This contribution provides an overview of the evolution of the current international drug control system. It also highlights some of the contradictory forces built into the system since early in its genesis. It examines the microeconomic contradictions inherent in the supply-centric model of control. These contradictions have created a central policy paradox within the system and thereby help explain the latter’s continued failure to achieve its goals as well as its active propagation of widespread policy harms. The contribution then looks at the systemic macroeconomic problems of the globally planned licit drug market and how this relates to the provision of essential medicines. The contribution concludes by outlining the core tenets for a new strategy for international efforts.