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%).

New psychoactive substance use in the Republic of Estonia

A previous version of this paper is available here.

By Jamie Bridge (IDPC), Christopher Hallam (IDPC), Marie Nougier (IDPC), Miguel Herrero Cangas (IDPC), Martin Jelsma (TNI), Tom Blickman (TNI), David Bewley-Taylor (GDPO) & Daisy Bowdery (IDPC)

Diplomatic processes at the United Nations (UN) are notoriously slow and difficult, perhaps increasingly so in a modern world of multi-polar geopolitics and tensions. This is certainly no different for the highly charged issue of international drug control. After the UN General Assembly Special Session (UNGASS) on the ‘world drug problem’ in New York in April 2016 – many stakeholders had come away with mixed feelings at best. Despite acknowledgements of the progress made in certain areas of the debate, and the rich content of some of the country and civil society statements, the UNGASS failed to deliver the ‘wide-ranging and open debate that considers all options’ that had been called for by the UN Secretary-General at the time, Ban Ki-Moon.

Three years later, member states met again – this time in Vienna – at a Ministerial Segment aimed to evaluate progress made since the adoption of the 2009 ‘Political Declaration and Plan of Action on international cooperation towards an integrated and balanced strategy to counter the world drug problem’, and to pave the way for the next decade of drug policy. The event resulted in a Ministerial Declaration that looked back at ongoing challenges, and proposed actions for the way forward.

In order to help digest and contextualise the UNGASS Outcome Document and the 2019 Ministerial Declaration, it is useful to take a broader look at how the agreed UN language on drug control has evolved and developed over the last quarter of a century. To this end, this paper explores a selection of key themes by analysing the consensus based language agreed by UN member states in:

The ‘1990 Political Declaration and Global Programme of Action on international cooperation against illicit production, supply, demand, trafficking and distribution of narcotic drugs and psychotropic substances’ – agreed at the first UNGASS on the topic of ‘drug abuse’.

The 1993 General Assembly resolution entitled ‘Measures to strengthen international cooperation against the illicit production, sale, demand, traffic and distribution of narcotic drugs and psychotropic substances and related activities’ – agreed at a high-level meeting of the General Assembly as a follow-up to the 1990 Political Declaration.

The 1998 Political Declaration – agreed at the 20th UNGASS on the ‘world drug problem’ – and the accompanying ‘Declaration on the Guiding Principles on Demand Reduction’. •

The ‘2003 Joint Ministerial Statement and further measures to implement the action plans emanating from the twentieth special session of the General Assembly’ – agreed at the 46th UN Commission on Narcotic Drugs (CND) after a mid-term review of the 1998 Political Declaration.

The ‘2009 Political Declaration and Plan of Action on international cooperation towards an integrated and balanced strategy to counter the world drug problem’ – agreed at the highlevel segment of the 52nd CND.

The ‘2014 Joint Ministerial Statement on the implementation by member states of the political declaration and plan of action on international cooperation towards an integrated and balanced strategy to counter the world drug problem’ – agreed at the 57th CND after a mid-term review of the 2009 Political Declaration.

The 2016 Outcome Document (UN General Assembly Resolution S30/1) entitled ‘Our joint commitment to effectively addressing and countering the world drug problem’ – agreed at the 30th UNGASS last April.

The 2019 ‘Ministerial Declaration on strengthening actions at the national, regional and international levels to accelerate the implementation of joint commitments to address and counter the world drug problem’.

Edging forward: How the UN’s language on drugs has advanced since 1990 (Version 2)

A civil society-led monitoring of harm reduction can play an essential role in improving service delivery and contribute to the generation of crucial data for advocacy purposes. Civil society organisations (CSO’s) work directly for, and with, people who use drugs (PWUD) and have a good understanding of their daily needs. Their inside knowledge is critical in developing adequate drug policies and practices.

To complement the work of other monitoring agencies, and to bring insight into how the implementation of harm reduction occurs, Correlation -European Harm Reduction Network (C-EHRN) has published a report on Civil Society Monitoring of Harm Reduction in Europe since 2019. It gathers data on the experiences of harm reduction service providers and service users at ground level, building on a network of national Focal Points (FPs) in Europe. For the 2020 monitoring, C-EHRN includes 35 FPs in 34 countries, as shown in the map below. To get insight at the implementation level, and to profit from the experiences and expertise of FPs, the 2020 monitoring focuses mostly on cities rather than countries.

Civil society monitoring of harm reduction in Europe, 2020

Internationally, there is a growing understanding and acceptance that policy approaches to personal drug use which rely on the punishment of the individual cause avoidable harms and need to change. A number of evidence-based policy options are available that offer opportunities to improve outcomes for public health and reduce drug-related harm to people who use drugs and their communities, and thereby contribute to reducing social iniquities. One of these policy options is the decriminalisation of drug offences related to personal use (hereinafter, ‘decriminalisation’). Across the globe, a number of jurisdictions have implemented some form of decriminalisation. There is equally a lot of work focused on bringing about progressive change in this policy space ongoing around the world.

The Ana Liffey Drug Project (ALDP), supported by the Global Drug Policy Program of the Open Society Foundations (OSF), invited some advocates for decriminalisation from around Europe to join a two-day meeting in February 2020. The meeting took place in Dunboyne, Ireland, and brought together delegates to share their experiences in advocating for decriminalisation in their own countries and to benefit from the insights of others.

This paper provides some key insights from this event, and from conversations which followed it, with largely the same group of advocates. At its core, this paper has a peer-to-peer focus. The target audience is primarily people who are advocating for decriminalisation in their own jurisdictions, or who are considering doing so. Public health, community safety and criminal justice stakeholders more generally may also find it of interest. The aim is to provide insights from ‘in the field’, sharing the views and experiences of people actively working on advocacy projects related to decriminalisation. It does not purport to be a full or academic treatment of the issue – rather, it is intended to provide insights that can help advocates frame and focus their work.

Decriminalisation Insights for Advocates

Key populations and their sexual partners have higher HIV prevalence than the general population and 62% of global new HIV infections are amongst this group. UN agencies including UNAIDS, WHO, UNODC, UNDP, as well as the Global Fund, PEPFAR, bilateral donors and private foundations, such as the Bill and Melinda Gates Foundation recognize that effective and evidence-based HIV response must focus on key populations who are most vulnerable to HIV transmission. For example, in Pakistan, there is an estimated 37,173 – 111,330 number of people who inject drugs, with a HIV prevalence rate of 38.4%, a mere 4.3% of which are virally suppressed, and low HIV prevention coverage of 29%. In Ukraine, there are an estimated 319,500 people who inject drugs with a 19.1% - 22.6% HIV prevalence rate. In Nigeria, the number of people who inject drugs is estimated at 80,000, with 9.2% HIV prevalence rate.

People who use drugs are a population group disproportionately vulnerable to HIV and AIDS, and are often left out of HIV prevention and treatment services. Criminalisation, stigma and discrimination, including within health care settings, are some of the main barriers they face when accessing services. Accordingly, decriminalisation should be a core component of public health and HIV prevention responses. Moreover, policy makers often make political and moral judgements about who to prioritise in programmes. People who use drugs bear the brunt of these types of decision-making.

Imprisonment, arbitrary detention and compulsory forced rehabilitation is a reality for many people who inject drugs. UNAIDS estimates that 56-90% of people who inject drugs will be incarcerated at some stage during their life. Therefore, it is essential to promote harm reduction and provide services in closed settings as well as in the community.

Harm reduction interventions are evidence-based and have a proven record of effectiveness and cost-effectiveness in the fight against HIV. Additional benefits include a reduction in criminal activity related to the need to access drugs, and individual, family and community social and health benefits. The unit costs of harm reduction interventions are relatively low, making it good value for money at $100 - $1000 per HIV infection averted.

From Invisibility to Influence: The evolution of participation of people who use drugs in the Global Fund

Gender-based violence (GBV) is caused by systemic gender inequalities and encompasses all acts of physical, emotional, sexual and psychological violence perpetuated against a person due to their gender (UNHCR, 2020). It is estimated that 35% of women worldwide have experienced some form of physical and/or sexual violence by an intimate partner, or sexual violence perpetrated by a non-partner (WHO, 2013a). Prevalence is estimated to be higher in sub-Saharan Africa (Pack, L’Engle, Mwarogo, & Kingola, 2014).

Although a number of studies have investigated GBV, including both intimate and nonintimate partner violence in the general population and among sex workers, relatively few studies have investigated the experience of GBV among women who use drugs (WWUD). Data on the prevalence of GBV and its underlying factors among this vulnerable group therefore remains relatively sparse and anecdotal. Considering literature that has found links between intimate partner violence, substance use, sexual decision making and HIV/AIDS, there is a gap in evidence on vulnerable populations especially WWUD in sub-Saharan Africa. This study therefore seeks to explore the lived experiences of WWUD and their children in Kenya, in relation to different types of GBV; and structures that perpetuate GBV among this population.

Physical abuse intersected with psychological control and included demands to stay indoors, violence, humiliation e.g. tearing of clothes or destroying WWUD’s personal and other effects sometimes in front of a victim’s family or their children. The reasons ranged from stealing partner’s money or drugs, suspicion of unfaithfulness, stealing from clients, partner’s frustration at WWUD for not earning money from sex work, refusing partner selling household goods, and rejection of partner’s forceful demands for sex.

Physical abuse was aimed at ensuring control and dependence of partners. Psychological abuse took many forms including family isolation and feelings of diminished worth, and was normalised by WWUD. Children of WWUD also suffered psychological abuse through separation from their mothers and direct verbal abuse from others.

Understanding experiences of gender-based violence among women who use drugs (WWUD)

The former communist countries of Eastern Europe and Central Asia (EECA) are transition economies, attempting to manage rising healthcare costs whilst reforming their health systems. EECA is one of the few regions in the world where the incidence of Human Immunodeficiency Virus (HIV) is going up. Because of competing needs, public health interventions for HIV have been low on policymakers priority lists, with the allocation of domestic funds to scaling-up HIV prevention programmes falling short of demand.

Criminalisation of drug use and incarceration for drug-related offences are one of the main influences behind an increase in prison populations in EECA countries. Arresting and putting people who inject drugs (PWID) in prison is both expensive and associated with an increase in HIV infections. The funds allocated to incarcerating PWID massively outweigh those spent on prevention and treatment for this group. The stigma associated with drug use in EECA further hinders the expansion of HIV prevention programmes within mainstream public health.

In parts of Western Europe, evidenceinformed, properly scaled up, community-led harm reduction services exist, where criminal sanctions for individual use and possession of drugs are removed and human rights are respected.9 Such harm reduction approaches have helped decrease problems with drug use, reduce overcrowding in prisons and dramatically reduce the incidence of HIV in PWID.9 The case for addressing punitive criminalisation strategies and stigma associated with HIV in PWID in EECA is clear, yet progress towards decriminalisation remains slow.

This Economist Intelligence Unit (EIU) report aims to capture the attention of policy-makers in four study countries in the EECA region; Belarus, Kazakhstan, Kyrgyzstan and Russia to make the case for the cost effectiveness and health gains achieved when the criminalisation of drug use is reduced, harm reduction is scaled up and stigma and discrimination towards PWID and other vulnerable populations is reduced.

Drug control policies in Eastern Europe and Central Asia - The economic, health and social impact

By Jerome Evanno / Paroles Autour de la Santé (PAS)

Between 4000/6000 “problematic / precarious” drugs users (DU's), frequent at least a hundred open consumption scene (in Monrovia). There are between 10 to 20% of women, the average age is 32/36 years and it has been noted the presence of children. The main illegal drug consumed remains cannabis. However, we were able to observe and confirm a significant consumption of cocaine in the form of crack, heroin (white) smoked with aluminum foil (the most common way of use is smoking), and non-prescription drugs (tramadol, valium, diazepam, etc.). At first, it was easy to see that in Liberia, and more particularly the capital Monrovia, that interventions related to the use and abuse of drugs (from a global health point of view), will require a multisectoral and holistic approach. The analysis of the data collected revealed a strong will on the part of all stakeholders to reform the current law « obsolete and very repressive » and strong expectations and needs on the part of the DU's.

Regarding the recommendations, they have been classified into 5 parts. Firstly, addictology, it will be more precise to reflect on the implementation of a « national rehab center », a « therapeutic community », « capacity building » of medical staff (more specifically for health staff and prescribers), « promote the prescription of methadone and OST », and « create self-support groups and / or support groups ». Then, for the aspects of Harm Reduction, it's recommended to carry out a « community and participatory diagnosis » of the needs and assessments of the DUs, to create « adapted tools », « self-support groups » and to promote « socio-economic reintegration activities ». It will also promote the activities and the Harm Reduction approach during the next funding requests and more particularly with the Global Fund (GF) and PEPFAR.

Regarding health care, we must support and validate the relevance of the implementation of « specific services », « TB / HIV adapted services », « food activities », « mobile health care service » and give « primary medication » without forgeting the mental health approach. Regarding drug policy, the organization of a « symposium for NGO » (position paper, recommendations, etc.), « promote the West African drug model law », support a « technical group » and drug policies / advocacy / lawyers team, a better knowledge of the current law, purpose of « alternatives of incarceration », and fostering participation and « regional / international technical/High level/experts groups ». Finally, for the community approach, although transversal, it is recommended to strengthen them in capacities and promote empowerment and support the implementation of the first community based organization.

Community and contextual analysis on drug use and drugs policies in Liberia

By Alexander Söderholm, PhD Candidate at the London School of Economics and Political Science

The disruption caused by the COVID19 pandemic has exposed the health inequities within our societies, and particularly in prisons. By February 2021, at least 504,000 people deprived of liberty had tested positive for COVID19 -approximately a 4.5% of the global prison population. This resulted in a minimum of 3,800 deaths, though this is likely to be an underestimate as many countries lack testing equipment within prisons. Across the world, our overcrowded prison systems have failed to protect the life and health of people deprived of liberty.

Through four case studies that focus on the response to the pandemic in Colombia, Indonesia, Ireland, and Kenya, this briefing, launched by IDPC together with Harm Reduction International, Penal Reform International, LBH Masyarakat, and Reprieve, draws several lessons from this still ongoing crisis.

At the outset of the pandemic, a number of countries committed to reduce the number of people in prison in order to prevent the spread of the virus. However, in many cases decongestion measures have arbitrarily excluded people detained for certain drug offences.

Many countries that implemented de­congestion measures simultaneously failed to halt the disproportionate imprison­ment of people for drug offences, thus undermining attempts to reduce prison overcrowding.

In most cases, states responded to the pandemic by isolating prisons from the community. As a result, people deprived of liberty have been unable to access the most basic legal, health, and drug services. In many countries, this also means that incarcerated people cannot receive the food, clothes, and money regularly provided by their families.

Before COVID19, there was already a dramatic lack of appropriate drug treatment and harm reduction services in prisons. Even were such ser­vices existed, incarcerated people have ex­perienced serious restrictions in accessing them during the pandemic.

Community integration programmes have failed to support people released from prison dur­ing the COVID-19 pandemic. Upon release, formerly incarcerated people have faced severe challenges, including exclusion from the formal economy, social stigma, and exploitation.

Prisons and COVID-19: Lessons from an ongoing crisis

In the same way that the COVID-19 pandemic has profoundly impacted all aspects of our lives, it is reasonable to expect that with lockdowns and global restrictions on movement, the drug market will also be impacted. The European Monitoring Centre for Drugs and Drug Addiction has stated that there is “a critical need to investigate the impact of these developments on drug markets in order to identify changes that may require an immediate policy or operational response… and to learn lessons about how we might better anticipate emerging threats in the future”.

The availability of controlled drugs - whether bought via online platforms or via face-to-face transactions - will likely be compromised by COVID-19, particularly where those drugs are transported across borders. In anticipation of possible drug shortages, some people who use drugs may ‘stockpile’ their drugs of choice; contributing further to potential shortages. Given a rapid shift to online purchasing of licit goods during the pandemic, we might expect a similar shift in respect to drug purchasing behaviour, with an increase in darknet purchasing.

Since the beginning of the first national coronavirus lockdown, Release has operated a public, online survey designed to monitor how people are buying their drugs. The purpose of this survey, which is open to anyone residing in the UK over the age of 18, is to determine the impact that the COVID-19 pandemic, and corresponding restrictions, have had on buying illegal substances. Release also set up a national ‘Drug Market Monitoring Network’, made up of people who use drugs, harm reduction and recovery activists, as well as people working on the frontline, who continue to regularly report on developments in their local drug markets during the pandemic.i Qualitative feedback from the Drug Market Monitoring Network will be used where appropriate to contextualise quantitative findings from the survey.

Publications from IDPC Members