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The temporal relationship between drug supply indicators : an audit of international government surveillance… Werb, Daniel; Kerr, Thomas; Nosyk, Bohdan; Strathdee, Steffanie A.; Montaner, Julio; Wood, Evan Aug 17, 2013

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The temporal relationship betweendrug supply indicators: an auditof international governmentsurveillance systemsDan Werb,1 Thomas Kerr,1 Bohdan Nosyk,2 Steffanie Strathdee,3 Julio Montaner,2Evan Wood1To cite: Werb D, Kerr T,Nosyk B, et al. The temporalrelationship betweendrug supply indicators: anauditof international governmentsurveillance systems. BMJOpen 2013;3:e003077.doi:10.1136/bmjopen-2013-003077▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2013-003077).Received 18 April 2013Revised 16 July 2013Accepted 19 July 20131Urban Health ResearchInitiative, BC Centre forExcellence in HIV/AIDS,Vancouver, Canada2BC Centre for Excellence inHIV/AIDS, Vancouver, Canada3University of California SanDiego, Institute of theAmericas, La Jolla, California,USACorrespondence toDr Evan Wood;uhri-ew@cfenet.ubc.caABSTRACTObjectives: Illegal drug use continues to be a majorthreat to community health and safety. We usedinternational drug surveillance databases to assess therelationship between multiple long-term estimates ofillegal drug price and purity.Design:We systematically searched for longitudinalmeasures of illegal drug supply indicators to assess thelong-term impact of enforcement-based supply reductioninterventions.Setting: Data from identified illegal drug surveillancesystems were analysed using an a priori defined protocolin which we sought to present annual estimatesbeginning in 1990. Data were then subjected to trendanalyses.Main outcome measures: Data were obtained fromgovernment surveillance systems assessing price, purityand/or seizure quantities of illegal drugs; systems with atleast 10 years of longitudinal data assessing price, purity/potency or seizures were included.Results:We identified seven regional/internationalmetasurveillance systems with longitudinal measures ofprice or purity/potency that met eligibility criteria. In theUSA, the average inflation-adjusted and purity-adjustedprices of heroin, cocaine and cannabis decreased by81%, 80% and 86%, respectively, between 1990 and2007, whereas average purity increased by 60%, 11%and 161%, respectively. Similar trends were observed inEurope, where during the same period the averageinflation-adjusted price of opiates and cocainedecreased by 74% and 51%, respectively. In Australia,the average inflation-adjusted price of cocaine decreased14%, while the inflation-adjusted price of heroin andcannabis both decreased 49% between 2000 and 2010.During this time, seizures of these drugs in majorproduction regions and major domestic marketsgenerally increased.Conclusions:With few exceptions and despiteincreasing investments in enforcement-based supplyreduction efforts aimed at disrupting global drug supply,illegal drug prices have generally decreased while drugpurity has generally increased since 1990. These findingssuggest that expanding efforts at controlling the globalillegal drug market through law enforcement are failing.OBJECTIVESThe United Nations (UN) recently estimatedthat the global illegal drug trade is worth atleast US$350 billion annually,1 and illegal druguse remains a major threat to communityhealth and safety.2 3 In addition to the rangeof harm associated with the direct healtheffects of drugs, including fatal overdose,4 5illegal drug use is also one of the key globaldrivers of blood-borne disease transmission, inparticular HIV infection.6 7 Illegal drugmarkets also contribute to community con-cerns, such as high rates of violence in settingswhere the trade proliferates.8In response to the health and social con-cerns associated with illegal drug use, severalUN conventions were organised to control thepossession, consumption and manufacture ofillegal drugs.9–11 As a result, during the lastARTICLE SUMMARYArticle focus▪ Studies have demonstrated that illegal drug useremains a threat to community health and safety.▪ However, less is known regarding the long-termimpact of efforts to reduce the overall supply ofillegal drugs.Key messages▪ Using longitudinal governmental surveillance data,this study demonstrates that during the past twodecades, the supply of major illegal drugs hasincreased, as measured through a general declinein the price and a general increase in the purity ofillegal drugs in a variety of settings.Strengths and limitations of this study▪ This study was limited by the quality and consist-ency of surveillance data on illegal drug supply.▪ This study presents data on trends in illegal drugsupply in a variety of settings during two decades,including consumer and export drug markets.Werb D, Kerr T, Nosyk B, et al. BMJ Open 2013;3:e003077. doi:10.1136/bmjopen-2013-003077 1Open Access Researchseveral decades, most national drug control strategies haveprioritised drug law enforcement interventions to reducedrug supply, despite recent calls by experts to explore alter-native models of drug control, such as systems of drugdecriminalisation and legal regulation.12–14 Some unin-tended consequences of this approach, such as recordincarceration rates, have been well documented.15–18 Inaddition, a small number of studies assessing aspects ofdrug supply, measured through indicators of drug price,purity/potency and seizures, have been undertaken todescribe the global relationship between these indicatorsover the long term.19 However, systematic evaluation ofthese relationships is still needed to elucidate patterns ofdrug supply. The present study, therefore, sought to sys-tematically identify international data from publicly avail-able illegal drug surveillance systems to assess long-termestimates of illegal drug supply.DESIGNOutcomes of interestThe primary outcomes of interest were long-term pat-terns of illegal drug supply, measured through indicatorsof price and purity/potency for three major illegaldrugs: cannabis, cocaine and opiates (eg, opium andheroin). While data on amphetamine-type stimulantsexist in some countries (eg, the UK), this class of drugswas not included given inconsistent data collection andclassification, and fluctuating surveillance periods andoverall data quality. A secondary outcome of interest wasdata on illegal drug seizures in (1) major illegal drugsource regions and, (2) major destination markets, asidentified by the United Nations Office on Drugs andCrime (UNODC).20 These secondary outcome datawere used as an additional proxy measure to assess theavailability of illegal drugs in specific regions, as hasbeen carried out previously.21 22 All outcomes were sys-tematically identified through publicly available illegaldrug surveillance systems. Linear-by-linear associationtrend tests were carried out on annual estimates of alloutcomes of interest. Price and purity estimates repre-sent median values for each year, while estimates for sei-zures represent crude totals of quantity seized. All priceestimates are expressed in 2011 USD and are, where pos-sible, adjusted for purity.23Illegal drug surveillance systemsAn online search of surveillance systems monitoringillegal drugs using two a priori defined inclusion criteriawas carried out. Search terms included the following:drugs, illicit, illegal, price, purity, potency, surveillancesystem, government data, longitudinal, annual, estimate.Inclusion/exclusion criteria were as follows: only surveil-lance systems that included continuous longitudinalassessments of these outcomes of interest for at least10 years were included because we specifically sought toassess the long-term impact of enforcement-based supplyreduction strategies on illegal drug price and purity/potency. Finally, data extraction was restricted to 1990and onwards to focus on patterns of supply duringrecent decades.Data were obtained through online searches of regis-tries of surveillance systems (eg, governmental websites,UN databases), governmental reports and peer-reviewedpublications, through referrals from experts in the field,and through data requests to relevant organisationsincluding the UNODC. All authors had complete accessto all data and all had final responsibility to submit forpublication. Ethics approval was not required given thatwe relied exclusively on publicly available data.RESULTSWe identified seven government surveillance systemsthat met inclusion criteria. Of these, 3 (43%) reportedon international data, 3 (43%) on data from the USAand 1 (14%) on data from Australia. One of the longestrunning surveillance system identified, the US-basedMarijuana Potency Monitoring Project, is funded by theUS National Institutes of Health and was established in1975, while the most recent surveillance system wasestablished in 2001 (eg, the US-based National DrugThreat Assessment). With respect to international surveil-lance systems, the UNODC administers two separate sur-veillance systems that collect data from all participatingUN member states: the Annual Reports Questionnairesurveillance system that collects price and purity/potency data, and the Drug Seizures Database that col-lects seizure data. Finally, the European MonitoringCentre for Drugs and Drug Addiction administers theReitox drug surveillance system network, which aggre-gates data from several country-level surveillance systemsin Europe, as described below.24Price and purity/potencyTable 1 presents surveillance systems that matchedsearch criteria. An assessment of data provided by thesesurveillance systems demonstrated several broad trends.First, purity and/or potency of illegal drugs generallyremained stable or increased overall during the studyperiod. Second, the price of illegal drugs, with fewexceptions, generally decreased. Third, seizures of can-nabis, cocaine and opiates generally increased in majordrug production regions and major domestic markets.Figure 1 presents data from the US Drug EnforcementAdministration’s System To Retrieve Information fromDrug Evidence (STRIDE). As can be seen, between 1990and 2007 (the last year for which data are publicly avail-able), the purity of heroin and cocaine, and the potencyof cannabis herb in the US increased, while theinflation-adjusted and purity-adjusted retail street pricesof these three drugs declined.25 Specifically, heroinpurity increased by 60% (p=0.568), cocaine purityincreased by 11% (p=0.181) and cannabis herb potencyincreased by 161% (p<0.001) during this time. Duringthe same period, the prices of heroin, cocaine and2 Werb D, Kerr T, Nosyk B, et al. BMJ Open 2013;3:e003077. doi:10.1136/bmjopen-2013-003077Open AccessTable 1 Major illegal drug data surveillance systemsSurveillance systemCountry/regionInceptiondateIllegal drugs considered Outcomes consideredSummary of findingsCannabis Cocaine Heroin Price Purity Use SeizuresUniversity of MississippiMarijuana ProjectUSA 1975– X X Cannabis potency increased between 1990 and 2009STRIDE SurveillanceSystemUSA 1986– X X X X X Price decreased and purity/potency increased across allillegal drugs consideredUNODCDrug Seizures Database International 1980– X X X X Seizures of all drugs have increased between 1995 and2006UNODC Annual ReportsQuestionnaireInternational 1990– X X X X X X Prices of opiates, cocaine, and cannabis have generallydecreased in Europe and the USA while purity and potencyhave increasedReitox (EMCDDAdatabase)Europe 1993– X X X X X Price of all illegal substances decreased in 2002–2007.Cocaine, cannabis and heroin seizures increased between2002 and 2007Illicit Drug ReportingSystemAustralia 2000– X X X X X X Between 2000 and 2010, the price of cocaine, cannabis andheroin decreased, while perceived purity remained stableNational Drug ThreatAssessmentUSA 2001– X X X X X Between 2005 and 2009, cocaine purity decreased whereasprice increasedEC, European Commission; EMCDDA, European Monitoring Centre For Drugs and Drug Addiction; EU, European Union; STRIDE, System To Retrieve Information from Drug Evidence;UNODC, United Nations Office of Drug Control.WerbD,KerrT,NosykB,etal.BMJOpen2013;3:e003077.doi:10.1136/bmjopen-2013-0030773OpenAccesscannabis decreased 81% (p<0.001), 80% (p<0.001) and86% (p<0.001), respectively.Figure 2 presents data collected by the UNODC on thestreet price of cocaine and opiates in participatingEuropean countries (ie, Austria, Belgium, Denmark,Finland, France, Germany, Greece, Italy, Luxembourg,Netherlands, Norway, Iceland, Portugal, Spain, Sweden,Switzerland, UK and Ireland).26 In these countries,between 1990 and 2009, the aggregate average retail streetprice of cocaine decreased by 51%, from US$198/g to US$98/g (p<0.001). Similarly, the aggregate average price ofopiates in Europe decreased 74%, from a high of US$295/g in 1990 to US$77/g in 2009 (p<0.001).Data from the Australian Illicit Drug Reporting System(IDRS) were available from 2000 to 2010. IDRS datasuggest that the price of illegal drugs in Australia fluctu-ated substantially during this period. Specifically, afteradjustment, the price of heroin decreased by 49%, fromapproximatelyUS$460/g to approximately US$235/g(p<0.001), despite the well-described heroin ‘drought’ of2001,27 which saw a reduction in the supply and availabilityof heroin in Australia. Additionally, the price of cocainedecreased 14% from approximately $A255/g to $A220/g(p=0.477), and the price of cannabis decreased 49% fromapproximately $A25/g to $A13/g (p<0.001).28SeizuresDomestic marketsFigure 3 presents data on cannabis and cocaine seizuresin the USA between 1990 and 2010. As shown, data fromthe US Drug Enforcement Administration’s STRIDE sur-veillance system demonstrate that the amount of canna-bis herb seized by the Drug Enforcement Administrationboth in, and destined for, the USA increased 465%,from approximately 130 000 kg in 1990 to approximately720 000 kg in 2010 (p<0.001). During this same period,despite fluctuations, the amount of cocaine seized bythe US Drug Enforcement Administration decreased49%, from approximately 57 000 kg in 1990 to 29 000 in2010 (p=0.409), whereas the amount of heroin seizedincreased 29% from approximately 535 kg in 1990 to690 kg (p=0.979, heroin seizure data not shown).29Figure 4 presents data on cannabis, cocaine andheroin seizures in countries participating in theEuropean Monitoring Centre for Drugs and DrugAddiction’s Reitox surveillance network (ie, EuropeanUnion member countries, as well as Croatia, Norway andTurkey), between 1995 and 2009. As can be observed,annual estimates of the quantity of both cocaine andcannabis herb seized fluctuated throughout this period;however, the quantity of heroin seized increased rela-tively steadily. Specifically, the number of kilograms ofcannabis herb seized was at a low of approximately57 000 kg in 1995, and peaked 1 year later in 1996 atapproximately 138 000 kg (p=0.446). The number ofcocaine seizures was at a low of approximately 21 000 kgin 1995, and peaked at approximately 121 000 kg in2006 (p=0.018). Finally, the number of kilograms ofheroin seized increased 380% from a low of approxi-mately 5000 in 1995 to a high of approximately 24 000in 2009 (p<0.001).Production regionsWith respect to opiate seizures, the Golden Triangleincludes parts of Thailand, Laos, Vietnam and Myanmar,and according to the UNODC, this region is the secondlargest supplier of heroin globally, although productionhas declined throughout the last decade, with opiumproduction decreasing by approximately 60% and 90%Figure 1 Estimated price and purity of heroin, cocaine andcannabis in the USA, 1990–2009.4 Werb D, Kerr T, Nosyk B, et al. BMJ Open 2013;3:e003077. doi:10.1136/bmjopen-2013-003077Open Accessin Myanmar and Laos, respectively.30 In this region,trends in seizures of opium have fluctuated; 3198 kg ofopium were seized in 1990, with a high of 12 462 kgseized in 2007 before a steep decline to 1225 kg in 2010(p=0.856). Similarly, seizures of heroin fluctuated, with adecrease of more than half, from 1337 kg in 1990, to627 kg in 2010 (p=0.085), and a peak of 1565 kg seizedin 2009. In Afghanistan, which is believed to supplymore than 90% of the world’s opium,30 seizures of rawand prepared opium increased by more than 12 000%,from 453 kg in 1990 to 57 023 kg in 2010, and seizuresof heroin increased by more than 600%, from 1256 kgin 1990 to 9036 kg in 2010 (note: missing data preventeda trend test for annual opium and heroin seizures inAfghanistan).With respect to cocaine seizures, according to theUNODC, Latin America’s Andean region, which includesPeru, Bolivia and Colombia, is the primary global supplierof this drug, as coca leaf is grown exclusively in thisregion.31 While seizures of cocaine in the Andean regiondecreased 81%, from 97 437 kg in 1990 to 17 835 kg in2007 (p=0.028), seizures of coca leaf increased 188% from601 038 kg in 1990 to 1.73 million kilograms in 2007(p=0.004). During the same period, the area of cocaFigure 3 Cocaine and cannab is seizures in the USA, 1990–2010.Figure 2 Average inflation-adjusted price of opiates and cocaine in Europe, 1990–2007.Werb D, Kerr T, Nosyk B, et al. BMJ Open 2013;3:e003077. doi:10.1136/bmjopen-2013-003077 5Open Accesscultivation in this region declined slightly, from approxi-mately 210 000 to 180 000 ha (p=0.004).Finally, according to the UNODC, major areas of can-nabis cultivation exist in North Africa, Afghanistan andNorth America. These areas are net exporters of canna-bis, although most cannabis-producing countries alsoproduce the drug for internal consumption.20 In NorthAfrica (ie, Algeria, Morocco and Tunisia), seizures ofcannabis herb increased by 208% from 67 930 kg in1990 to 209 445 kg in 2007 (p=0.015). In North America(ie, Canada, the USA and Mexico), seizures of cannabisherb increased by 288% from 782 607 kg in 1990 to 3.05million kilograms in 2007 (p<0.001). In Afghanistan,while data on cannabis herb seizures are not available,seizures of cannabis resin increased 630% from 5068 kgin 1990 to 36 972 kg in 2006 (p=0.061).CONCLUSIONSLongitudinal data from government surveillance systemsdemonstrate that during the past two decades there hasbeen a general pattern of increased illegal drug supply asdefined through lower price and higher purity of heroin,cocaine and cannabis. During the same period, patternsof drug seizures either increased or remained stable,although the trends detected in some of these indicatorsdid not reach statistical significance. As such, we conclude,consistent with previous studies,19 that the global supply ofillicit drugs has likely not been reduced in the previoustwo decades. In particular, the data presented in this studysuggest that the supply of opiates and cannabis, in particu-lar, have increased, given the increasing potency anddecreasing prices of these illegal commodities. Theseresults have implications for the development of evidence-based drug policies, particularly given the interest in noveldrug policy approaches in a number of settings in LatinAmerica, North America and Europe.32–34As noted elsewhere,35 36 there are limitations of eco-logical analyses based on international surveillancesystems. First, some states collect little or no data on indi-cators of illegal drug supply, whereas other states spendsignificant energy on monitoring drug availability.Second, even in states that closely track indicators ofsupply, the degree to which seized samples of illegaldrugs reflect purity of retail drugs sold on the street issubject to variation, though where possible we presentedpurity-adjusted prices to address this limitation.23Nevertheless, the long-term trends in increasing purityand decreasing price presented here likely reflect theoverall trends in many regions, though it should benoted that in some regions (eg, Europe), indicators ofprice and purity may have been strongly influenced by afew countries such as the UK and Spain. In addition,some exceptions in the trends were observed. Australiafor instance, while experiencing a significant decrease inthe prices of heroin as well as cannabis, did not experi-ence a significant decrease in the price of cocaine,which may reflect the geographic isolation of the regionor other market factors. It is also of note that Australia’s‘heroin drought’,37 which saw a sudden drop in mea-sures of the supply and availability of heroin, appears tohave had a limited long-term impact on supply, thoughsome experts suggest that it may have resulted in higherlevels of polysubstance use among Australian heroinFigure 4 Cocaine, cannabis and heroin seizures in Europe*, 1990–2010.6 Werb D, Kerr T, Nosyk B, et al. BMJ Open 2013;3:e003077. doi:10.1136/bmjopen-2013-003077Open Accessinjectors.27 Third, limitations in longitudinal data collec-tion precluded our ability to include amphetamine-typestimulants and other emerging synthetic substances, asthis data is limited to certain countries and the focus ofthis study was on regional trends. It is noteworthy in thisregard that the production of synthetic substances—aswell as indoor cannabis cultivation—present particularchallenges for supply reduction strategies, given thatthese drugs can be mass produced in clandestine loca-tions regardless of climate or other factors that limittraditional drug production.20 38 Finally, while thisreview focused on patterns of price and purity ofselected illegal drugs, these measures are only a markerof drug supply and do not measure other factors deter-mining availability and concomitant rates of drug use.These limitations in assessing global drug supply usingclassic proxy measures such as price, purity and, to alesser extent, seizures, suggest that there may be a needto expand the range of measures systematically collectedby governments and international bodies such as theUNODC and the European Monitoring Centre forDrugs and Drug Addiction. In particular, meaningfullyincorporating measures derived from street-level ques-tionnaires of people who use drugs may provide a morereliable metric of supply and availability. Indeed, somebodies, such as Australia’s IDRS, collect such data,28 andthis methodological approach should be considered bythose coordinating surveillance of illegal drugs. Otherbodies have also prioritised emphasising measures ofcommunity health including reduced HIV infections,reduced drug-related violence and reductions innumber of individuals incarcerated.39 40In summary, longitudinal illegal drug surveillancesystems demonstrate a general global pattern of fallingdrug prices and increasing drug purity and potency,alongside a relatively consistent pattern of increasing sei-zures of illegal drugs. Although source data have limita-tions and there are some exceptions to these trends,these findings should be useful given the currentdebates and drug policy experimentation under way inLatin America, North America and Europe.32–34 It ishoped that this study highlights the need to re-examinethe effectiveness of national and international drug strat-egies that place a disproportionate emphasis on supplyreduction at the expense of evidence-based preventionand treatment of problematic illegal drug use.Acknowledgements The authors would like to thank Deborah Graham, PeterVann, Katherine Quayle, Samantha MacLean and Kevin Lutz for theiradministrative assistance.Contributors All authors contributed substantially to the design and draftingof the manuscript. DW and EW designed the initial methodological approachand drafted the manuscript; TK, BN, SS and JM provided substantial revisionsto the manuscript.Funding This study received funding from the Open Society Foundationsthrough the International Centre for Science in Drug Policy (OR2012-01945).Competing interests DW, TK, BN, JM and EW have support from the BCCentre for Excellence in HIV/AIDS for their submitted work; SS has supportfrom the Division of Global Public Health, Department of Medicine, Universityof California, San Diego. JM has received grants from, served as an ad hocadviser to, or spoken at events sponsored by Abbott, Argos Therapeutics,Bioject Inc, Boehringer Ingelheim, BMS, Gilead Sciences, GlaxoSmithKline,Hoffmann-La Roche, Janssen-Ortho, Merck Frosst, Panacos, Pfizer Ltd,Schering, Serono Inc, TheraTechnologies, Tibotec ( J&J) and Trimeris. DW issupported by the Trudeau Foundation and the Canadian Institutes of HealthResearch. TK is supported by the Canadian Institutes of Health Research andthe Michael Smith Foundation for Health Research.Provenance and peer review Not commissioned; externally peer reviewed.Data sharing statement This study employed publicly available data, asdescribed in the section above.Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/REFERENCES1. Pietschmann T, Walker J. Estimating illicit financial flows resultingfrom drug trafficking and other transnational organized crimes.Vienna: UNODC Studies and Threat Analysis Section, Division forPolicy Analysis and Public Affairs, 2011.2. Jurgens R, Ball A, Verster A. 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