It has taken decades for some to accept the devastating effects of climate change on our planet. Despite scientific evidence that was available years ago, many people were reluctant to make the connection between increasing use of fossil fuels, rising global temperatures and devastating weather events.
Author
- Ian Hamilton
Honorary Fellow, Department of Health Sciences, University of York
A key reason for this reluctance is the dislocation of cause and effect, both in time and geography. And here there are clear parallels with another deadly human activity that is causing increasing levels of suffering across the planet: the production, trafficking and consumption of illicit drugs. Here are some troubling "highlights" from the UN's latest World Drugs Report :
Cocaine production is reaching record highs, with production climbing in Latin America coupled with drug use and markets expanding in Europe, Africa and Asia.
Synthetic drugs are also inflicting great harm on people and communities, caused by an increase in methamphetamine trafficking in south-west Asia, the near and Middle East and south-eastern Europe, and fentanyl overdoses in North America.
Meanwhile, the opium ban imposed by the de facto authorities in Afghanistan is having a significant impact on farmers' livelihoods and incomes, necessitating a sustainable humanitarian response.
The report notes how organised criminal groups are "exploiting instability and gaps in the rule of law" to expand their trafficking operations, "while damaging fragile ecosystems and perpetuating other forms of organised crime such as human trafficking".
Illicit drug use is damaging large parts of the world socially, politically and environmentally. Patterns of supply and demand are changing rapidly. In our new longform series Addicted , leading drug experts bring you the latest insights on drug use and production as we ask: is it time to declare a planetary emergency?
At every stage of the process of producing drugs such as cocaine, there are not only societal impacts but environmental ones too. An example of the interconnected relationship between climate change and drugs is demonstrated in the use of land.
Demand for cocaine has grown rapidly across many western countries, and meeting this can only be met by changing how land is used. Forests are cleared in South America to make way for growing coca plants. The refinement of coca into cocaine involves toxic chemicals that pollute the soil and nearby watercourses. This in turn compromises those living in these areas as access to clean water and fertile land is reduced.
Until this is reversed, these local communities will not be able to cultivate the land to earn an income or rely on water sources to live. And each year, some of their number will add to the hundreds of thousands of people around the world who die, directly or indirectly, as a result of illicit drug use.
People in the world with drug use disorders (1990-2021)
Having spent most of my career researching the human toll of drug use at almost every stage of the supply and consumption chain, I believe a complete shift in the way we think about the world's drug problem is required.
We already have many years of evidence of the ways that drugs - both natural and (increasingly) synthetic - are destabilising countries' legal and political institutions, devastating entire communities, and destroying millions of lives. My question is, as with climate change, why are we so slow to recognise the existential threat that drug use poses to humanity?
The disconnect between users and producers
For decades, problems with drugs have been viewed as a mainly western issue, affecting Europe, North America and Australasia in terms of drug taking. This perception was fostered in part by US president Richard Nixon's "war on drugs" announcement in June 1971, when he declared drug abuse to be "public enemy number one".
This western-centric focus has come at a cost - we still have little data and information about drug use and problems in Africa, for example. But we are beginning to see how far drugs and their associated devastation has reached beyond traditional western borders.
Deaths attributed to illicit drug use (2021):
Illicit drug use has increased by 20% over the past decade, only partly due to population growth. Almost 300 million people are estimated to consume illicit drugs regularly, with the three most popular being cannabis (228 million users), opioids (60 million) and cocaine (23 million). According to the UN report :
The range of drugs available to consumers has expanded, making patterns of use increasingly complex and polydrug use a common feature in most drug markets. One in 81 people (64 million) worldwide were suffering from a drug use disorder in 2022, an increase of 3% compared with 2018.
There are multiple harmful consequences of drug use. The largest global burden of disease continues to be attributed to opioids, use of which appears to have remained stable at the global level since 2019, in contrast to other drugs.
In the same way that climate change has threatened whole populations, so too have drugs. Yet many of us remain disconnected from how they are produced and distributed - and the misery they cause throughout the supply chain, all over the world.
The production of cocaine, for example, is associated with violence and exploitation at every stage of the manufacturing process. Death threats to farmers and unwilling traffickers have all increased in parallel with the growing demand for cocaine in the US and Europe.
Global drug use disorder deaths by substance (2000-21):
Organised crime groups not only supply and distribute drugs but also trade in people , whether for the commercial sex trade or other forms of modern slavery . This makes sense as the infrastructure and contacts to move drugs are similar to those used to move humans across borders and even continents. Yet many cocaine users are oblivious - wilfully or otherwise - of the violence associated with how this drug is supplied to them. As the UK National Crime Agency points out :
Reducing demand is another critical factor in reducing the supply of illegal drugs. Many people see recreational drug use as a victimless crime. The reality is that the production of illegal drugs for western markets has a devastating impact in source countries in terms of violence, exploitation of vulnerable and indigenous people and environmental destruction.
While some of the suffering associated with the production of drugs like cocaine makes the headlines, it's often overshadowed by the glamorisation of criminal drug gangs in films and on TV. To the extent that people worry about the impact of drugs, it's usually focused on those in our immediate communities, such as people dependent on heroin who are sleeping rough and vulnerable to exploitation. But there have already been other victims before the drug reaches our streets.
Shifts in the global supply chain
Tracking heroin routes demonstrates the way that drug supply is an international effort which affects every community on its journey, from the Afghan farmer to officials who are bribed so the drug can cross borders or be let through ports without being seized, to the person injecting or smoking the finished product.
Much of Europe's heroin is produced in Afghanistan by small farming operations growing opium, which is then transformed into the drug. Most Afghan farmers are simply surviving growing the crop, and don't reap significant wealth from their harvest. It is those supplying and distributing the opium as heroin who can make serious money from it.
Meanwhile, following the return of the Taliban to power in Afghanistan in August 2021, those farmers' livelihoods have faced a new threat.
The Taliban is ideologically opposed to the production of opium. Soon after assuming control, its leaders issued a decree banning farmers from growing opium. They have enforced this by destroying crops when farmers have ignored the ban - although there is still believed to be a significant stockpile of heroin in the country, meaning that as yet, there has not been a big impact on supply to Europe and the UK. But this could change amid the emergence of more deadly synthetic alternatives, including nitazenes and other new synthetic opioids.
Heroin trafficking flows based on reported seizures (2019-22):
Either way, the drug gangs who traffic heroin won't worry about the opium farmers' wellbeing. As so often happens with changes in the availability of illicit drugs, when there is a shortage, these groups prove adaptable and nimble at providing alternatives quickly.
While gathering intelligence about organised crime gangs is difficult and potentially dangerous, the European Union Drugs Agency (EUDA) has provided some insights about who these groups are and how they operate. The Netherlands remains an important hub for the distribution of heroin, with several Dutch criminal groups involved in importing and distributing heroin from Afghanistan.
But others are involved too: the EUDA's intelligence shows that criminal networks with members from Kurdish background are central to the wholesale supply and have control over many parts of the supply chain. These professional, well-organised groups have established legal businesses throughout the route of supply that facilitate their illicit activities - largely along the Balkan route with hubs in Europe.
Intermediate & final recipients of heroin shipments (2019-22):
Unlike these organised crime gangs, governments and law enforcement appear to respond to emerging threats slowly and lack the flexibility and ingenuity that the gangs repeatedly demonstrate.
As drug detection techniques have improved, organised crime has shown how inventive it can be. Taking advantage of the COVID-19 pandemic, dealers used consignments of surgical masks to conceal large quantities of cocaine being trafficked to China and Hong Kong from South America.
And as western markets for cocaine become saturated, organised crime gangs have exploited new markets in Asia , where cocaine seizures, a proxy for use of cocaine, have increased. But the shifting landscape is also reflected in changes in consumption, with use of the synthetic stimulant methamphetamine growing rapidly in Asia - reflected in record levels of seizures in the region in 2023.
Main methamphetamine trafficking flows (2019-22):
For the organised crime gangs, production and supply of synthetic drugs is in many ways easier, as it is not reliant on an agricultural crop in the way that heroin and cocaine are and can be manufactured locally. This reduces the distribution logistics and distance needed for an effective supply chain. According to the UN Office on Drugs and Crime , organised crime gangs are exploiting gaps in law enforcement and state governance to both traffic large volumes of drugs and expand their production in the region.
Where there is destabilisation, there is opportunity for those who seek to profit from drug addiction. In Syria, Russia and Ukraine, war has made some people very rich.
Syria and Russia: the new drug hotspots
The wars in Syria and Ukraine bear testament to the way drugs provide solutions to people who are experiencing the worst of times - and to governments that are ready to exploit evolving situations.
As the war in Syria progressed, the Bashar Al-Assad regime actively developed a strategy to dominate the captagon market in the Middle East and North Africa. First produced in the 1960s in Germany to treat conditions such as attention deficit disorders and narcolepsy and other conditions, captagon is a stimulant that staves off hunger and sleep , making it ideal for military use - particularly in countries where food supplies are inconsistent. It has been referred to as the "drug of jihad" used by Islamic fighters in the region.
As the war progressed in Syria, the country and its leader became increasingly isolated, its economy crashed creating the perfect conditions to develop the trade in captagon. Rather than drug production leading to the collapse of law and order, it was the other way round.
Isolated by the west and with a historically strained relationship with its neighbours including Saudi Arabia, the Assad regime - under the guidance, reportedly, of Assad's brother Maher al-Assad- ruthlessly positioned itself as the world's main producer and distributor of this drug, then used this position to leverage its influence and try to reintegrate into the Arab world .
Captagon also provided much-needed revenue for the Assad regime. The drug was estimated to be worth US$5.7 billion annually to the Syrian economy - at a time when western governments have placed severe sanctions on the country, restricting its ability to raise revenue. Saudi Arabia was one of the main countries being supplied captagon by Syria. Until the fall of Assad, it was the senior leadership in Syria that controlled the supply and distribution of the drug - giving rise to the label "the world's largest narco state" .
The Assad government achieved this position by making captagon good value - a viable alternative to alcohol in terms of price and for those who don't drink. Exploiting many of its own citizens, the regime encouraged individuals and businesses to participate in manufacturing and distributing the drug.
The fall of Assad and his hurried escape to Russia left the rebel fighters to pick up vast hauls of captagon and other drug ingredients. "We found a large number of devices that were stuffed with packages of captagon pills meant to be smuggled out of the country. It's a huge quantity," one fighter belonging to the Hayat Tahrir al-Sham (HTS) group told the Guardian . What this will do to drug production and supply in the region is unclear.
While the latest UN World Drug Report highlights "a rapid increase in both the scale and sophistication of drug trafficking operations in the region over the past decade", it goes on to highlight that "one of the most striking changes worldwide in drug trafficking and drug use over the past decade has taken place in Central Asia, Transcaucasia [Armenia, Azerbaijan and Georgia] and eastern Europe", where there has been a shift "away from opiates, mostly originating in Afghanistan - towards the use of synthetic stimulants, notably cathinones … There is hardly any other region where cathinones play such a significant role."
This is part of "a groundbreaking shift in the global drug trade, pioneered in Russia and now spreading globally," according to the Global Initiative Against Transnational Organized Crime . This shift is changing the nature of drug sales, using "darknet markets and cryptocurrency for anonymous transactions, allowing buyers to retrieve drugs from hidden physical locations or 'dead drops' , rather than direct exchanges."
The rise of Russia's dead drop drug trade stems from several unique national factors: restrictive anti-drug policies, strained western trade relations, and a strong technological foundation. Enabled by these conditions, the dead drop model has reshaped how drugs are distributed in Russia.
Drug transactions now involve no face-to-face interactions; instead, orders are placed online, paid for with cryptocurrency, and retrieved from secret locations across cities within hours. This system, offering convenience and anonymity, has seen synthetic drugs - especially synthetic cathinones like mephedrone - overtake traditional imported substances like cocaine and heroin in Russia … These potent synthetic drugs are cheap, easy to manufacture, and readily distributed through Russia's vast delivery networks.
The report notes that this shift in drug distribution has been accompanied by rising levels of violence including punishment beatings, and a public health crisis.
Yet officially, there is very little reliable data about drug use in Russia. Under the premiership of Vladimir Putin, Russia has no sympathy with those who are dependent, viewing them as weak and without value. And its invasion of Ukraine three years ago has had ramifications for Ukraine's users too.
Prior to the war, Ukraine had demonstrated an increasingly progressive policy towards those who had problems with drugs, establishing treatment centers and encouraging access to treatment. Since Russia invaded Ukraine in February 2022, this strategy has been severely set back, with many people who need access to substitute treatments such as methadone unable to secure consistent supply of these drugs .
Another global blind spot is China, where, like Russia, little is known about the extent or type of problems that drugs are causing. Both regimes are ideologically opposed to recreational or problem drug use and, as far as we know, there is no state-funded rehabilitation provided in either country; the approach is to criminalise people rather than offer health-based interventions.
We shouldn't be too critical as many western countries, including the UK, also need to pivot from a criminal approach to drug problems towards a health-focused one. Portugal made such a policy change several years ago, recognising that people who develop problems with drugs such as dependency need help rather than punishment.
This radical shift in thinking has made a significant change to the way those using drugs are treated, in the main offered help and specialist support rather than being arrested and sent to jail, only to be released and then repeat the same cycle of drug use, arrest and prison.
The evidence of this policy change is impressive: not only have drug-related deaths fallen, but population-level drug use is among the lowest in Europe. Nowhere is this policy shift more urgent than the US.
North America: epicentre of the opioid crisis
In the US, the synthetic opioids fentanyl and oxycodone have contributed to more than 100,000 fatal overdoses each year since 2021. While there are signs this deaths toll is at last beginning to fall , the harm and pain of addiction and overdose affects every strata of American society - as shown in moving portrayals of America's opioid crisis such as Painkiller and Dopesick . Most fatalities are caused by respiratory depression where breathing is significantly slowed or stops altogether.
Fentanyl is an analgesic drug that is 50-100 times more potent than heroin or morphine . Where China used to be the principal manufacturer and supplier of fentanyl to the US, Mexico is now the primary source. In December 2024, Mexican authorities announced "the largest mass seizure of fentanyl pills ever made" - amounting to more than 20 million doses of fentanyl pills worth nearly US$400 million. The pills were found in Mexico's Sinaloa state, home of the Sinaloa drug cartel and a hub of fentanyl production ,
"This is what makes us rich," one fentanyl cook recently told the New York Times . He was scathing about the idea that Donald Trump would be able to stamp out the supply of fentanyl from Mexico to the US by threatening Mexico's government with tariffs. "Drug trafficking is the main economy here."
However, the introduction of synthetic opioids to the US came not via organised crime but through a deliberate strategy of the pharmaceutical industry. Upon launching its prescription opioid painkiller OxyContin (a brand name for oxycodone) in 1996, Perdue Pharma, owned by the Sackler family, devised a plan to increase prescriptions of the drug by incentivizing and rewarding doctors to give these drugs to their patients. On a business level, this was a success; on a human level, it has been a disaster.
As patients quickly developed tolerance to drugs such as OxyContin, they had to take higher doses to avoid withdrawal symptoms or the positive feelings it gave them. Taking more of these opiates increases the risk of accidental overdose, many of which proved to be fatal. It has also driven those dependent on drugs to the black market, and into the hands of organised drug gangs, as they seek the drugs in greater quantities.
US overdose death rates by drug type (1999-2020):
Dependency on fentanyl and other opioids is all-consuming. When not using these drugs, people are entirely focused on ensuring sufficient supply of the next dose. This includes funding supply which can take people to places they thought they would never be, for example breaking the law, shoplifting or getting involved in commercial sex to make enough money to buy drugs.
Synthetic opiates like OxyContin and fentanyl have proved to be classless, ageless and sex blind. The first-hand experience of addiction and fatalities have radically altered the way many Americans think about drugs and the problems they cause. Canada, too, is suffering a major crisis.
Compounding this tragedy is the failure of the state to provide interventions and treatment that could have reduced fatal and non-fatal overdoses. It is only now that evidence-based interventions are beginning to be made widely available, such as access to Naloxone - a drug that can reverse the effects of opiates and potentially save a life.
Of course, it isn't just hospitals and health professionals that are challenged by the results of widespread use of opioids, but public services like the police and fire service. In some areas of the US, there have been so many daily overdoses that every service was called on to try and deal with it. Local mayors have made it a priority to train police and fire personnel to be trained as first responders, such is the scale of the problem.
But it is not just in North America that we see the failure of politicians and the state to act when faced with growing problems with drugs. In the UK, where record numbers are dying because of using drugs such as heroin, the government has not invested in overdose prevention strategies. At a time when fatal overdoses increase year on year, budgets for specialist treatment have been reduced. It remains to be seen what the recently elected Labour government will do, if anything, to tackle the tragic rise in drug related fatalities.
Death rates from opioid use disorders (2021):
What connects both examples from the US and UK is the attitude and perception of drug use many of us have. Drug use and the heavy use of prescription painkillers is still heavily stigmatised . Many of us still view this as something individuals bring on themselves or have a choice about.
So, if we don't care about what happens to people who develop problems with drugs, why should our elected representatives? In part, it is our bigotry that is enabling the lack of timely intervention, despite us possessing the knowledge and evidence of how drug harms can be minimised.
Latin America: breakdown of the rule of law
Under the last Conservative government, the UK Home Office asserted that people who used cocaine recreationally are supporting violence not only in the UK but in the countries that produce its raw ingredients. It's not clear if this has made any difference to those using cocaine in the UK - personally, I doubt many people consider or are aware of how cocaine is produced or its provenance.
Perhaps if those using cocaine, mainly in western countries, realised the extent of violence and suffering that cocaine manufacture causes they might think again. Latin America has suffered enormously, with few countries there not touched in some way by the violence and breakdown of law associated with drug production and supply. According to the latest UN World Drugs Report :
Global cocaine supply reached a record high in 2022, with more than 2,700 tons of cocaine produced that year, 20% more than in the previous year … The impact of increased cocaine trafficking has been felt in Ecuador in particular, which has seen a wave of lethal violence in recent years linked to both local and transnational crime groups, most notably from Mexico and the Balkan countries.
Cocaine seizures and homicide rates increased five-fold between 2019 and 2022 in Ecuador, with the highest such rates reported in the coastal areas used for trafficking the drug to major destination markets in North America and Europe.
Cocaine trafficking flows based on reported seizures (2019-22):
As with opium production in Afghanistan, it is small-scale farmers in Colombia, Peru and Bolivia that grow the coca plant that will be turned into cocaine. Like their Afghan counterparts, they grow coca as it is more profitable than alternatives such as coffee. While it may be profitable in the short term, there are greater costs to them and their society.
Cocaine production brings with it violence as those further up the drug production chain try to control its trade. Few parts of these societies are unscathed, from bribing local politicians through to whole regions that are controlled by organised crime. Keeping control means that the use of firearms and violence increases. Against this backdrop, it is unsurprising that basic health and social services suffer.
So, while a coca grower may have more money, every other aspect of their life is negatively impacted. Whether it is regional or state institutions, both are compromised by the drug trade and those that control it. While this may not lead to the total collapse of law and order, it does create injustice and distorts the rule of law in many areas of Latin America and the Caribbean, where competition between gangs has also resulted in an increase in homicides.
The impact is on all sectors of society, now and into the future. For example, while historically the role of women has been largely underrepresented in research and drug policy, the UN report recognises that this is changing:
As women increasingly participate in economic activities, the role that women play in the drug phenomenon may become increasingly important. For example, a shift away from plant-based drug production may affect many women in rural households involved in opium poppy and coca bush cultivation.
The UN also identifies the specific risk to young people and the drugs trade, highlighting:
Long-term efforts to dismantle drug economies must provide socioeconomic opportunities and alternatives, which go beyond merely replacing illicit crops or incomes and instead address the root structural causes behind illicit crop cultivation, such as poverty, underdevelopment, and insecurity. They must also target the factors driving the recruitment of young people into the drug trade, who are at particular risk of synthetic drug use.
Meanwhile, demand for treatment in Europe due to problems with cocaine has risen significantly in recent years, since 2011 there has been an 80% increase in treatment presentations. This reflects the growing number of people using cocaine and the rise in purity of the drug.
Death rates from cocaine use disorders (2021):
Change is possible
Amid what may seem to be a story of unrelenting despair and hopelessness, there are local initiatives and even a few state-wide policies that provide optimism that change is possible.
In my roles both as clinician and scientist, I've often been amazed by how ingenious people can be when faced with the apparently impossible. For example, the way some people use heroin to dampen their psychotic symptoms, such as auditory and visual hallucinations - or the development of Naloxone, a drug that can temporarily reverse the effects of opioids, providing a short window for emergency services to treat people who have overdosed.
Early in my career, I witnessed the emergence of HIV in the UK in the 1980s. The speed at which this disease spread was not matched by our ability to treat it. Our response to HIV was undoubtedly hampered by prejudice and stigma towards marginalised groups in society, namely gay men and those using drugs (particularly injecting them).
However, unexpectedly and courageously, the Conservative government recognised those who were most at risk of contracting HIV, and organised a package of measures to contain the spread of infection. One part of this was a media campaign based on public health messaging designed to reduce the risk of contracting the disease. But the government also invested in treatment for those who had been infected and engaged with people at high risk, such as those intravenously injecting drugs.
I worked in specialist HIV clinics for those using drugs. At the time, methadone and diamorphine were provided as an alternative to heroin. Regulations and protocols that restricted the prescribing of these medical opioids were eased, so we could ensure patients attending these clinics were given sufficient oral and injectable opioids that they didn't need to source street heroin.
This meant they had access to medical grade opioids and, crucially, were given regular supplies of sterile injecting equipment. It was this that reduced the risk of contracting HIV, as some people would share injecting equipment when using heroin.
This impressive policy ran counter to the Conservative party's ideology at the time, which was to punish rather than help those using drugs like heroin. It showed me how, even with traditional mindsets, it is possible to shift policy thinking in the face of a health crisis. And make no mistake, the global drug problem is an ongoing health crisis. Today, the UN points to the risks that intravenous users of drugs still face:
An estimated 13.9 million people injected drugs in 2022, with the largest number living in North America and East and South-East Asia … The relative risk of acquiring HIV is 14 times higher for those who inject drugs than in the wider population globally.
There are, though, signs of positive change in the way some countries and regions are changing their drug policies. Scotland recently opened a drug consumption facility in Glasgow - a safe place for people to use their drugs, usually injecting drugs like heroin. Such spaces provide access to sterile injecting equipment, reducing the risk of blood-borne infections such as HIV or Hepatitis. At the same time, they offer the opportunity to engage with people who have not accessed traditional health services.
Portugal, as mentioned earlier, has made substantial changes to the way it approaches drug use and the problems associated with it. This policy shift since 2000 has saved lives and brought a more humane way of treating people who develop problems with drugs.
Contrast this with the wasted effort and resources ploughed into the war on drugs - initiated by Nixon and followed by so many western governments ever since. My plea to policymakers is simple: employ the same evidence-based science you use for health issues towards drugs and problem drug use.
Science and research can help in many ways, if given the chance. Some of it might seem radical, like providing safe drug consumption spaces. Some of it is more mundane, but vital - like tackling inequality, a clear driver of problem drug use across the world.
But while we often look to politicians to take the lead on change, it is people - us - that really hold the solution. By far the greatest threat to people and society from drugs is ignorance and bigotry . So many lives have been lost to drugs because of shame, either as a driver of drug use or a barrier to seeking help.
Beliefs are notoriously difficult to shift. As with climate change, the most powerful driver of change is personal experience. We know that when a family or community is affected by a drug overdose, their beliefs and perceptions change . But this is not the way any of us should want to see change happen.
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Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
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