Nations Population Fund; United Nations High Commissioner for Refugees; United Nations Children's Fund; United Nations Office on Drugs and Crime; United Nations Entity for Gender Equality and the Empowerment of Women; World Food Programme; World Health Organisation; and Joint United Nations Programme on HIV/AIDS. Joint Statement: Compulsory drug detention and rehabilitation centres. Geneva: UNAIDS; 2012. Available from: http://www.unaids.org/en/media/unaids/contentassets/documents/document/2012/JC2310_Joint Statement6March12FINAL_en.pdf [accessed 8 March 2013] .
3. Human Rights Watch, Open Society Institute, Canadian HIV/AIDS Legal Network and International Harm Reduction Association. Human rights and drug policy: compulsory drug treatment [briefing 4]. London: Count the Costs. Available from: http://www.countthecosts.org/sites/default/files/IHRA_Compulsory_Treatment.pdf [accessed 8 March 2013] .
4. New Human Rights Watch report on compulsory drug treatment and forced labour in China. New York: Phoenix Media Group; 2010. Available from: http://www.humanrightsanddrugs.org/2010/01/human-rights-watch-compulsory-drug-treatment-china / [accessed 8 March 2013] .
5. Amon JJ. Chinese addiction study and human rights. Science 2012;337:522 - 3. doi:10.1126/science.337.6094.522 PMID:22859468
6. United Nations Office on Drugs and Crime. HIV prevention among young injecting drug users. New York: United Nations; 2004. Available from: http://www.unodc.org/pdf/youthnet/handbook_hiv_english.pdf [accessed 8 March 2013] .
7. HIV/AIDS and human rights [Internet]. Geneva: Office of the High Commissioner for Human Rights; 2006-2013. Available from: http://www.ohchr.org/EN/Issues/HIV/Pages/HIVIndex.aspx [accessed 8 March 2013] .
8. Drugs and crime - a complex relationship. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, 2007. Available from: http://www.emcdda.europa.eu/attachements.cfm/att_44774_EN_Dif16EN.pdf [accessed 8 March 2013] .
9. Lind B, Chen S, Weatherburn D, Mattick R. The Effectiveness of Methadone Maintenance Treatment in Controlling Crime: An Australian Aggregate Level Analysis. Br J Criminol 2005;45:201 - 11. doi:10.1093/bjc/azh085
10. WHO, UNODC and UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. Geneva: World Health Organization; 2009. Available from: http://www.who.int/hiv/pub/idu/targetsetting/en/index.html [accessed 8 March 2013] .
11. Assessment of compulsory treatment of people who use drugs in Cambodia, China, Malaysia and Viet Nam: an application of selected human rights principles. Geneva: World Health Organization; 2009. Available from: http://www.wpro.who.int/publications/docs/FINALforWeb_Mar17_Compulsory_Treatment.pdf [accessed 8 March 2013] .
12. Csete J, Kaplan K, Hayashi K, Fairbairn N, Suwannawong P, Zhang R et al. Compulsory drug detention center experiences among a community-based sample of injection drug users in Bangkok, Thailand. BMC Int Health Hum Rights 2011;11:12. doi:10.1186/1472-698X-11-12 PMID:22014093
13. Addendum A/HRC/16/52/Add.2. Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E Méndez. In: Sixteenth session of the Human Rights Council, Geneva, 25 February 2011. Geneva: Office of the High Commissioner for Human Rights; 2011. Available from: http://www2.ohchr.org/english/issues/torture/rapporteur/docs/A.HRC.16.52.Add.2.doc [accessed 8 March 2013] .
14. From coercion to cohesion: treating drug dependence through health care, not punishment [discussion paper]. Vienna: United Nations Office on Drugs and Crime; 2009. Available from: http://www.unodc.org/docs/treatment/Coercion_Ebook.pdf [accessed 8 March 2013] .
* Correspondence to Ruth Birgin (e-mail: rlbirgin@yahoo.com.au).