This report considers substance use prevention in Europe through the lens of a system, highlighting the wide range of factors that need to be addressed to successfully implement substance use prevention programmes and policies. They are considered from different viewpoints by practitioners, policymakers and researchers. Systems thinking may have the potential to unify these differing perspectives within a single model.

Drug prevention: Exploring a systems perspective

The aim of this guide is to familiarize civil society to the Outcome Document of the 2016 United Nations General Assembly Special Session (UNGASS) on the world drug problem (UNGASS 2016) and highlight the potential for civil society participation in the implementation of the operational recommendations and their respective Sustainable Development Goals (SDGs). The guide uses examples from UNODC’s work and from NGOs around the world to demonstrate how they support the implementation of these international commitments related to drugs – in order to make the UNGASS Outcome Document and the SDGs easily understandable for civil society organizations on the ground, and to demonstrate the linkages between them. Full descriptions of these examples can be found in accompanying web annexes – CSO examples and – UNODC examples in electronic version. Abbreviations used in this guide can be found at the back of the guide in the glossary, whereas relevant SDGs and targets in full text are available in Annex 1. Annex 2 contains all endnotes.

The development of the guide was led by the Civil Society Team of the United Nations Office on Drugs and Crime (UNODC), in collaboration with the Vienna NGO Committee on Drugs (VNGOC). All civil society examples have been provided by civil society organizations themselves. The content in each of these examples reflect the position of the civil society organization that provided it only.

Working together – Drugs and the Sustainable Development Goals: A Guide for NGOs

The World Health Organization’s (WHO) Expert Committee on Drug Dependence (ECDD or Expert Committee) released in January 2019 the outcomes of the first-ever critical review of cannabis, recommending a series of changes in the current scheduling of cannabis-related substances under the UN drug control conventions.

Eagerly awaited, the ECDD recommendations contain some clearly positive points, such as acknowledging the medicinal usefulness of cannabis by removing it from Schedule IV of the 1961 Single Convention on Narcotics Drugs; clarifying that cannabidiol (CBD) is not under international control; and addressing some long-standing scheduling inconsistencies.

But the ECDD recommendations also reveal problematic underlying evaluation methods and scheduling procedures along with a very questionable rationale for keeping cannabis in Schedule I. Moreover, the recommendations leave many questions unanswered regarding levels of control for different types of medical cannabis preparations. The potential repercussions of those more questionable aspects of the ECDD recommendations trigger legitimate concerns that merit a close examination by governments and by civil society. These concerns are heightened precisely because the recommendations result from the first-ever WHO critical review of cannabis. Allowing the questionable aspects of the recommendations to escape scrutiny risks not only accepting dubious scheduling recommendations now, but also risks acquiescing to problematic underlying evaluation methods and procedures. Governments should seriously consider their options for challenging these aspects of the review, since their acceptance now could set a damaging precedent for the future. The limitations of the ECDD review also highlight that even far greater progress in bringing the UN drug treaties’ cannabis scheduling in line with modern science will be unlikely to clear the path for legal regulation of non-medical cannabis. Since such an approach remains outside what the drug control treaties permit, countries wishing to regulate cannabis for non-medical use in a way that comports with international law will need to find a different pathway out of the treaty structures. Among the treaty reform options not requiring consensus, the procedure of inter se modification, provided for by the Vienna Convention on the Law of Treaties, appears to offer the most elegant approach.

The WHO’s first-ever critical review of cannabis

Supervised drug consumption rooms (sometimes referred to as ‘safe injecting rooms’ or ‘overdose prevention centres’) allow people who use illicit drugs to consume substances whilst under the supervision of trained staff. Drug consumption facilities aim to reduce risks of disease transmission, overdose and public nuisance whilst also providing a location for people who have substance dependence to access treatment, employment, and housing support services.

The UK currently does not have any supervised drug consumption rooms, although proposals for facilities have been made by local agencies in West Midlands, North Wales, Southampton, Glasgow, and Bristol. In 2016, the UK Advisory Council on the Misuse of Drugs recommended that consideration be given to the potential of drug consumption rooms within areas of high injecting drug use in order to reduce drug related deaths. The government response was that no plans existed to introduce drug consumption rooms in the UK.

A 2018 survey of injecting drug users in the UK found that a large majority (89%) expressed willingness to use a drug consumption room and accepted the need for rules within such facilities such as no drug sharing (84.3%), no assistance with injecting (81.8%), compulsory supervision (76.7%) and compulsory hand washing (92.1%).8 The following paper will outline the need for drug consumption rooms in the UK, evidence supporting their use and considerations for implementation at a local level.

Room for improvement: How drug consumption rooms save lives

In 2017, key populations (KP) and their sexual partners accounted for approximately 40% of new HIV infections globally (UNAIDS, 2018). A range of policy and legal barriers and harmful social dynamics increase the HIV vulnerability of KP and undermine their access to HIV and other services. The criminalization of sex between men, sex work, drug use and HIV transmission, as well as high rates of incarceration, homophobia, trans phobia, violence and social marginalization, all serve to influence risk practices and undermine access to services. People from key populations often migrate to cities in search of safer and more secure communities (UNAIDS, UN Habitat 2015). Women in key populations face specific challenges and barriers, including gender-based violence (GBV) and poorly tailored services. These factors further intensify their vulnerability to HIV.

There are five groups recognized by United Nations (UN) agencies as key populations at increased risk for HIV. Each has a significantly higher risk of acquiring HIV infection than the general population, globally. Sex workers (SW) face unsafe working conditions, barriers to negotiating condom use, violence and inadequate access to health care services, which all contribute to their increased HIV risk and burden when compared to the general population. The risk of acquiring HIV for female sex workers (FSW) was 13 times higher than adult women aged 15-49 years (UNAIDS, 2018). Transgender sex worker, male sex workers, and also male sex workers who have sex with men are subpopulations of sex workers who appear to be at extremely high risk of acquiring HIV. Sex workers also experience marginalization and increased vulnerability to violence globally (WHO, 2013).

In many settings, men who have sex with men (MSM) make up increasing proportions of new HIV infections. Gay men and other MSM were 28 times as likely to acquire HIV when compared to heterosexual men (UNAIDS, 2018). Men who have sex with men are disproportionately affected by HIV when compared to the general population in any country, but most notably in low- and middleincome countries. In these countries, MSM are 19.3 times more likely to be living with HIV compared to the general population (UNFPA, 2015).

Global summary of findings of an assessment of HIV services packages for key populations in six regions

People who use drugs have human rights and fundamental freedoms, which countries must respect, protect and promote, both nationally and internationally.

Yet human rights and drug control have existed in parallel universesI for decades, and drug policies receive little scrutiny from human rights mechanisms. This has contributed to repressive policies and practices for the control of drugs, which have led to or enabled a wide range of human rights violations and abuses worldwide. These violations and abuses disproportionately impacts the most vulnerable people in society, perpetuating cycles of poverty, violence, discrimination and marginalisation, while failing to reduce drug-related harms and risks.

The Universal Periodic Review (UPR), alongside other international and national human rights mechanisms, is an important tool for holding countries that are part of the United Nations, known as UN Member States, accountable for respecting, promoting and fulfilling the human rights of people who use drugs, as well as fulfilling the pledges countries have made through the Sustainable Development Goals (SDGs). The UPR has the potential to improve human rights everywhere, for everyone. Countries can use it to initiate national human rights processes, and it can provide a valuable opportunity for civil society to engage governments on issues relating to human rights in the context of drug policies and people who use drugs.

According to a PITCHII research study on the UPR and HIVIII, drug-related issues have been barely visible in the UPR process to date. This research shows that UPR recommendations relating to HIV and connected topics, such as policies in response to drug use, are an important tool for civil society actors to use to advocate for governments to take action, to respect, promote and fulfil the human rights of people living with HIV and key populations.

Introduce the UPR and explain its relevance to people who use drugs and civil society activists.

Present a global analysis of the recommendations made by UPR cycles completed between 2008 and 2017 (cycles 1 to 3), focusing on the level of attention paid to drug-related issues by the UN Member States under review in regard to both recommendations and voluntary commitments.

Provide recommendations and guidance to civil society on how to maximise the opportunities of the UPR.

Making the Universal Periodic Review work for people who use drugs

This study places itself at a rarely-examined crossroads: drug policy, incarceration and the rights of children and youth. Its focus is the specific toll that having a parent in prison for a minor, nonviolent drug offense has on children and youth. The research is both qualitative and quantitative and comes from across Latin America and the Caribbean. The research for this study was conducted in eight countries: Mexico, Colombia, Chile, Costa Rica, the Dominican Republic, Brazil, Uruguay and Panama. Each study involved relevant experts on drug policy, the penal system and policies directed towards children. Some of the questions that guide this study are: How does drug policy affect children and youth when their guardians are in prison? What do children think of drug crimes and the authorities’ response to them? What are these children’s feelings, worries and experiences? In what way are international policies and agreements taken into account when designing, applying and monitoring public policies specifically oriented toward children and youth? In what way should public policies regarding children, drugs and incarceration inform and transform each other in order to ensure the most important factor, the child's ultimate wellbeing?

Through the voices of 70 girls and boys with incarcerated parents, as well as those of their caretakers, we offer answers to these questions. We also offer tools that may be useful for organizations working with children, attempting to influence drug policy in the region and creating or implementing public policies related to the rights of children, incarceration and drug legislation.

The predecessor of this report was the study Invisible No More: Children of Incarcerated Parents in Latin America and the Caribbean. Case Study: Brazil, the Dominican Republic, Nicaragua and Uruguay. As the title indicates, Invisible No More was an exploratory study on the impact that a parent or relative’s incarceration has on children and youth. It also reached a preliminary estimate of how many Children of Incarcerated Parents, or COIP, exist in Latin America and the Caribbean. It found the number at that moment to be between 1,500,651 and 1,868,214.

This study updates the estimate and finds that between 1,710,980 and 2,307,048 children in the 25 countries in the region have at least one parent in prison. Of these children, between 359,305 and 484,480 have parents incarcerated specifically for drug crimes — a trend that, without profound and timely changes, will continue to increase.

In general terms, drug laws in the eight countries in this study share certain traits: the application of mandatory minimum sentences, the disproportionate use of criminal law and a preference for incarceration over other alternatives. There is also a tendency toward increased sentencing and, as a result, increased levels of incarceration.

This study summarizes and compares the information contained in the eight country reports. In each of these, we analyzed policies on children’s rights and how these link to the Convention on the Rights of the Child. Despite any legislative progress, the problems identified in the region relate to the implementation of current provisions related to children. As well, we identified a lack of coordination between the agencies responsible for safeguarding children's rights. Another important problem is the inadequacy of quantitative data. There is a dearth of public information related to the numbers of children with incarcerated parents in all these countries.

The COIP testimonies are the heart of this study. These are organized into several key topics:

a) Violence. COIP are surrounded by multiple forms of violence. In general terms, children and youth report that arrests and raids are profoundly violent experiences. They witness their spaces and possessions being destroyed and their mothers or fathers manhandled. Sometimes they themselves may be victims of beatings and threats. In addition to this violence from authorities, the children can experience violence in their neighborhoods stemming from rival criminal groups jostling for control of the drug market.

b) Impacts of incarceration on the daily lives of children and youth. In regard to the roles and arrangements of caring for children, the detention of a guardian impacts the whole family. It affects the incarcerated person, his or her children and the people (usually women) who will now care for the children. The prison sentence is, ultimately, a sentence that transcends families. Both in cases where detention comes as a surprise, and in those where crimes and incarceration are routine experiences, COIP report feeling a certain hopelessness and resignation. They are faced with something out of their control but that they must helplessly suffer the impacts of.

c) Stigma versus support. A child’s feelings of loss, abandonment, sadness and rebellion can either be amplified by stigma or mitigated by support from his or her family, community and/or school.

e) Prison visits and security searches. Children often have mixed feelings about prison visits. On the one hand, if the COIP has a good relationship with his or her imprisoned parent, the child will want to see and spend time with him or her. On the other hand, the time and costs that the visit entails, as well as the treatment of visitors — especially during examinations — discourages them from wanting to visit.

e) Perception of drug-related crimes. Children and youth perceive drug crimes as a way to face poverty in a context of social exclusion. There is also criticism; selling drugs is seen as an activity that damages others and negatively affects the sons and daughters of the sellers. COIP also mention the normalization of this activity in certain places, and how it can increase a person's status within the neighborhood. They express ambivalent feelings, just as they do in most other categories of this analysis, that combine affection with anger for what their parents have done.

f) Perception of state authorities. In regard to the authorities, the COIP mostly refer to the police and to raids. They perceive the police as a source of violence and corruption, where police officers detain only the minor players in the drug trade or even "plant" drugs to frame their victims, while drug trafficking leaders can act with impunity through corruption.

Click here to access a short related video.

 Childhood that matters: The impact of drug policy on children of incarcerated parents in Latin America and the Caribbean

This research represents the first effort to assess the legal needs and paths to justice for people who inject drugs and sex workers in Macedonia. It was conducted at the end of 2016 and the beginning of 2017 using a mixed-methods research approach. The quantitative phase included 250 respondents chosen through stratified random sampling in two stages, out of which 169 injected/had injected drugs, and 107 were/had been engaged in sex work at the moment of the interview or in the prior three and a half years. The qualitative research phase, on the other hand, was comprised of focus group discussions with 69 respondents from both communities, as well as individual or group interviews with 7 representatives from competent institutions.

The research results showed that people who inject drugs and sex workers in Macedonia are ten times more likely to experience non-trivial justiciable problems in comparison to the general population in the country. In addition, low level of legal literacy, lack of trust in the institutions and systematic discrimination, among other factors, prevent citizens from these communities to seek protection of their rights and delivery of justice through institutional mechanisms. Such circumstances confirm the communities’ high vulnerability and underline the need for advancement of their access to information, legal advice and protection.

Legal needs and access to justice for people who inject drugs and sex workers in Macedonia

The Chronic Illness Advocacy & Awareness Group, Inc. (CIAAG) is a national non-profit organization that promotes both a common-sense, compassionate and research-based approach to palliative care along with the responsible prescribing of opioid medication to those experiencing chronic pain and illnesses, including: serious injuries, intractable pain, and those who suffer from painful chronic diseases.

CIAAG’s mission is to work collaboratively with legislators in crafting the policy changes and legislation enacted to combat opioid abuse (including heroin and illegallyobtained fentanyl) in a way that does not restrict patients’ access to their medication. Restricting access is not just a problem for the individual; it negatively impacts the nation’s public and economic health, resulting in previously functioning members of society being forced into unemployment and disability in response to the relentless, inhumane and debilitating pain they experience.

Intractable pain and forced isolation often leads to depression and other mental health crises as well. Unfortunately, some patients have turned to the street to find unsafe alternatives (including dangerous counterfeit pills) in a desperate effort to relieve their untreated pain, while others have succumbed to suicide as a final escape.

CIAAG offers lawmakers and other decision-makers fact-based research on prescription opioid use from qualified physicians, as well as policy white papers, testimonials and other resources to aid in crafting sensible policies around opiate use.

Dossier: The Violation of a Nation

Women are estimated to account for one third of the 275 million people who use drugs globally. Women who use drugs are consistently reported to have less access to harm reduction services and to be at higher risk of HIV and hepatitis C infection than men who use drugs. Despite these reports, robust data on this subject is scarce, and research on drug use and related health issues rarely produces information about women.

The Global State of Harm Reduction 2018 identifies a number of key issues and themes reflected across the world that limit women’s access to harm reduction services, and highlights cases of good practice. This includes: A lack of gender-sensitive harm reduction services, stigma and discrimination and barriers to harm reduction for women in prison.

Harm reduction services worldwide remain overwhelmingly gender-blind or – more commonly – male-focused. This leaves women underserved and the specific issues they may face poorly understood. Around the world, women who use drugs face double stigma based on both their gender and their drug use. Entrenched patriarchal social norms in many contexts lead to women, and especially women who use drugs, being reluctant to access health care in general. Pregnant women and women with children experience even greater stigma: in some jurisdictions, drug use alone is grounds for the removal of children or prosecution for child abuse.

When women who use drugs are detained, access to harm reduction services is severely lacking. Worldwide, only 54 countries provide opioid substitution therapy in any prison, and only ten provide needle and syringe programmes in any prison. This is compounded by the even greater absence of services in women’s prisons: for example, in Canada, opioid substitution therapy is reportedly implemented to a lesser extent in women’s prisons.

We reccommend that harm reduction services work to provide women-only spaces or dedicated hours for the treatment of women, as well as, working to met the needs of women with children. Women who use drugs should be involved in service design to minimise the impact of stigma. Training health professionals and employing female outreach workers can also support this.

Women and harm reduction

By Bruce Walace, Flora Pagan and Bernadette Pauly

Drug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use.

A multiple case study design was used with the Consolidated Framework for Implementation (CFIR) informing the analysis. Three sites in a single city were included with each site constituting a case. In this paper, we focus on qualitative interviews with 15 staff and their perceptions of the implementation of the OPSs as well as provincial and local documents.

The legislative process to implement OPSs was unprecedented as it sanctioned supervised injection services as an extraordinary measure under a declared public health emergency. Innovative and inclusionary practices were possible within state-sanctioned OPSs, as the sites were government-directed yet community-developed, with PWUD centred in service design, implementation and delivery. OPSs lack permanency and may be limited to the duration of the public health emergency.

The rapid implementation of OPSs provides an international example of an alternative to lengthy and often onerous sanctioning processes for supervised consumption services (SCSs). Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned injection services with community-driven implementation. Such evidence questions the continued acceptability of governments’ restrictive sanctioning processes, which have limited expansion of SCSs internationally and the implementation of services that are not necessarily aligned with the needs of PWUD.

The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency

How is cannabis use controlled in the legal systems in the Nordic countries? How do the Nordic legal systems see cannabis as a drug, and how does this affect the cannabis user? The Nordic Welfare Centre´s new report Cannabis policy and legislation in the Nordic countries looks at the similarities and differences in legislation and the ways in which the law is enacted in legal practice, police work, and other arenas.

After alcohol, cannabis is the second most common intoxicant in the Nordics and cannabis use is increasing among young adults in most Nordic countries. It is therefore not insignificant how society views cannabis use: is it a social problem, a health problem, or a problem of law and order? The answer matters a great deal to the user. Increasing use will put pressure on the societal responses although the majority of cannabis users are not problem users in need of treatment.

The Nordic countries rely on a restrictive approach in their cannabis control. All countries, except for Denmark, are influenced by the vision of the drug-free society where the justice system is seen as the main actor in solving the drug problem. The majority of all cannabis crimes in the Nordic countries have to do with use and/or possession for personal use. The proportion has varied over the decades depending on enforcement priorities.