On 20-22 November 2017, the INCB sent a delegation to Switzerland to discuss its drug policy and the country's implementation of the UN drug conventions.

Switzerland's drug policy has been praised for its balanced approach towards drug control, as reflected in its four-pillar policy focusing on prevention, treatment, harm reduction and law enforcement. The country is also known for its innovative approaches towards drugs, including the early opening of safe injection facilities, heroin-assisted treatment programmes and - in some cantons - discussions on pilot programmes for the legal regulation of cannabis. We therefore welcome the INCB's visit of drug injection facilities and its engagement with the NGO Contact Foundation.

The INCB's position on safe injection facilities has evolved positively over the years, with a significant shift in favour of this harm reduction approach in its Annual Report for 2016. We hope that future INCB missions will continue to visit life-saving harm reduction facilities and reflect the positive impacts of these interventions on the health and social welfare of people who use drugs in its future Annual Reports.

Below is a short article published on the INCB website about the mission.

An INCB mission visited Switzerland from 20 to 22 November 2017. The mission was conducted by Dr. Galina Korchagina, Member of the Board, accompanied by Ms. Ha Fung NG (Cilla) of the INCB secretariat. The objective of the mission was to discuss the implementation by Switzerland of the three international drug control conventions and to review drug control developments in the country regarding the implementation of the international drug control conventions since the Board's last mission in 2000.

The mission, which was coordinated by the Federal Office of Public Health, held consultations with the directors and senior officials of the Federal Office of Public Health, Swissmedic, Foreign Affairs, Federal Police and Cantonal Police Berne. Meetings with members of Federal Commission on Addiction and NGO representatives were also held. The mission also visited a company manufacturing internationally controlled substance and the drug injection facilities provided by the NGO "Contact Foundation" in the Canton of Berne.

Discussions focused on latest developments in drug control situation in Switzerland, trafficking and abuse of narcotic drugs, psychotropic substances and control precursor chemicals, and measures taken to address them, as well as challenges regarding access and availability of substances under international control for medical purposes.

The findings of the mission will be considered by the Board at its session in February 2018, transmitted to the Government, and reflected in the INCB Annual Report for 2018, expected to be released in March 2019.

INCB visits safe injection facility during its mission in Switzerland

This article was first published on the Blog of the West Africa Civil Society Institute (WACSI).

By Charles Kojo Vandyck and Chamrid Kpadonou

Drug trafficking has become a visible threat to governance and development in West Africa. The region is increasingly becoming a hub in the global drug trade and a transit point for narcotics from Latin America through to Europe. Organized crime syndicates are also operating in West Africa with substantial increases in local drug production especially methamphetamines.

West Africa is no longer just a transit zone for drugs from Latin America to Europe. Local production and drug use continue to be major issues. This situation poses a threat to good governance, peace and stability, economic growth and public health in a region that has only recently emerged from decades of violent conflict.

In response to these growing threats, Kofi Annan, former UN Secretary General, convened the West Africa Commission on Drugs (WACD). After eighteen months of research, consultations, and visiting some of the most affected countries and communities in the region, the Commission released their flagship report in June 2014, including a series of evidence-based recommendations for drug policies across the region.

The report suggests that policies crafted to combat the phenomenon must be firmly rooted in the public health sphere. Therefore, removing criminal sanctions for drug use is one of the most effective ways to reduce drug-related harms, to facilitate access to treatment, and to free up resources for law enforcement to focus on more selective deterrence and targeting of high-value traffickers.

The report also recommended that there was the need for more systematic collaboration between West African states and civil society in the fight against drugs. However, civil society in the region lacked the necessary expertise to make a meaningful contribution to the effort.

This situation led to the creation of the West Africa Drug Policy Network (WADPN), which advocates for evidence-based drug policy reform that seeks to reduce harm, protect public health and human rights, and educate the public on the impact of drug trafficking and abuse in the region.

In preparation for the United Nations, General Assembly Session (UNGASS) on the world drug problem that took place in April 2016, West Africa Drug Policy Network organized a series of National Multi-Sectoral meetings on drug policy reform in three target countries; Benin, Senegal and Ghana, to shape discourse among key stakeholders in these countries from relevant public-sector institutions. The national meetings culminated in a regional consultation that shaped and consolidated a West Africa position for UNGASS.

The network’s engagements have translated into action with the new Ghana Narcotics Commission Bill, which is due to be presented before parliament before the end of 2017. Under the prospective legislation, people will not face criminal sanctions for possessing drugs for personal use. If the law passes, Ghana will become the first Sub-Saharan country to decriminalize personal drug use and possession.

However, during these engagements, it became clear that there was a need to develop standards and guidelines for new drug laws within the region based on evidence to support advocacy and policy influencing efforts. It is within this context that the West Africa Commission on Drugs (WACD) and the International Drug Policy Consortium (IDPC) conducted a desk review of existing drug legislature from the fifteen (15) ECOWAS countries (Benin, Burkina Faso, Cabo Verde, Côte D'Ivoire, the Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone and Togo), as well as Mauritania and Morocco. The report highlighted the punitive nature of the current legislation in the region and the current discrepancies with the sentencing regime in the region. For example, in Benin, drug supply, trafficking and production is punishable by 5-10 years prison sentence; however, in Mauritania drug supply is punishable by 15-30 years prison sentence and the death penalty for repeat offenses.

This mapping report served as baseline for a 2-day expert workshop on a model drug law for West Africa. The workshop was organised by the West Africa Commission on Drugs (WACD) in collaboration with the West Africa Civil Society Institute (WACSI) with support from the Open Society Initiative in West Africa (OSIWA) and the Global Commission on Drug Policy (GCDP). The workshop interrogated the findings of the mapping exercise and strategized on the way forward. The meeting provided an opportunity for stakeholders within the drug policy space to intervene and proactively shape a model drug law that responds to the particularities of the region. According to experts an effective model drug law should take into cognisance and leverage on current initiatives by institutions such as ECOWAS and the UNODC. It is also noteworthy to emphasize that the work already done by the WACD and ongoing reform efforts in Senegal and Ghana can be used as a foundational framework.

During the meeting, experts agreed that a regional model drug law must be responsive to the major challenges government will face as they implement reforms. The law should define an effective approach to ensure that various government ministries, departments and agencies responsible for drug control work in tandem with other non-state actors. Other issues that need to be addressed are access to essential medicines for palliative care and pain relief, access to treatment for problematic users, provisions to enable harm reduction, alternatives to criminal sanctions for possession for personal use and a proposed integration with existing frameworks and existing models, e.g. ECOWAS model law for money laundering.

It has become apparent that a comprehensive model drug law for West Africa is an important step to advancing drug policy reform efforts and sustainable development goal three (SDG-3) that seeks to ensure healthy lives and wellbeing for all. Therefore, efforts to harmonise drug laws within the region must be given the necessary support by governments and non-state actors. These efforts can only bear fruit if there is cross-border multi-sectoral support from governments and drug policy stakeholders within the region.

Charles Kojo Vandyck is Head of Capacity Development at the West Africa Civil Society Institute (WACSI).

Chamrid Kpadonou is Project Coordinator (Drug Policy) at WACSI.

Reforming drug control in West Africa through a model drug law

Today, on World AIDS Day, we call on governments, communities and families to stand with people living with HIV. Taking this stand means acting to protect the dignity and value of every life. This means not attacking nor marginalising people in situations of vulnerability; including gay men and other men who have sex with men, sex workers, transgender people and people who inject drugs. It also means ending the war on drugs, which continues to rage in many parts of the world.

This war on drugs is waged with notorious brutality in the Philippines. More than 12,000 people are estimated to have been killed by police and vigilantes in the 16 months since Rodrigo Duterte became President. They were killed because of alleged drug use or dealing, but the circumstances of these executions remain obscured by generalised impunity. Thousands more have been forced to surrender themselves to authorities after being arbitrarily listed as suspects, many of whom are now locked up in inhumane, over-crowded prisons and detention facilities. The threat of mandatory drug testing of students, reinstating the death penalty for drug offences, and reducing the minimum age of criminal responsibility from 15 to 9 still hangs over the country.

On the weekend just passed, Philippines Drug Enforcement Agency (PDEA) officers, accompanied by a camera crew, raided a hotel room and arrested 11 men alleged to be engaged in group sex and drug use. The ‘mug shots’ of all men as well as their names, professions and age were released by the PDEA and widely reported in the media. The fact that one of them was living with HIV was also disclosed, contravening national and international norms, and fuelling virulent attacks on social media.

The drug war normalises stigmatisation and violence against vulnerable groups, subjects people living with HIV to indignity and fear, and fuels HIV transmissions. Indeed, the number of people diagnosed with HIV has risen dramatically in the last 10 years, from 1 person a day in 2008, to 31 in 2017.

A person’s sexual orientation, private life, and HIV status must not be exploited for media sensationalism and political gain. People who use drugs should not be treated as criminals. The HIV epidemic will only subside if the dignity and value of every life is respected and protected. For this to be realised, UNAIDS recommends that governments:

remove punitive laws against vulnerable populations such as men who have sex with men and people who use drugs

take a public health and harm reduction approach to drug use.

It is time to leave behind harmful politics, ideology and prejudice; and prioritise the health and welfare of affected populations, their families and communities. #SupportDontPunish.

In the Philippines and beyond, the war on drugs fuels the HIV epidemic.  Let’s end it.

On November 25, we commemorate the International Day to Eliminate Violence Against Women, which this year takes place under the banner of “Leave No One Behind”. That such a day is taking place this year amidst controversies involving acts of sexual harassment and abuse by prominent male celebrities and other high-profile public figures speaks volumes of the continued, structural, oppression of women worldwide, thirty-six (36) years after the entry into force of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) in 1981.

While we can only laud the courage of the women speaking out against sexual violence, a large number of women remain invisible and extremely vulnerable to different forms of abuse – Among them, women incarcerated for drug-related offences.

Women make up a small percentage of the global prison population, but the number of women in prison are increasing and at a much faster rate than their male counterparts. Many women in prison are incarcerated for low-level, non-violent drug-related offences, ranging from about 25% in Europe and Central Asia, to as high as two-thirds (2/3) of women in federal prisons across the United States. A Thailand Institute of Justice study shows that a whopping 80% of women in Thai prisons are incarcerated for drug related offenses.

Punitive drug laws and the criminalisation of drug use and possession have resulted in overcrowded prisons, including facilities for women. Many women in prison do not have access to basic health care and other gender-specific services. They are vulnerable to physical and sexual abuse and potentially-fatal infectious diseases. Moreover, the stigma against women incarcerated for drug offences is magnified exponentially by stereotyped ideas on womanhood and femininity, and intersecting forms of discrimination. Women imprisoned for drug use, possession or low-level drug trafficking are often ostracised by their own families and communities, with terribly negative impacts on life outcomes.

As we call for the elimination of violence against women, let us not forget the women who are invisible because they are locked up in prisons. Aside from pushing for the full implementation of universal standards for the treatment of women prisoners, like the Bangkok Rules, we must not lose sight of the main culprit – punitive drug policies that prioritise criminalisation over human dignity.

Thumbnail: Jessamine Bartley-Matthews/Washington Office on Latin America

“Leaving no one behind”? For women incarcerated for drug offences, there is no justice without reform.

At the Lisbon Addictions Conference in October 2017, a team of researchers launched two ground- breaking new global reviews: one looking at the prevalence of injecting drug use and various sociodemographic factors, and the other estimating the global, regional and national coverage of harm reduction services. Both papers have been published in The Lancet and are currently available through open access, to ensure their widespread use and dissemination. They represent long overdue updates to the previous Lancet papers by the former UN Reference Group on HIV and Injecting Drug Use from 2008 and 2010.

After considering tens of thousands of articles, sources and datasets, the headline figures include:

Evidence of injecting drug use found in 179 countries (31 more than in 2008)

A new global estimate of 15.6 million people who use drugs (range: 10.2 – 23.7 million)

An estimated 18% of people who use drugs are living with HIV – with prevalence as high as 25% in Eastern Europe, and 36% in Latin America

More than 50% of people who use drugs globally are living with hepatitis C – and in Eastern Europe this affects two third of people who use drugs

Needle and syringe programmes were available in 93 countries: but with low coverage in most cases

Around 16% of people who inject drugs are receiving opioid substitution therapy

60% of people who inject drugs reported being arrested in the past

The numbers – and particularly the coverage data – are a stark reminder of the continuing funding gap for harm reduction services, despite their increasing acceptance around the world. Reassuringly, the research team found more and better quality data than before, but significant gaps remain (hence the large ranges provided for most of the estimates they have made). Most of the new reports of injecting drug use came from countries in Sub-Saharan Africa: 13 of which reported this behaviour in 2007, compared to 36 in 2017.

Crucially, the research also estimated the global rates of incarceration and arrest of people who inject drugs – identified as two of the main risk factors and “structural barriers” for this population. A staggering 60% of people who inject drugs reported being arrested in the past (equating to more than 9 million people), and just fewer reported being incarcerated. Arrest rates were higher than 90% in the Americas, and the incarceration rate was as high as 82% in the Caribbean and 81% in the Middle East and North Africa. These data show the negative impact that current drug laws are having on this population. As the authors note:

“roughly three in five [people who inject drugs] surveyed globally report exposure to incarceration, where high levels of risk often occur both in terms of drug use and other risks to wellbeing.Prisons often have limited or no health-care services, an issue of importance given that risk of drug withdrawal, suicide, and overdose following prolonged abstinence can all be elevated in that environment”.

“Our data highlight the substantial exposure of [people who inject drugs] to risk environments, suggesting that efforts to reduce harms among [them] also need to address structural and environmental factors”.

Finally, the global estimates for injecting drug use are also notable for being significantly higher than the UNODC data from their World Drug Report 2017 (which reports an estimated 11.8 million people who inject drugs, and a HIV prevalence of 13.1%). While the new Lancet reviews employ a systematic analysis of the available scientific data, the cross-UN estimates are predominantly reliant on self-reporting from governments. This demonstrates the value and need for independent scientific analysis on these issues. It is worth noting that, while the previous 2008 and 2010 reviews were performed under the guise of a UN Reference Group on HIV and Injecting Drug Use, this Group was defunded by the UN soon after. Thankfully, these latest independent reviews were at least part-funded by the Open Society Foundations, the Global Fund, the World Health Organization, UNAIDS and UNODC – due in part to their collective participation in the UN Strategic Advisory Group on HIV and Drug Use (which IDPC currently chairs).

New reviews show global extent of criminalisation among people who inject drugs

0n 7th September 2017, the Ugandan Ministry of Health authorized the Uganda Harm Reduction Network (UHRN) and Community Health Alliance Uganda (CHAU) to pilot needle and syringe programmes (NSP) in a few designated health facilities in the country.

This passage was the culmination of years of work by UHRN and our partner organisations. Although it has long been recognized that Uganda has a problem regarding drug use, unsafe injecting drug use was something that most of the people had limited knowledge about. In Uganda, people who inject drugs are one of the key population groups who together account for about 21% of new HIV infections. Recent studies estimate that HIV prevalence among this group is between 17-20% - much higher than the 6% prevalence in the general population.

Through advocacy by UHRN in partnership with CHAU and other stakeholders, the Government and general public have started recognizing the issue of unsafe injecting drug use in relation to HIV and hepatitis transmission. UHRN and CHAU have engaged with Uganda’s Ministry of Health and the Parliament’s committee for health, culminating with a realization of the need for NSP as a key intervention for strengthening Uganda’s HIV/AIDS response. As a result of several engagement meetings, Standard Operating Procedures (SOPs) are being drafted to allow for a demonstration NSP project in the designated health facilities in Mulago MARPI Clinic, Mbarara Regional Referral Hospital, Mbale Regional Referral Hospital, Gulu Regional Referral Hospital, and Butabika National Referral Hospital in Uganda.

The introduction of these supervised injecting facilities will have a real and positive impact in Uganda, both for people who inject drugs and for the wider community.

Slowly but surely, harm reduction programming is taking shape in Uganda and across the region, and we look forward to working with different partners and stakeholders to give UHRN the necessary support for implementing NSP in Uganda. The struggle continues – Support Don’t Punish!

Keep up-to-date with drug policy developments by subscribing to the IDPC Monthly Alert.

Thumbnail: Support. Don't Punish action, Mozambique

Finally, the Ugandan Government agrees to start harm reduction!

The INCB was once regarded as the ‘dinosaur’ of the international drug control regime, opposed to policy-innovation and unwilling to speak out on human rights issues. However, its has recently condemned the Philippines over its continued acts of violence toward those suspected of involvement in drug-related crimes. The previous President, Mr Werner Sipp, was critical of the Philippines actions.

This year, however, the current INCB President, Professor Viroj, had spoken out on the Philippines as part of his presentation on the ‘International Day against Drug Abuse and Illicit Trafficking’ which takes place each 26 June. However, the recent speech is more explicit and more radical than any previous dialogue.

‘The Board’, states the INCB, ‘is also deeply troubled by allegations that these acts have been condoned and encouraged by senior Government officials’. It goes on to reiterate in ‘the strongest possible terms’ that such extrajudicial responses that drug-related crimes are ‘in clear violation of the international drug control conventions’, and reaffirms its ‘categorical rejection’ of extrajudicial acts of any kind.

The Board reminds the Government of the Philippines of the conventions’ commitment to prevention, treatment, education and aftercare, and to a humane and balanced approach to people who use drugs. The President of the INCB, Dr Viroj Sumyai, calls on the Government of the Philippines to cease immediately perpetrating and supporting acts of violence against those suspected of drug-related crimes and to ensure that due process is fully observed. An equivalent message appeared in the INCB Annual Report.

This statement by the INCB represents an encouraging example its progressive position, and its support for human rights and due process in the carrying out of drug control policy. It demonstrates the newly energised and radical force that the INCB has become.

The ‘dinosaur’ has evolved into a progressive force.

INCB speaks out over Philippines killings

The INCB has produced a series of alerts, including one in late June on the therapeutic use of cannabis. This INCB alert represents a much more considered discussion than some of the earlier accounts published by the Board, in keeping with the organisation’s discourse under the leadership of Werner Sipp, which ended on 14th May 2017.

The alert notes that a growing number of governments have authorised the use of cannabis for medical purposes. Such a policy is permissible under the 1961 Single Convention on Narcotic Drugs, as amended by the 1972 Protocol.

However, a number of conditions must be met by the government in question. First, they should produce estimates of anticipated consumption, which should be submitted to the INCB along with further details such as the numbers of people using the drug for medical purposes. If cultivation is planned, details of the area and geographical location must be included. Furthermore, cultivation must be accompanied by the formation of a national cannabis agency to oversee proceedings, according to articles 23 and 28 of the 1961 Single Convention.

According to the alert, the INCB has ‘urged in the past all Governments that have established programmes for the use of cannabis for medical purposes to ensure that the prescription of cannabis for medical use is performed with competent medical knowledge and supervision and that prescription practice is based on available scientific evidence and consideration of potential side effects’.

The World Health Organisation is presently reviewing the therapeutic utility of cannabis, and the results will be made available in due course.

While these are positive developments, particularly in contrast to the attitudes and position adopted by the Board in the past, they fail to engage with the problems of the present and future: the non-medical use of cannabis for pleasure and entertainment. The medical and scientific use of drugs has been permitted – at least in theory – since the foundational treaties of the Hague Opium Convention of 1912 and the following international legislation passed in Geneva under the auspices of the League of Nations.

Several of the states of the United States of America, along with Uruguay, have already permitted the legal use of non-medical consumption of cannabis (with Canada next in line), and it is estimated that cannabis is the most widely illicitly used drug, for the purpose of pleasure, in global society. It is in this territory that the INCB remains a conservative force, with the Board in its 2016 Annual Report reminding governments ‘that, in recognition of the public health risks associated with its abuse, cannabis has been subjected to the highest levels of control under the international drug control treaties through its inclusion in Schedules I and IV of the 1961 Convention’. To reiterate: cannabis is subject to 

Doubtless there are pharmacological risks to health from cannabis; however, cannabis and other controlled drugs are imbued with added dangers, both medical and legal, superimposed upon it by the framework of international and national controls. It is these, too, with which we would like to see the INCB come to terms.

INCB on therapeutic cannabis

On 26th June, thousands of people across 205 cities in 93 countries took part in the fifth global day of action for the Support Don't Punish campaign to call for an end to the war on drugs. Four years ago, I wrote a blog about the "growing momentum for drug policy reform", after the first ever 'Global Day of Action' had taken place - with 41 cities holding events. This year, the global movement for drug policy reform got even bigger!

There were concerts, large public protests, seminars, radio shows, street art, sports matches and meetings with policy makers. The actions were imaginative, innovative, diverse and vibrant. In the UK, students from the University of East London ran an information stand outside of a busy shopping centre to inform the public about harmful drug policies and the "Rat Park" experiments of the 1970s. In India, colleagues embarked on a 470-kilometre motorcycle outreach tour with public interactions and photoshoots along the Delhi-Rajasthan highway. In Paris, drug users opened a mock "drug store". In Mauritius, there was a silent protest in front of Parliament, and meetings with religious leaders. In some cities, a handful of people gathered, taking photos and sharing the Support Don't Punish message. The Global Commission on Drug Policy joined the campaign this year, adding their political weight to the campaign's message. People from all four corners of the globe came out in their droves to join the ever-growing community that Support Don't Punish has now become.

"It is vital that we examine the effectiveness of the War on Drugs approach, and its consequences for human rights" ~

António Guterres, United Nations Secretary-General

So, what does all this achieve? There may be a long way to go until we can really say that the war on drugs has ended - but days like this show that the momentum is on our side. To have people taking to the streets on this scale for an issue like reforming drug policy would have been unthinkable ten years ago. Support Don't Punish has managed to capture and feed an appetite for action - whether through organising an event, turning up on the day, or even tweeting a photo. The 26th June - despite being the UN's official day against drugs - was once again turned into 'Support. Don't Punish Day', a global show of force for social justice, for human rights and for fairer drug laws.

Here's why drug policy activists in 205 cities took to the streets last month...

The recently elected President of the INCB, Professor Viroj Sumyai, gave a statement to mark the ‘International Day against Drug Abuse and Illicit Trafficking’ which takes place each 26 June.

As is so often the case in drug control, the INCB President’s discourse remains ambivalent. While the broad theme consists of an anti-drug message, the specific contents involve many of the more progressive elements that have featured in the INCB’s discourse in recent years.

‘The health and welfare of humankind is at the heart of the drug control conventions’, said Professor Sumyai, noting that the Board has recently emphasized ‘that the conventions are founded upon respect for human rights and the principle of proportionality in responding to drug-related offences’. Professor Sumyai went on to stress the importance of human rights and proportionality in drug-related sentencing. The INCB also encouraged states that still maintain the use of the death penalty to abolish it in the case of drugs offences. Adding that women are too often the victims of disproportionate sentencing for minor offences, he completed what is a largely powerful and progressive statement of the Board’s objectives.

He also strongly contested the use of extrajudicial killings, which is not only contrary to the international drug control conventions, ‘but is also a serious breach of human rights and an affront to the most basic standards of human dignity. The Board strongly, categorically and unequivocally condemns extrajudicial targeting of people suspected of illicit drug-related activity’.

It is encouraging to see that the INCB maintains its new, progressive stance, as was widely hoped within civil society. It appears, at least in the short to mid-term, that the Board’s position has been consolidated, and is set to endure, and that the new President will continue on the lines of his predecessor.

The new INCB President speaks on human rights and dignity

On Friday June 16, 2017, the President’s Commission on Combating Drug Addiction and the Opioid Epidemic held its first meeting at the White House. The meeting occurred after months of a lack of clarity regarding the Commission’s position within the federal government. Although established by executive order in late March 2017, the Commission’s role had remained unclear since its inception.

Observers questioned what relationship the Commission would have with the Office of National Drug Control Policy (ONDCP), an organization already established to provide federal guidance on drug-related issues. The Commission’s role became even less clear when a New York Times Article published in May of 2017 claimed a document obtained from the Office of Management and Budget showed that President Trump’s budget proposal intended to remove 95% of funding from the Office of National Drug Control Policy.

Richard Baum, President of ONDCP, later stated that this 95% figure was inaccurate and clarified the role of the Commission in relation to ONDCP. The Commission serves to review the state of drug dependence and the opioid epidemic and make recommendations to the President regarding how the federal government can best address the opioid crisis. Baum further explained that the Commission is staffed by the ONDCP. The White House has underpinned Baum’s explanations, writing that the Commission’s role is to review the state of drug addiction and the opioid epidemic and make recommendations regarding how the federal government can best address the opioid problem. The Commission is also charged with monitoring drug dependence treatment services, identifying and reporting on best practices for drug prevention and examining the effectiveness of state and federal prescription drug monitoring program, as well as writing a report advising the President on these issues, among other responsibilities. It was in this context that the first meeting was publicly held.

The Commission’s membership includes New Jersey Governor Chris Christie (chair), Massachusetts Governor Charlie Baker, North Carolina Governor Roy Cooper, former U.S. Representative Patrick Kennedy, and Dr. Bertha Madras of Harvard Medical School, all of which were present for the June 16th meeting. Following statements by U.S. Secretary of Health and Human Services Tom Price and and U.S. Secretary of Veterans Affairs David Shulkin, nine stakeholders and non-profit organizations working in the field of drug dependence spoke about addressing drug addiction in the United States.

Major themes emerged early in stakeholder presentations, including calls for increased access to ‘medically-assisted addiction therapy’ (that is, substitution treatment), access to long-term drug treatment programs and the need for comprehensive and integrated solutions that did not glorify one response over another. The need to diversify approaches to reducing drug dependence was echoed by Roy Cooper, Governor of North Carolina, who stated “we cannot arrest our way out of this problem”. Many participants insisted that the issue of parity was central to the problem and questioned why drug use was treated less seriously than physical diseases such as cancer. Stakeholders also voiced concern about stigma and the need to understand drug dependence as a health issue, and not a moral failing.

Over the course of the two-hour meeting, a tone of empathy and compassion was employed to discuss individuals dependent on drugs as well as their families. Participating stakeholders stressed that the obstacle to relieving opioid related deaths was not one of a lack of knowledge or understanding. “We know what to do, the money is available, we’ve known for years what to do” stated a representative from the American Academy of Addiction Psychiatry. “It’s really simple, we have the CDC guidelines” said a representative from ShatterProof, a not-for-profit organization dedicated to ending the effects of addiction on families.

But while participants stressed that they already were aware of ways to effectively reduce drug dependence, harm reduction policies – a critical response for many people who use drugs – were unfortunately not mentioned. This is likely a result of the lack of presence of harm reduction representatives invited to testify at the meeting. Some participating stakeholders, particularly from the health and science-based organizations, noted the importance of equipping first responders with the opioid-reversing drug Naloxone. But beyond overdose prevention measures, harm reduction interventions such as needle and syringe programs, the promotion of safe-injection facilities, and increased access to drug checking kits were not mentioned.

The silence on these harm reduction strategies was made worse by the fact that only five days earlier the American Medical Association, one of America’s most esteemed medical organizations, came out in support of piloting safe-injection facilities. And while a common theme of the discussions was the need for a public-health based approach to drug use and dependence, criminal justice reform was mentioned only once by any of the participants (the intervention on criminal justice was made by the American Academy of Addiction Psychiatry). This is particularly concerning in a country where 80% of drug-related arrests between 1993 and 2011 were for simple possession for personal use. As in other parts of the world, it seems clear that any health-based approach will not be possible unless the country reviews its overly repressive stance on drug control.

The Commission is due to submit their report to the President in October of 2017. If the first meeting of the Commission is any indication of this future report’s contents, it is likely that any success the report could have in advising the President on addressing drug use will be diminished by its failure to consider harm reduction strategies.

The first meeting of the US Commission on opioid dependence hears calls for a ‘health-based approach’ to addiction, but ignores harm reduction

The INCB visited Egypt between 11th and 14th June 2017.The previous visit was in May 2001, and was included in the INCB’s Annual Report 2001, when the Board congratulated the commitment of Egypt to international drug control. These congratulations were prompted by actions such as the country’s determination to eradicate cannabis and opium crops in the Sinai Peninsula. The INCB were more critical, however, of the availability without prescription of controlled substances.

The purpose of the latest visit was to review the implementation of the three international drug control treaties, and to discuss drug control developments since the 2001 mission. Likewise, the INCB wished to review the country’s challenges in the availability of controlled drugs for medical purposes, an area of particular relevance given Egypt’s concerns with tramadol.

The INCB appear to have had a close relationship in recent years over the synthetic opioid tramadol. At the 60th CND, Egypt submitted a conference paper concerning the tightening of control over tramadol, in which it made extensive use of INCB documentation dealing with tramadol including the Annual Reports for 2012, 2013, 2014 and 2015. The Conference Paper then states that:

The Egyptian authorities believe that the negative consequences of tramadol abuse necessitate that its control be expanded beyond a national control mechanism to be included under international control. In 2013, the Egyptian government proposed to the CND during its 56th session, a draft decision to support the international cooperation to prevent non-medical use of tramadol.

Again, as it did in the case of ketamine, the INCB is arguably exceeding its mandate under the international drug control conventions by making a similar argument to the Egyptian government. Recommendation on the scheduling of substances lies within the mandate of the WHO’s Expert Committee on Drug Dependence (ECDD), which has repeatedly undertaken pre-reviews on tramadol in recent years. Most recently, the ECDD carried out an update, which was contained in its 36th Report from 2014. Its recommendation on tramadol was: ‘Based on the evidence available regarding dependence, abuse and risks to public health, the Committee recommended that a critical review of tramadol is not warranted at this time.’ A critical review is the next step in the ECDD review process, and without its being undertaken a substance cannot be scheduled.

Amongst those who contributed evidence and views into the 2014 update process were pain specialists and pharmaceutical manufacturers, who commented that:

International control of tramadol would unnecessarily adversely affect the availability of tramadol for medical purposes in many countries worldwide that are not in need of further controls. In addition it is important to stress that tramadol is in many countries the only available stronger analgesic for patients suffering from moderate to severe pain. Therefore, an unwarranted scheduling of tramadol would contribute to worsening of the existing under-treatment of pain and lead to needless suffering of pain patients, especially in developing countries.

It will necessary to maintain a watch on the INCB and countries such as Egypt and their conduct in relation to tramadol. The campaign that prevented the international scheduling of ketamine can be marshalled again, but we cannot be certain that it will be as successful.

Keep up-to-date with drug policy developments by subscribing to the IDPC Monthly Alert.