The dangers posed by COVID-19 to people detained and staff working in cramped, overcrowded conditions in prison were acknowledged in the earliest stages of the pandemic. High-level United Nations (UN) and government figures made statements highlighting the risk to life and health in prisons and, as Global Prison Trends 2021 describes, most countries implemented some form of emergency releases to reduce the prison population. As countries continue to navigate new waves of the pandemic, prisons remain hotbeds for virus transmission. Also, new offences for breaching COVID-19 regulations and the resumption of court processes have led to increases in prison numbers.

The challenges faced by prisons over the past year have been compounded by decades of inadequate funding and criminal justice reform. The pandemic has exposed the impact of overcrowding and underresourcing of prisons in the gravest of terms – through the loss of life. We mourn every death in prison, both people detained and staff, and encourage all actors to learn from the experience of the past year, as detailed in Global Prison Trends 2021, to ensure prison systems protect the human rights of those they hold.

Health crises and other emergencies are not unprecedented in prisons. This year’s Special Focus examines prisons in crises, and how authorities respond to health crises, natural hazards and extreme weather, or in fragile and conflict-affected settings. We look at how prisons and the people within them are affected, as well as the involvement of prison populations in times of such crises and consider what measures authorities can put in place for better preparedness and response.

Global Prison Trends 2021

New psychoactive substances (NPS) started to appear on the Lithuanian drug market in 2005. However, they have gained momentum only in the last few years. For comparison, in 2012 there were 62 cases of confiscation of NPS, while in 2016 there were 433, and in 2017, 441.14 The most commonly used NPS by people who have drug use experience in Lithuania are synthetic opioids and cannabinoids, whereas young people who use drugs occasionally tend to use synthetic cathinones, as well as dissociative hallucinogen NPS and classic hallucinogen NPS.

Drug policy laws in Lithuania were changed in 2017 with the aim to decrease drug supply and demand. However, different data (see Chapter 4) show that drug use is stable or, in some populations, increasing. Meanwhile, more people are being punished for minor drug offenses, and the State is investing in the persecution of people who use drugs, while treatment and harm reduction programs are suffering and struggling to survive. There is no sustainability of funding, and existing funding is not covering the entire need.

The project “New Psychoactive Substance Use in Kazakhstan, Kyrgyzstan, Georgia and Serbia” was undertaken to generate a more accurate picture of the use of new psychoactive substances (NPS) in Kazakhstan, Kyrgyzstan, Georgia, Serbia, and additionally in Estonia and Lithuania, to assess harm reduction and law enforcement responses to the emerging issues related to the use of NPS. In 2019, similar research was conducted in Belarus and Moldova. Results from this project will supplement scarce international data on the use of NPS in these countries, present a more accurate picture of their use, and provide information to national civil society organizations for political advocacy.

The present report provides research results from Lithuania. The study was conducted in partnership between the Eurasian Harm Reduction Association (EHRA) and the School of Law, Swansea University, and supported by the Global Challenges Research Fund. The Principal Investigator for the overall project was Dr. Rick Lines of the Swansea University School of Law, and the research methodology was reviewed and approved by the Ethical Review Committee at Swansea University. This report was prepared by the coordinator and researcher for this project, Eliza Kurcevič, Senior Program Officer at EHRA.

New psychoactive substance use in the Republic of Lithuania

The Biden-Harris Administration has an unprecedented mandate to advance equity, which it has identified as a key priority. The advancement of equity cannot be meaningfully achieved without bold action in the domain of drug policy, as recognized by the Office of National Drug Control Policy (ONDCP) by including racial equity among its priorities for the first year of the Biden-Harris Administration. For decades, current policy approaches to drug use and addiction have been amplifying inequities across racialized and economically marginalized Americans.

This is the direct result of an overreliance on the criminal justice system and supply-side enforcement (collectively described as drug prohibition) to control drug-related harms. This continues to be the status quo despite clear scientific evidence that this approach is ineffective. To address emerging and long-standing drug-related crises, the United States needs drug policies grounded in the best available scientific evidence. This is critical to addressing three interrelated issues: the opioid overdose epidemic, the disproportionate harms of the criminal justice among racialized Americans, and the potential opportunities presented by drug decriminalization and regulation.

Below, we outline five key drug policy issues that require immediate, bold, and evidence-grounded action. These are: 

 Removing obstacles to harm reduction for overdose and infectious disease prevention; 

 Increasing access to medication for opioid use disorder; 

 Elevating the use of discretion in drug law enforcement.

Redressing inequities in America’s drug policies: An evidence-grounded call for bold action

By Penelope Hill, Orsi Fehér & Jamie Bridge

Civil society, including addiction practitioners, have been actors in policy spaces since United Nations (UN) drug control debates began under the Leagues of Nations (Bruun, 1975). Since the early 1990s, prime responsibility for UN drug-related matters has been held by Viennabased institutions. Although initially experiencing limited space for engagement with UN institutions and Member States, opportunities for civil society to influence international drug policy have grown, with the recognition of the importance of collaboration with non-government organisations (NGOs) increasing across all major UN agencies and institutions managing drug-related matters.

International debates and decisions directly influence and shape on-the-ground practice in the field of addiction. Though national policies are generally made on the state-level, signatories of the drug control conventions are bound to follow their commitments to the treaties and have limited sovereignty in unilaterally regulating internationally scheduled substances. The narratives, power-dynamics and decisions on the highest levels trickle down to regional policy making, so it is very important to shift the debate from substances to people at the highest level, so drug policies can operate effectively on the national level.

Civil society engagement and attendance at CND sessions throughout the year is crucial, in order to bring “real world” issues and the voices of affected populations to the forefront of the UN debates. Addiction practitioners are critical in relaying information on evidencebased practice to these forums, to ensure that international drug policies follow scientific evidence and not preconceived ideologies, and to guarantee health-centred and rights-based approaches prevail in the global drug control framework.

International drug policy: The impact of civil society and opportunities for addiction professionals to engage

At its 47th meeting, the UNAIDS Programme Coordinating Board (PCB) adopted a new strategy to end the AIDS epidemic as a public health threat by 2030. The PCB is made of 22 Member States, elected from among the Member States of the Cosponsoring Organizations. Five non-governmental organizations, three from developing countries and two from developed or transitioning countries, are also invited to participate in meetings of the PCB but without the right to take part in the formal decision-making process and without the right to vote.

The UNAIDS 2016–2021 Strategy is one of the first in the United Nations system to be aligned with the Sustainable Development Goals, which sets the framework for global development policy over the next 15 years. The new global AIDS strategy will serve as a road map for the whole world, guiding key stakeholders to ensure effective country-led AIDS responses.

The strategy was developed through a datadriven and consultative process involving the UNAIDS staff, the Cosponsors, civil society, people living with HIV and key populations, young people, faith institutions, ministers of health, finance, and gender and parliamentarians, scientists, donors, and the private sector.

Briefing Note: Global AIDS Strategy 2021 - 2026

For too long public attitudes, political debate and government policy in Scotland failed to take full account of the real drivers of problem drug use. A drug problem is neither a lifestyle choice nor a personal failing; drug problems originate in a lack of support to parents, families and vulnerable young people; the failure of health and other services to engage people in need of support and in Scotland’s social, income and health inequalities that result from poverty.

Recently, a consensus has emerged that begins to recognise all this and address problem drug use and the harms caused by drug use as a public health issue.

Scotland needs a new drugs strategy that reflects this reality. Scotland’s new drugs strategy should provide a full response to our drug overdose deaths public health crisis, improve the overall quality of life of people with a drug problem and prevent problem drug use by supporting vulnerable young people and their families. This strategy needs to articulate with government poverty, equalities and other strategies.

Drugs: Policy and Aims - A Manifesto for Scotland

The global drug market is expanding and becoming more complex. Globally, opium production and cocaine manufacture remain at record levels (despite declines observed in some regions), with synthetic opioids and their analogues (for example fentanyl, Tramadol) continuing to pose a serious threat to health (UNODC Global Drug Report, 2019; 2020). Heroin continues to reach the market despite declining opium production in 2018 in Afghanistan and record levels of seizures (UNODC Global Drug Report, 2019; 2020). Methamphetamine use and related harms are of rising concern across several regions (South East Asia, North America). There has been observed diversification of cannabis products (with increased potency) consumed in some jurisdictions that permit the non-medical use of cannabis.

IDU continues to represent a key global public health issue of importance due to the associated elevated risks of drug overdose, dependence, and BBV transmission (Degenhardt et al., 2016; Larney et al., 2020; Hines et al, 2020). An estimated 15.6 million people aged 15–64 years inject drugs (Degenhardt et al., 2017). Untreated chronic HCV and opioid use disorders are responsible for most of the deaths and disability attributed to the use of drugs (UNODC Global Drug Report, 2019). Of those injecting drugs, some 1.4 million live with HIV and 5.6 million live with HCV. Patterns of HIV infection among PWID also have wide regional variations (UNODC Global Drugs Report, 2019). In 2017, 40.5 million people were dependent on opioids and 109 500 people died from opioid overdose (Degenhardt et al., 2019).

Harm reduction approaches are underpinned by the principles of pragmatism and public health, alongside dignity and human rights and focus on reducing the health, social, and economic harms associated with drug use (Harm Reduction International, 2019; Sander et al., 2019). The provision of harm reduction both in community and in prison is widely recognized as a legally binding human rights obligation (Puras, 2015).

We report here on the 2020 assessment of situation and response of drug use and its harms in the MENA region for MENAHRA. These countries are diverse in terms of geography, population size and demographics, characteristics of key populations, nature and extent of the BBV problem, and scale of harm reduction implementation. They included Afghanistan, Algeria, Bahrain, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, UAE and Yemen.

Assessment of situation and response of drug use and its harms in the Middle East and North Africa

Universal Periodic Review of Belgium (38th UPR session, May 2021) - Recommendations related to health and people who use drugs

1. Adopt a public health approach to drug use and drug addiction, and decriminalize people who use drugs:

The Belgian law on the trafficking of poisonous, soporific, narcotic, psychotropic, disinfectant or antiseptic substances provides for prison terms of three months to five years and fines of one thousand to one hundred thousand euros. While this law does not punish consumption 

, drug users are nonetheless targeted through the criminalization of drug possession for personal use.

This law dates back to February 24, 1921, and urgently requires an in-depth revision. Despite a century of prohibition, the prevalence of drug use in Belgium has only increased (more than twofold in the last 20 years), as has drug trafficking. The differentiated enforcement of this law, based on ethnic and social profiling, has also given rise to serious inequalities and injustice. But the biggest failure of criminalization lies in its inability to provide an adequate response in terms of public health, protection and empowerment of people who use drugs, and support to those with addictions and other use problems related to illegal drugs. It is therefore urgent to take into account the positive public health outcomes witnessed elsewhere as a result of the decriminalization of users.

Countries that have decriminalized use and possession for personal use for at least some drugs include Argentina, Colombia, Costa Rica, Czechia, Germany, the Netherlands, Ghana, Italy, Portugal, Spain, South Africa, Switzerland, Uruguay.

The recommendation to decriminalize drug use and ancillary activities has already been made by a plethora of international human rights bodies, including the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, the United Nations Committee on Economic, Social and Cultural Rights, as well as the guidelines for action set out in the UN System Common Position on drug matters (2018). A recent analysis of over 100 peer-reviewed studies showed criminalization has a negative effect on access to HIV prevention and treatment.

 Amend the Law of February 24, 1921 in order to adopt a public health approach to drug use and drug addiction, including through the decriminalization of drug possession for personal use.

2. Provide legal certainty to drug consumption rooms

Drug consumption rooms (DCRs) are spaces in which illegal drugs can be used under the supervision of trained staff, with the aim of reducing the risks of disease transmission through unhygienic injecting, preventing drug-related overdose deaths, and connecting high-risk drug users with addiction treatment and other health and social services. In 2018, a total of 78 DCRs operated across seven countries in the EU alone (including Denmark, France, Germany, Luxembourg, the Netherlands, Spain), as well as in other countries such as Canada, Switzerland and Australia. As shown by the EU agency on drugs and drug addiction, there is a substantial body of evidence showing their effectiveness in reducing high-risk injecting behavior. The UN Special Rapporteur on the right to health has also encouraged the establishment of DCRs.

A DCR reopened in Liège in 2018, and others are planned in Brussels and Charleroi. However, the law of February 24, 1921, which had been adopted, among other reasons, to ban opium dens, formally prohibits "providing a premise" to facilitate the consumption of a controlled substance. While city and regional authorities support and subsidize these projects, DCRs 

remain in violation of the law, and exist in great legal uncertainty.

 Amend the law of February 24, 1921 in order to provide legal certainty to health interventions such as drug consumption rooms (DCRs).

Health and people who use drugs: Recommendations for the UPR of Belgium

From the early days of cannabis prohibition, traditional producing countries have stressed the importance of finding alternative livelihoods for rural communities dependent on cannabis cultivation. The first crop-substitution projects in the 1960s in Lebanon and Morocco were the genesis of continuing UN debate on ‘alternative development’ and ‘shared responsibility’. Growing demand for cannabis in the North and crashing prices of agricultural commodities like coffee, cocoa and banana due to free trade policies, turned the ever-expanding illegal cannabis market into a survival economy for millions of people. Almost no-where have small cannabis farmers been offered substantial development assistance for moving out of the illegal market.

The recent wave of policy changes and fast-growing legal spaces in the medical cannabis market offer new opportunities for small farmers to transition out of illegality while continuing to grow cannabis. Several traditional producing countries have started to explore this option of ‘alternative development with cannabis’. Barriers to entry, however, are not easy to overcome and few small farmers have been able thus far to conquer some space in the billion-dollar medical cannabis market. The emerging legal markets are increasingly captured by big corporations, pushing out small farmers from the South. This report argues that lessening the barriers for small farmers while raising them for large companies can help to steer legal cannabis markets in a more sustainable and equitable direction based on principles of community empowerment, social justice, fair(er) trade and sustainable development.

A sustainable future for cannabis farmers ‘alternative development’ opportunities in the legal cannabis market

Billions of dollars have been spent on the ‘War on Drugs’. People who use and inject drugs have been criminalised, harassed and pushed to the fringes of society. However, the number of people using drugs has not decreased; and nor have drug-related harms. Of the estimated 11.3 million people who inject drugs worldwide, 12.6 % are thought to be living with HIV. Only countries that adopt a balanced approach of decriminalisation and harm reduction have seen steep declines in blood borne infections associated with drug use and in other harms, such as overdose deaths.

Most people who use drugs live in the shadows of society, reluctant to seek services. The threat of punishment pushes them underground. We back innovative and flexible community-based approaches, built around an understanding of the wishes, fears and needs of people who use and inject drugs.

COVID-19 has brought significant challenges for everyone, but marginalised groups have been especially hard hit. The barriers to health and wellbeing faced by people who use drugs have been exacerbated by this pandemic and the measures to mitigate it. This has not stopped our partners; they have shown their adaptability and found innovative ways to continue delivering services and support.

In many countries, drugs are harder to come by during COVID-19 lockdowns. More and more people have experienced sudden withdrawal as a result, but providers of OAT and other harm reduction services have been reluctant to take on new clients, and in some instances these services have been cut back or stopped altogether while resources are diverted to COVID-19.

Harm reduction in action

In 2018, at a time of much debate about drug law reform and growing global interest in decriminalisation, INPUD published a ground-breaking analysis of the Portuguese decriminalisation model – Is Decriminalisation Enough? Drug User Community Voices from Portugal. For the first time, this landmark report sought to assess the impact of decriminalisation in Portugal from the perspectives of those most affected by the reforms – people who use drugs. The report noted that:

The lived experiences, perspectives, and rights of the drug-using community are equally important, and these considerations are rarely taken into account in assessing the outcomes of decriminalisation […]. Interactions with the state and the police, and issues of violence, social exclusion, stigmatisation, and discrimination, are often entirely omitted from discussion and analysis of decriminalisation.

Over the past decade there have been increasing claims that we are moving towards a critical turning point in international drug policy. This is based on a growing recognition that the so-called war on drugs is futile and that it is time for governments to consider alternative approaches including decriminalisation. More recently, this shift has come to be celebrated as a virtual ‘new dawn’ of drug policy reform liberalisation, especially in the face of mounting evidence of the failures of repressive drug policies where countries are finally said to be rethinking their approaches to addressing drug use in society. In the case of Portugal this has involved a shift from viewing people who use drugs as criminals to treating them as patients.

This shift away from criminalising responses and towards more public health-oriented approaches is said to be a sign of progress. But one might rightly question the extent to which a shift from criminalising people to pathologising them as patients can really be classified as progress. In this context, INPUD believes there are some important and much overlooked questions that need to be asked about this socalled progress in relation to decriminalisation. For example, how is progress being defined and measured? Whose interests are being served by current definitions of progress associated with decriminalisation? Has there really been progress and has it gone far enough? These questions also raise issues about how these said changes have been experienced by people who use drugs, and the extent to which the needs and rights of people who use drugs are being foregrounded in countries that are said to have decriminalised drug use.

Drug decriminalisation: Progress or political red herring?

By Villu Kangur, for the Eurasian Harm Reduction Association (EHRA) and the School of Law, Swansea University.

The Republic of Estonia is a country on the eastern coast of the Baltic Sea in Northern Europe. It is bordered to the north by Finland across the Gulf of Finland, to the west by Sweden across the Baltic Sea, to the south by Latvia, and to the east by Lake Peipus and Russia. With a population of 1.3 million people, Estonia is one of the least populous members of the European Union.

According to the general population study on drug use in Estonia4 in 2018, 25% of people aged 16–64 have tried an illegal substance at least once during their lifetime, 7% within the last year, and 3% within the last month. Cannabis was the most commonly used drug, with 24% of the population having tried cannabis during their lifetime. In addition, the use of stimulants (e.g. amphetamine, ecstasy, and cocaine) was reported more frequently than that of other narcotic substances (amphetamine 6%, ecstasy 5%, and cocaine 5% lifetime use). While drug use, including cannabis use, was more common among people under the age of 35, more frequently among men, there was no difference between men and women in the youngest age group (16–24 years).

Estonia has a high prevalence of people who inject drugs (PWID), of whom about half are living with human immunodeficiency virus (HIV). According to a study done between 2010 and 2015, there are an estimated 6,000 to 17,300 PWID. In 2015 the prevalence of PWID was estimated to be 8,600. Among key populations, the prevalence of HIV is 54% among PWID, 13% among prison inmates, 4% among men who have sex with men (MSM), and 13% among sex workers (SWs).

Opioid substitution treatment (OST) with methadone has been available in Estonia since 1999. Currently OST is being offered in nine different institutions across the country (excluding prisons and detention centers, where methadone treatment is also available). In 2018 there were 1,052 registered patients who received OST. OST coverage remains low (under 20%).

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