On International Overdose Awareness Day 2018, the Women and Harm Reduction International Network (WHRIN) calls attention to the gender specific needs of women who use drugs (WUD) and the need for urgent responses to address the ever rising death toll for accidental overdose.

Women who inject opioids face unique challenges in accessing lifesaving information, support to develop personal strategies to prevent overdose and the tools to effectively manage overdose. Where harm reduction services exist, they are generally established without a gender lens and cater best for the male majority of their clients. This means the services lack relevance and accessibility for WUD, particularly those with children and those who have been subject to intimate partner violence. WUD with children, especially single mothers, are often reluctant to attend drug services for fear of being identified as a drug user and losing child custody. As a result of this fear, women may inject secretly and alone, compounding the risk of fatal outcomes. Fortunately, some jurisdictions are starting to respond to these short comings by developing gender sensitive services (see for example, Insite the women only safe injecting facility in Vancouver). However, these examples are exceptional and in no way proportionate to the scale of need nor the rising death rates.

To put the death toll on a downward trajectory, it is vital that women who inject opioids be meaningfully engaged in planning and delivering life saving services. Peer to peer naloxone distribution and administration programs must become a feature of all harm reduction services and other organisations engaging with WUD. In addition, services should make all efforts to reach WUD with a low threshold. Women-sensitive harm reduction services must be redoubled.

On Overdose Awareness Day, WHRIN grieves for the women who have lost their lives to this war on drug users. The losses are harder to bear given the preventability and injustice surrounding this deplorable failure of prohibition. The damaging ideology surrounding the war of drugs is killing people by acting as a core barrier to preventing accidental overdose and must end.

Women and Harm Reduction International Network statement at the occasion of International Overdose Awareness Day

By Leo Beletsky, Pieter Baker, Jaime Arredondo, Ashley Emuka, David Goodman-Meza, Maria Elena Medina-Mora, Dan Werb, Peter Davidson, Joseph J Amon, Steffanie Strathdee, Carlos Magis-Rodriguez

The first safe consumption facility (SCF) opened its doors in 1986, in Bern, Switzerland, intending to curb drug overdose-related deaths and prevent other drug-related harm in people who inject drugs (PWID).1 Since then, communities who have adopted the SCF approach have seen decreases in HIV incidence, injection related litter and disorder, and drug overdose.2,3 Use of SCFs is also associated with uptake of treatment for drug use and other recovery assistance services.4

Mounting evidence that SCFs are both highly successful and cost-effective has made them a core public health response to problematic drug use and its sequelae.5,6 Nowadays, more than 100 SCFs are in operation across Europe, Australia, and Canada, with Canada having recently approved dozens of additional facilities to address the country’s overdose crisis.7 Although several US locales have made concrete steps towards opening SCFs, progress has been dismally slow, and the ultimate fate of these efforts remains uncertain.

Shockingly, not one such programme operates in low-income and middle-income countries, despite the reality that these countries bear a disproportionate burden of the harm to public health associated with drug use. For example, the prevalence of HIV infection in PWID living in Latin America (35·7%), South Asia (19·4%), and eastern Europe (24·7%) is markedly higher than the global average (17·8%).

Although technically a high-income country, Russia now has the third highest HIV incidence in the world, driven primarily by injection-related transmission.8 Moreover, abusive law enforcement practices are prevalent in areas with a weak rule of law and widespread informal settlements.9,10 Adverse encounters with police and other security personnel exacerbate the health risk to PWID, while limiting the accessibility of harm reduction services.11 In such contexts, the human rights and public health imperatives of safe consumption spaces are especially pressing, whereas their absence plainly offends global equity principles.

Tijuana, Mexico is illustrative of a global setting where the potential benefit of SCFs is readily evident. As a border node in the international drug trade, rates of drug consumption, injection-related infectious disease, and overdose are high.12 Reflective of many other places in low-income and middle-income countries, access to naloxone and opioid substitution therapy in Tijuana (and elsewhere in Mexico) is limited. If operated at scale, a SCF could substantially decrease overdose-related morbidity and mortality while facilitating access to appropriate drug treatment.12 Tijuana’s street market for opioids does not yet appear to be dominated by fentanyl, but such a shift would almost certainly cause a surge in overdose fatalities.

Existing drug consumption dynamics and the proliferation of informal and unsafe injection sites leave PWID in Tijuana vulnerable to police harassment.10,11 In the context of structural challenges and poor coverage of high-quality and accessible harm reduction programmes, a SCF could save lives and reduce drug-related harm. The integration of SCFs with a range of assistance programmes would also catalyse the connection of marginalised drug users to other essential services. Analogous to several jurisdictions in the global South, Tijuana’s legal environment is already favourable to the operation of a SCF because small-scale drug possession is decriminalised.10 Finally, a department-wide police education programme in Tijuana has built a foundation for better alignment of law enforcement with harm reduction programmes like SCFs.13

In Tijuana, as elsewhere, SCFs provide an opportunity to integrate a suite of key harm reduction services under one roof. However, these spaces potentiate much more than access to sterile equipment and basic medical help. In contexts where the lived experience of PWID is characterised by pervasive exposure to police violence, poor availability of stable housing and basic sanitation, and little ability to vindicate one’s rights, SCFs can create a rare oasis of structural safety and empowerment. The diversity of models for SCF—ranging from simple pop-up and mobile sites to fully-integrated clinics—create an opportunity to tailor interventions to particular environments and resources available globally. Despite barriers to operating SCFs in high-income settings, advocacy and persistence have supported the diffusion of this intervention throughout Europe, Australia, and Canada.1 With pressing public health and global equity imperatives to support this cause, the time to scale SCFs globally has long arrived.

The global health and equity imperative for safe consumption facilities

For the first time ever, the United Nations (UN) is launching an in-depth review of whether marijuana is properly classified under international drug treaties.

In a related development, the UN’s World Health Organization (WHO) has announced that cannabidiol (CBD), a compound in marijuana that is increasingly used for medical purposes, does not warrant being controlled under the global agreements.

“The Committee recommended that preparations considered to be pure CBD should not be scheduled within the International Drug Control Conventions,” WHO Director-General Tedros Adhanom Ghebreyesus wrote in a letter announcing the moves. “The Committee concluded that there is sufficient evidence to proceed to a Critical Review” of marijuana, hashish, cannabis extracts and THC.

That broader review is set for November, and follows the results of an initial pre-reviewconducted by WHO’s Expert Committee on Drug Dependence (ECDD) in June.

“A pre-review is the first step of the ECDD’s assessment process, where it is determined whether there is enough robust scientific information to proceed to the next step, called a critical review,” an explanatory document accompanying the new letter reads. “This initial evaluation is also an opportunity to identify gaps in the available scientific data. A critical review is carried out when there is sufficient scientific evidence to allow the ECDD to make informed an recommendation that the substance be placed under international control, or if its level of control should be changed.”

The reviews include analyses of the chemistry, pharmacology, toxicology, epidemiology and therapeutic use of the substances.

UN launches first-ever full review of marijuana’s status under international law

The UN Committee against Torture invited PRI to facilitate a one-day workshop on vulnerable groups in detention on 2 August 2018, within their regular session in Geneva.

The workshop was supported by the American Civil Liberties Union and the Association for the Prevention of Torture. PRI brought together a range of expert representatives from national prison systems, civil society, academia and the European Court of Human Rights.

PRI has long focused on advocating for and working with authorities to meet the specific needs of vulnerable groups, for example by delivering training to prison staff on meeting the needs of certain groups and working with monitoring bodies to ensure assessment of their treatment.

The starting point for the discussion was that while all detainees are inherently vulnerable because of the power imbalance between the detaining authority and detained person, social status and social context mean that some individuals are particularly vulnerable. Furthermore, while it is important to address vulnerability that may come with individual component identities – like gender, sexual orientation or health status – intersectionality and how this impacts on someone’s situation of vulnerability in detention must be understood.

‘The principle of non-discrimination, reiterated in Rule 2 of the UN Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), places a positive obligation on detaining authorities to address any vulnerabilities of people they have under their supervision, to protect them from ill-treatment or torture. Furthermore, PRI argues that the prevention of torture and ill-treatment of people with high vulnerabilities requires their diversion from imprisonment in the first instance, particularly where there is overcrowding and a lack of resources to protect them,’ said PRI’s Policy and Programme Manager, Olivia Rope.

The workshop focused on seven key groups of detainees who have specific needs and who, according to the Nelson Mandela Rules and other standards, therefore require specific measures to be put into place to protect them and safeguard their rights. These were: women, children, LGBTI people in detention, minorities and indigenous people in prison, life-sentenced prisoners, people who use drugs, and prisoners with physical and mental disabilities.

Prison Reform International works with UN Committee against Torture to address vulnerable groups in detention

For the fifth year in a row, the number of drug-related deaths reported in England and Wales has risen to record levels, according to the latest figures from the Office for National Statistics. In 2017, 2,503 deaths were recorded as “drug misuse”. This comes on top of July’s announcement of an 8% increase in drug-related deaths in Scotland.

In Great Britain, as a whole, deaths from drugs overtook traffic fatalities as a leading cause of death in 2008, and they have risen particularly sharply since 2012.

Jump in a car and everything around you is designed with safety in mind, from the roads to the construction of the vehicle. But with drugs, you are on your own. Policy effort is centred on preventing drug use rather than protecting people when they use substances.

The government’s response to these latest figures will undoubtedly be to deflect attention from the failure of policy and blame those who died instead, arguing that they were part of an ageing cohort of drug users whose lifestyles and poor choices contributed to their early deaths.

The people most likely to die are working class, over 40 and living in de-industrialised areas. Drug death rates are nine times higher in the most deprived neighbourhoods than in the richest areas.

Unfortunately, investment in treatment does not match local need, so those areas with the greatest need get the least resources.

Record level of drug deaths in England and Wales – latest official figures

Half-naked bodies writhe on the ground. A man lies in an empty bath, his eyes gazing into space. “No herbs, no medicine. They’ve mixed gutter water together—the eyes are now dirty,” cries out Olamide, a Nigerian rapper. His music video, “Science Student”, has been viewed millions of times. It’s a hypnotic commentary on the chaos caused by the addictive drugs sweeping through his country. But the problem is not just confined to Nigeria. While global headlines have often focused on America’s painkiller addictions, an opioid crisis is raging across west Africa. For decades, Latin American cartels have trafficked cocaine through fragile west African states and on to Europe. Narcotics have often found their way into the region’s conflicts. For example, during Sierra Leone’s war, child soldiers were reportedly given a combination of cocaine and smokeless gunpowder called “brown-brown” that would send them into a killing frenzy. However, many of the hard drugs used in Europe and America are too expensive for those Africans living outside metropolitan areas. This has left a gap in the market for cheap, powerful highs.

Opioids—strong painkillers—have filled that gap. The main ones used in west Africa are tramadol and codeine. These are weaker than their cousins, heroin and fentanyl, but are still potent, especially when combined with substances like cannabis. There are no reliable estimates on how many people in west Africa are taking these opioids, but there is evidence to suggest widespread use across a swathe from Senegal and Mali to Nigeria and Cameroon. The United Nations says that almost 90% of all the pharmaceutical opioids seized in the world in 2016 were seized in Africa (predominantly tramadol, in the west, centre and north). The drugs are mainly manufactured in India. In 2016, following the seizure of 40m tablets, America’s State Department reported that Benin, with a population of just 11m, was the largest importer of Indian tramadol, after the United States.

West Africa’s opioid crisis

Bekaa Valley, Lebanon (CNN)The farmer plucks a cannabis flower from a long stalk. He presses it against his nose, inhales deeply and begins to extol the therapeutic -- if not necessarily scientific -- properties of his crop. "Smell this. It smells like heaven," says Abu Salim, who doesn't want his real name used for security reasons. "This is the herb of happiness. My friend says that when he smokes a joint, his wife becomes a princess, the world shines, and life is beautiful!" This is part of the heartland of Lebanese farming, once considered the breadbasket of the Middle East. It is also home to some of the region's most conservative and controversial political groups. An expanse of cannabis -- almost the size of three soccer fields -- stretches out in front of Abu Salim. Harvesting season hasn't started yet, but the country has recently trained its sights on fields like these. Heeding the recommendation of international consulting group McKinsey, which was part of a broader development plan, Lebanon's parliament is preparing to legalize medicinal cannabis and its cultivation. It's meant to pave the way to a nearly $800 million industry, according to Economy Minister Raed Khoury, and could serve as a quick fix for some of the country's many economic woes.

Climate change is turning the Middle East's breadbasket into a cannabis farm

In the early morning of July 24, the dead body of 35-year-old Alamgir Hossain Badsha, an activist belonging to the student wing ofBangladesh's main opposition Bangladesh Nationalist Party (BNP), was found near a gas station in Sonargaon, a town 20km from the capital, Dhaka.

The paramilitary body, the Rapid Action Battalion (RAB), said that Badsha, who they accused of being a drug dealer, had been killed during a gun fight with its officers who had earlier been tipped off about a drug deal.

"When officers arrived there, Badsha started shooting at them. When RAB fired back, Badsha was killed," Sheikh Billal Hossain, a senior policeman, told journalists.

He said that they recovered a gun, bullets and 15 units of the drug - Yaba, a mix of methamphetamine and caffeine - from his body.

According to authorities, Badsha's killing was an inevitable consequence of the government's determined campaign, which began in May 2018, to deal with drug criminals who shoot at the sight of law enforcement officers when an arrest is attempted.

Are Bangladesh activists being killed amid the war on drugs?

The Colombian government has started to use drones to destroy the plants that produce cocaine.

Small aircraft loaded with herbicide are being sent to search for illegal fields of coca.

President Iván Duque has favoured the use of the unmanned aircraft to ensure that damage to neighbouring crops is kept to a minimum.

Critics have warned that the approach may be a technological fix to a problem that needs a political solution.

The Wall Street Journal reported that Colombian authorities had partnered with drone company Fumi Drones SAS to provide unmanned aircraft as well as to train police.

German Huertas, the drone company's director of operations, said the drones had eliminated about 90% of the coca on each acre (0.4 hectare) targeted during tests in the country's Narino province.

The trial has involved the deployment of 10 drones, each weighing 23kg (51lb) and carrying the plant-killing chemical glyphosate.

Drones hunt cocaine farms in Colombia

This article is adapted from AQ's latest issue on reducing homicide in Latin America.

Considering the drug trade’s role in fueling violence throughout Latin America and the Caribbean, it’s worth examining the impact of recent drug policy changes. Most involve the decriminalization of marijuana for personal use or the legalization of medical marijuana — often in the form of oil derived from the cannabis plant that can be taken orally as medicine. Most reforms have been too minimal to affect crime. In some cases, bureaucracy and poor implementation may have thwarted the intended positive effects.

The Senate passed a law approving medical marijuana in 2016. The government regulates the prescription and distribution of medical marijuana products, which must be imported since production is still illegal.

: Patients say the implementation of the medicinal policy has largely failed. Cannabis oil is only accessible to patients with refractory epilepsy, and patients remain unauthorized to grow their own cannabis. Meanwhile, further drug liberalization seems unlikely under President Mauricio Macri, who has scaled up efforts against trafficking. Macri’s approach includes a controversial expansion of the armed forces’ role in stemming the drug trade.

Bolivian farmers have chewed coca leaves for generations to ward off altitude sickness and as a mild stimulant. However, coca cultivation was largely illegal until 2004, when the government began working with coca farmers to regulate cultivation, setting limits to grow the leaf in certain regions. In 2009, a new constitution backed by President Evo Morales, a former coca farmer, described it as part of the country’s cultural heritage. In 2017, a new law increased the legal limit of coca cultivation to approximately 55,000 acres from 30,000 acres, to incentivize more farmers to grow it legally.

: The 2004 reform was followed by a fall in the share of Bolivia’s prisoners behind bars for drug-related convictions, from 41 percent in 2004 to under 20 percent in 2016. After the new constitution, coca cultivation also fell over time, reaching a peak of 76,600 acres in 2010 and then falling to just under 50,000 acres in 2015.

What became of Latin America's progressive drug reforms?

Incoming president Andrés Manuel López Obrador has pledged to overhaul Mexico’s militarized assault on the drug cartels that has left 200,000 people dead

Here in Mexico’s most murderous municipality the bodies appear with nauseating frequency – or at least, parts of them do.

Some are stashed in bin bags or hammocks; others in blood-soaked rucksacks. Some are dumped in bike lanes or canals; others left on street corners or football pitches – severed, shredded and stomach-churning symbols of the country’s failing war on drugs.

“Sometimes we don’t even know who they are,” admitted Arturo Bautista, the silver-haired administrator of Tecomán’s cemetery and the final custodian of the victims of this Pacific beach town’s relentless killing machine.

In few places can the ferocity and futility of Mexico’s war on drugs be felt more than Tecomán, a once tranquil coastal community. Last year its murder rate of a reported 172.51 deaths per 100,000 inhabitants resembled that of a war zone.

'Can't fight evil with evil': Life in Mexico's most murderous town

“Some people call this place The Living Room,” the young man I’ve just met tells me. And looking around the room, you can see why. Several people are relaxing on two comfy-looking couches. There are sandwiches on the table. A couple of guys are sitting on steps leading out onto a busy street in central Lisbon. Someone’s on Facebook at the counter. The xx are playing in the background. It could almost be an inner-city art collective, or an activist meet-up spot.

But several things suggest this is no ordinary living room. A poster on the wall says, ‘Aren’t We All Drug Users After All?’ Another: ‘Say No to the War on Drugs.’ People are coming and going into side-rooms, where a social worker in casual clothes occasionally shows her face. The young guy next to me is handing out snacks to people who approach him with a numbered slip of paper.

This place, I discover, has a few different functions. It’s a Harm Reduction Centre, run by GAT (Grupo de Ativistas em Tratamentos), a Portuguese HIV organisation. The GAT Centre links people to social services and helps people navigate the health system. It provides injecting and smoking materials, including syringes and crack pipes. It takes used syringes, deposited in a closed container behind the counter. It offers basic services to those living in the streets, including access to the internet and a phone, clothing, and hygiene products. The model focuses on relationship-building. One employee explains: “Maybe first, people come in for a drug kit and leave straight away. The next time they come in, we encourage them to have a coffee and take a kit. The time after, they might see a social worker or a nurse. We hope it builds from there.”

It feels different from other social service centres I’ve spent time in. People wear colourful clothing. One user of the centre comes up to chat, and leaves me with a band name to look up. There’s less shame about why people are there.

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