Heroin prohibition is significantly worse for society than letting companies sell the drug openly on the free market, according to evaluations of potential heroin use policies by an international team of drug policy experts.

In an International Journal of Drug Policy paper, published Feb. 25, the European authors make the case for a switch to state control of non-medical heroin use in places like the U.S., which is grappling with an opioid crisis that left nearly 50,000 people dead in 2019, according to the National Institute on Drug Abuse. 

"The 'war on drugs' narrative that underpins most drug policy thinking is cast in very stark moral binary terms of good versus evil," said Steve Rolles, the lead author of the paper and a senior policy analyst at the U.K. nonprofit Transform Drug Policy Foundation. "Drug use is actually described as 'evil' in the UN 1961 Single Convention on [Narcotic] Drugs, the legal foundation of global prohibition." 

But, he said, "There is little to no evidence of a deterrent effect associated with criminalization of people who use drugs, and considerable evidence of harm."

The paper was based on an unusual data-gathering process. Over the course of two two-day meetings, 19 drug experts gathered to categorize 27 desirable policy outcomes, including reducing harm to users and non-users from illness, injury or death; encouraging treatment; not criminalizing users; and reducing violent crime. The participants devised a weighted scoring system based on the outcomes, then scored and ranked policy models: state prohibition, decriminalization, state control and free market sale. State control got the best score — 89 — while the free market was the second-most desirable, with a score of 58 points, followed by decriminalization, with 33 points. 

The worst score by far — six points — was for prohibition. The only category in which prohibition slightly outperformed state control was in drug industry influence on government; the experts reasoned that state control would lead to the undesirable outcome of more lobbying, while a prohibition model would lead to relatively less lobbying.

The most significant factors putting state control ahead of other models were its impact on social and health outcomes, which accounted for 59% of its high score. Social factors included improving drug education and not impeding individual liberty, while health factors included reductions in user harm and accurate labeling. 

Assuring the quality and accurate labeling of heroin is an impossible task when nonmedical use is illegal, but better labels would likely save lives in the U.S.: Many opioid overdoses are caused by fentanyl that's been mixed into heroin or cocaine, often, according to the Centers for Disease Control and Prevention, without the user's knowledge.

Additionally, the experts determined that state control would better support international security and development. Most of the supply in the illegal international opium and heroin trade comes from the developing nations of Myanmar, Laos and Afghanistan, according to the United Nations, and powerful drug cartels can undermine stable government and sow violence.

Still, the free market scored the highest of all the examined policy models in terms of reducing the scale of the illegal market, Rolles pointed out. 

"This makes sense, as a free market would be able to lower prices and increase availability to compete with parallel illegal trade," he said. "This may, of course, have other negative health consequences regarding increasing use, captured in other outcome criteria." 

The free market got the second-highest score, Rolles said, because, "The free market was less bad, rather than 'good' as such."

Decriminalization scored lower than the free market and state control in most categories, but did have a higher public impact score than the free market. The public impact outcomes focused on protecting vulnerable people, including children and young people, and respecting cultural values.  

Most of the invited participants "worked in the addictions field providing different forms of support and treatment to people who use drugs  — including people who use heroin," Rolles said. 

He said the format of the meetings  — termed a multi-criteria decision analysis  — "ensures that decisions, even counterintuitive ones, are approached in a rational and structured way." 

"This isn't always how our brains work in day-to-day decision making," Rolles said. "The MCDA often throws up surprising and challenging outcomes when a more rationally determined decision runs contrary to our instinctive ones often clouded with cognitive biases."

Notably, none of the participants evaluating policy outcomes were themselves open current or former heroin users, Rolles said, and "repeating the process with different groups of of stakeholders would be a useful exercise." 

The paper, "A multi criteria decision analysis (MCDA) for evaluating and appraising government policy responses to non medical heroin use," published Feb. 25 in the International Journal of Drug Policy, was authored by Steve Rolles, Transform Drug Policy Foundation; Anne Katrin Schlag, Drug Science; Fiona Measham, University of Liverpool; Lawrence Phillips, London School of Economics & Political Science; David Nutt, Imperial College London; Daniel Bergsvik, Norwegian Institute of Public Health; and Ole Rogebergg, Ragnar Frisch Centre for Economic Research.