By Professor Catriona Matheson, Lesley Bon, Louise Bowman, Katy MacLeod, Adrienne Hannah, Anthony Knox

Scottish Drugs Forum was awarded Scottish Government funding to conduct baseline research with particular at-risk populations and frontline services to identify specific risks in terms of drug use and sexual health, treatment needs, information needs and what workers need to know in order to support these populations effectively. This would inform the development of information and training resources and programmes, ensuring that the workforce and service providers working with the three target groups are fully trained and equipped to support service users with their sexual health, blood borne viruses and harm reduction needs. The at-risk populations were:

Men who have sex with men (MSM) involved in Chemsex,

People who use image and performance enhancing drugs (IPEDs),

People (men and women) involved in transactional sex who use drugs.

It is key that these different populations have their individual risk behaviours and information needs understood and addressed rather than applying universal prevention/harm reduction approaches used when addressing substance use issues. Equally it is important that services are fully equipped, skilled and confident when responding to these target groups and engaging them in prevention/harm reduction.

Chemsex has been a growing and emerging trend within the MSM population over the last 5-10 years. Chemsex involves the use of psychoactive drugs, commonly referred to as “chems”. Mephedrone, gamma hydroxybutyrate/gamma butyrolactone (GHB/GBL) and methamphetamine are the most commonly used substances (Bourne et al, 2014). Some of these men inject the drugs intravenously, which they refer to as ‘slamming’. Chems are often used during sexual activity to enhance pleasure and reduce inhibitions. This can result in increased risk taking around sex and drug use, including condomless sex, which can lead to higher rates of STIs and BBVs (Ottaway, Finnerty, Amlani et al., 2017; Page & Nelson, 2016). According to the Scottish Government BBV framework, young people and MSM are identified as being the highest at-risk groups for STI transmission and MSM and people who inject drugs have the highest risk of HIV in Scotland (Scottish Government, 2015).

Recent IPEDs research has identified that people who use IPEDs report a broad range of illicit and prescription drugs taken alongside IPEDs which present a variety of possible health risks and may impact on additional risk-taking behaviours. The uptake of BBV testing and vaccination by people who use IPEDs is reported as low, although reasons for this are unclear. (Begley et al, 2017) Previous research with people who use IPEDs found they relied on other IPED users for information about drugs, which was often inaccurate. They also often had their drugs injected by other IPED users (Santos & Coomber, 2017). Some risk behaviours have already been identified such as using small narrow bore needles that can break off in muscle tissue (Dunn et al, 2014). Furthermore, in the UK tensions have been identified between service providers and IPED users as a result of different perspectives of potential risk behaviours and interventions (Kimergard & McVeigh, 2014). In addition to injecting risk taking, in terms of sexual health, people who use IPEDs often report high rates of sexual activity but low levels of condom use which would suggest a significant risk factor for STIs and BBVs (Begley et al, 2017).

People involved in transactional sex who use drugs may experience a range of challenges including stigma, exploitation and trauma which have an impact on risk taking behaviours relating to drug use and sex. These challenges may affect engagement with support services. There is evidence globally that sexual health services may focus on MSM and the general population whilst vulnerable female groups such as those involved in transactional sex are under-provided for (Pinkham & Sepruch, 2008). There are known risks for people involved in transactional sex such as the transmission of sexually transmitted infections, risks associated with injecting drug use (BBV, injection injury, overdose etc), and violence (Spice, 2007). However it is surprising how little research has been conducted recently which is specific to the Scottish population and considers changes in drug use (e.g. new psychoactive substances) as well as the rise in drug related deaths in women (Tweed et al, 2018).

As part of the funding agreement SDF, working with an experienced health service researcher (CoI, CM), undertook research across Scotland with each of these groups, to inform the content of a training programme for staff working with these populations. Although these three groups are quite distinct the information being sought, and the purpose of seeking that information is the same. This report describes the data collection and findings of interviews with each target group as well as focus groups with service providers. It then identifies key issues for training and service development.

Understanding the sexual health and blood borne virus risk behaviours of defined 'at risk' groups to inform a service training programme

Prior reports in this series, on the situation in Moldova and Belarus, are available here.

The phenomenon of new psychoactive substances (NPS) started decades ago with the growth and production of drugs that replicate the effects of controlled drugs (such as amphetamines, cocaine, cannabis and heroin) but avoid legislative control based on different chemical structures.

In recent years, the increasing use of NPS has led to new threats for health of people who use drugs (PWUD) – including overdose, psychotic reactions, high HIV risks due to multiple injections and increased number of sexual contacts. However, in many countries service providers such as harm reduction, drug treatment programs and ambulance services are not prepared to provide PWUD with quality support and counselling to reduce risks of NPS.

In the Central and Eastern Europe and Central Asia (CEECA) region the situation with NPS is truly alarming and has become one of the major challenges for the national public health systems, local NGOs, communities PWUD.

EHRA in partnership with School of Law, Swansea University undertook the project “New Psychoactive Substance Use in Moldova, Belarus, Kazakhstan, Kyrgyzstan, Georgia, and Serbia” to generate a more accurate picture of the use of new psychoactive substances (NPS) and to assess harm reduction and law enforcement responses to the emerging issues related to use of NPS. 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 (CSOs) for political advocacy.

New psychoactive substance use in Georgia, Kazakhstan, Kyrgyzstan and Serbia

In their Global State of Harm Reduction: 2019 updates, HRI note that the spread of harm reduction services is still stalling globally in continuation of a trend observed since 2012. The 2018 Global State of Harm Reduction 2018 briefing, highlights that although women are estimated to account for one third people who use drugs globally and are consistently reported to have less access to harm reduction services and to be at higher risk of HIV and hepatitis C infection, robust data on this subject is scarce, and research on drug use and related health issues rarely produces information about women. While tools exist to enable harm reduction services to institute a gender lens and gender mainstreaming in their programming in order to improve relevance and reach to women who use drugs, services that have introduced such approaches are thin on the ground. Where they do exist, there is not necessarily scope to document and promote experience. In order to leverage greater accountability from governments that have endorsed UN guidelines and resolutions around provision of services for women who use drugs, it is important to document and promote such services where they do exist, so that models of replication can be resourced and established at other harm reduction programmes, while pressure builds to reverse the stalling of actions that improve respectful access to health for women who use drugs. With this in mind, WHRIN undertook a survey, in order to attempt a ‘mapping’ of women friendly services around the world.

Regional focal points identified among membership worked with WHRIN coordinator to create survey participant lists targeting two well networked women who use drugs and two additional key informants (KI) with a good understanding of harm reduction services in their country. Per country (or state/province in Canada, US and Australia). Separate short survey monkeys were created per region, applying the same 7 questions aimed to identify key barriers to service access and to ‘map’ harm reduction services designed for women who use drugs.

In total, 15 people responded to the survey, and were either women who use drugs (WUD) or other key informants. Participants were based in the following countries; Greece, Netherlands, Italy, Spain, Sweden, England, Portugal, Germany. The majority of the respondents (80%) identified as WUD.

Mapping harm reduction services for women who use drugs: Western Europe region

By Vicki J. Hanson, Pien Metaal and Dania Putri

Following its first-ever critical review of cannabis, in January 2019 the World Health Organization (WHO) issued a collection of formal recommendations to reschedule cannabis and cannabis-related substances. 53 member states of the Commission on Narcotic Drugs (CND), two of which are Caribbean states, are set to vote on these recommendations in December 2020.

Among the WHO’s recommendations, two in particular appear to be the most urgent and relevant for Caribbean countries: namely recommendation 5.1 (concerning the acknowledgment of cannabis’ medicinal usefulness) and recommendation 5.4 (concerning the need to remove the term ‘extracts and tinctures of cannabis’ from the 1961 Convention). Supporting these two recommendations presents an opportunity for Caribbean governments and civil society to decolonise drug control approaches in the region, as well as to strengthen the international legal basis for emerging medicinal cannabis programmes in several Caribbean countries. Also, it provides the historical opportunity to gain global recognition for two deeply rooted and unique traditions: the use of cannabis as sacrament in religious Rastafarian practise, and its use as traditional medicine, particularly but not exclusively by the Maroon community.

In this regard, the recommended principle ‘asks’ for Caribbean advocates and policy makers are to:

Support the most urgent recommendations 5.1 and 5.4.

Actively engage with CND members, in particular Jamaica, the only English-speaking Caribbean member of CND, emphasising the urgent nature of recommendations 5.1 and 5.4.

Actively engage in relevant meetings and processes at the CND level, as well as emphasising the need for further follow-ups to the critical review.

Actively engage and encourage support from other Caribbean governments and other key stakeholders such as CARICOM and OECS, as well relevant civil society organisations, experts, and affected communities.

WHO cannabis rescheduling and its relevance for the Caribbean

2019 was a big year for drug policy globally, and especially in Africa. It marked the expiration of the targets set out in the 2009 United Nations (UN) Political Declaration and Plan of Action to ‘eliminate or reduce significantly and measurably’ illicit drug cultivation, trafficking, consumption and money laundering. Yet, as the world’s governments gathered for a High-Level Ministerial Segment of the UN Commission on Narcotic Drugs (CND) in March 2019, it was abundantly clear that these targets had been missed by a staggering margin. This briefing paper aims to outline the ways in which African non-governmental organisations (NGOs) can build on recent developments to enhance their drug policy advocacy work at the international, regional and national levels.

Held only three years after the 2016 UN General Assembly Special Session (UNGASS) on drugs, the UN High Level Ministerial Segment was a critical moment for member states to define the next decade of UN drug policy. Consensus was eventually reached in the form of the 2019 Ministerial Declaration on Strengthening our actions and the national, regional and international levels to accelerate the implementation of our joint commitments to address and counter the world drug problem. A new 10-year timeline running until 2029 was also agreed, with a midterm review scheduled for 2024. At the same time, the Chief Executives of all 31 UN agencies have signed on to a progressive Common position supporting the implementation of the international drug control policy through effective inter-agency collaboration’ – which provides strong commitment to balanced drug policies based on health, human rights and sustainable development.

The last few years have been significant for African drug policies as well. In 2019, a new African Union (AU) Plan of Action and Implementation Matrix on drugs was adopted at the AU Third Specialised Technical Committee on Health, Population and Drug Control (STC-HPDC-3) in Cairo, Egypt. This meeting was well attended by African civil society. For the first time, the words ‘harm reduction’ were explicitly included alongside ‘alternatives to punishment’, civil society engagement, the review of national drug laws, and many other welcome elements (the Plan even includes support for ‘local production of controlled substances and plants for scientific and medical use, in line with the international drug conventions’). The AU continues to demonstrate strong commitment to addressing the drug situation in the region by facilitating the availability of a wide range of evidence-based harm reduction and treatment options.

Elsewhere in Africa, numerous developments have been documented: moves towards the decriminalisation of cannabis for private use in countries such as South Africa; the start of harm reduction programmes in countries such as Nigeria and Mozambique; the tabling of new progressive drug laws and bills in countries such as Ghana; the introduction of programmes in Cote D’Ivoire and Sierra Leone; and the scale-up of existing harm reduction programmes in Senegal – to name just a few.

Building on developments at the international and regional level, 2019 also resulted in the development of the African Civil Society Common Position on Drugs. The Common Position seeks to incorporate the perspectives and guide the work of a wide range of NGOs from across the African continent, and to support, shape and guide civil society and governmental responses over the coming years.

This briefing paper is aimed at civil society organisations and allies across Africa, and serves as a guide on international advocacy, regional advocacy and how to utilise these to advance national advocacy. The paper also proposes advocacy priorities and approaches for 2020 and beyond – divided into three sections for international, regional and national-level work. It is designed to complement the more detailed global advocacy note published by IDPC after the UN High Level Ministerial Segment itself.

‘2020 vision’: Advocating for drug policy reform in Africa

As of 2018, 37.9 million people globally were living with HIV. 74.9 million people had become infected with HIV since the start of the epidemic and 32 million people had died from AIDS-related illnesses. In 2018 alone, 770,000 people died from AIDS-related illnesses, while 1.7 million people became newly infected with HIV. Reductions in new infections are stalling and progress is significantly off track from the goal of only 500,000 people newly infected with HIV by 2020.

Civil society efforts have been critical to overcoming many of the major challenges in the AIDS response. Networks of people living with HIV and AIDS deliver life-changing services to those most affected and provide support for adherence to treatment, prevention and other essential health services.

The involvement of civil society has also been crucial in successfully advocating for sustainable financial resources, improving HIV and AIDS programming, and advancing human rights, as seen in countries such as Kenya, Ethiopia and Uganda, according to the International Centre for Notfor-Profit Law.

But these achievements are at risk. Globally, we are witnessing the harmful effects of rising populism and ultra-conservatism on civil society space, especially for organisations and networks led by stigmatised and marginalised communities.

The CIVICUS Monitor, a cutting-edge research tool developed within civil society, which provides reliable, current data on the state of civil society freedoms in all countries, shows a precipitous decline in civic space, with only three per cent of the world’s population living in countries with open civic space. As noted by the United Nations Office of the High Commissioner for Human Rights, civil society actors are facing opposition across the world, and the space for marginalised groups is increasingly shrinking.

Activism and AIDS: Protect civil society's space to end the epidemic

The DPA proposal for decriminalization, the Drug Policy Reform Act, takes these first steps in dismantling the punitive apparatus built up over the past 50 years. To begin refocusing federal drug policies, the legislation shifts the authority for classifying and regulating controlled substances from the Drug Enforcement Administration (DEA) to the National Institutes of Health (NIH) within the Department of Health and Human Services (HHS).

The legislation eliminates criminal penalties for all possession of personal-use quantities of controlled substances, and shifts federal resources away from futile enforcement strategies to supportive initiatives to protect the public health and safety.

Eliminates the inequitable and harsh sentencing constructs, such as mandatory minimums drug conspiracy offenses, that have significantly led to mass incarceration;

Provides for decarceration and expungement of records for those imprisoned under the current system;

Eliminates collateral consequences of drug convictions, including denial of public benefits and educational loans, for individuals who have been convicted of drug offenses; and,

Abolishes the enforcement agencies that have been primarily responsible for creating the harmful enforcement strategies of the past.

Dismantling the federal drug war: A comprehensive drug decriminalization framework

This assessment has been initiated by the Eurasian Harm Reduction Association (EHRA) to assess the progress in reaching sustainability of the opioid agonist therapy (OAT) programme in the Republic of Belarus in the context of transition from donor support to domestic funding. The sustainability assessment of the OAT programme in the Republic of Belarus in 2020 was implemented with the funding provided through the technical support mechanism (TSM) of the Joint United Nations Programme on HIV/AIDS (UNAIDS).

This assessment was carried out in Belarus in February – April 2020. It covers the current situation, progress made, risks and opportunities to ensure the sustainability of OAT programs in the Republic of Belarus, with a focus on programmatic aspects and a focus on the following three areas: politics and management, finance and resources, and services. The assessment includes a review section, analysis of progress, obstacles and opportunities in each of the areas, as well as general conclusions and recommendations for government ministries and departments, national coordinating bodies, practitioners, civil society, technical partners and donors. The evaluation also includes relevant recommendations on adaptation of the OAT programs in the context of the COVID-19 pandemic.

Аssessment of the sustainability of the opioid agonist therapy programme in the context of transition from donor support to domestic funding in Belarus

This assessment has been initiated by the Eurasian Harm Reduction Association (EHRA) to assess the progress in reaching sustainability of the opioid agonist therapy (OAT) programme in the Republic of Tajikistan in the context of transition from donor support to domestic funding. The sustainability assessment of the OAT programme in the Republic of Tajikistan in 2020 was implemented with the funding provided through the technical support mechanism (TSM) of the Joint United Nations Programme on HIV/AIDS (UNAIDS).

This assessment was carried out in Tajikistan in February – March 2020. It covers the current situation, progress made, risks and opportunities to ensure the sustainability of OAT programs in the Republic of Tajikistan, with a focus on programmatic aspects and a focus on the following three areas: politics and management, finance and resources, and services. The assessment includes a review section, analysis of progress, obstacles and opportunities in each of the areas, as well as general conclusions and recommendations for government ministries and departments, national coordinating bodies, practitioners, civil society, technical partners and donors. The evaluation also includes relevant recommendations on adaptation of the OAT programs in the context of the COVID-19 pandemic.

Аssessment of the sustainability of the opioid agonist therapy programme in the context of transition from donor support to domestic funding in Tajikistan

In Canada, people who use drugs are dying in record numbers. Between January 2016 and September 2019, more than 14,700 people died of apparent opioid overdoses in this country. In Ontario alone, more than 1450 people died from opioid-related causes in 2018. The overwhelming majority of these overdoses and deaths involve fentanyl or its analogues, a potent drug that is now present in many street drugs. Never before have we experienced an overdose crisis of this magnitude, which is only exacerbated by the criminalization of personal drug possession.

 (“the Good Samaritan law”) was passed as a partial response to this ongoing crisis. The law amended the 

 to give immunity from prosecution for the offence of simple possession of a controlled substance to anyone who calls 911 to report an overdose as well as to anyone who is on the scene when emergency services arrive.

In 2019, with the support of a research grant from the Law Foundation of Ontario, the Canadian HIV/AIDS Legal Network (HIV Legal Network) embarked upon a research study in Ontario to evaluate familiarity with the Good Samaritan law, and what people who have experience with drug use believe to be true about this law. In the midst of the ongoing overdose crisis in Ontario and across Canada, it is critical to understand people’s awareness of this law, how (or whether) they interact with it, and how they experience its real-world impacts.

The Good Samaritan Drug Overdose Act: The good, the bad and the ineffective

By CELS, Dejusticia, Equis: Justice for Women, the Institute for Judicial Investigations at the Autonomous University of Chiapas, IDPC, the Prison Ombudsman’s National Office in Argentina, Instituto Pro Bono & WOLA

COVID-19 has shed light on the need for governments across the Americas to take steps to address prison overcrowding, given the high risk of deadly outbreaks in places of detention where social distancing and other sanitary measures are difficult to achieve. In this context, some governments have promoted decarceration measures and alternatives to incarceration including house arrest—that is, court-ordered detention of a person in their place of residence—as a way to reduce overcrowding.

When implemented effectively, house arrest is meant to be a less restrictive form of confinement and to help those deprived of liberty reintegrate back into their communities and avoid landing back in prison. But as detailed in a new report, 

Imprisoned at Home: Women under House Arrest in Latin America

, imposing strict house arrest without guaranteeing fundamental human rights, particularly for people in low-income situations, can make house arrest just as punitive as incarceration.

House arrest should not simply replace one form of incarceration for another.

 Governments across the Americas should guarantee that people subjected to this measure have their rights protected. If you’re placed under house arrest but aren’t given the option to remain employed or seek emergency medical help when you need it, those are unacceptable conditions. 

Authorities must ensure that those under house arrest receive the support they need to provide for their families and reintegrate into their communities.

The study focuses on the impact of house arrest on women across the Americas, given that, over the past two decades, the population of women deprived of liberty in this region has grown exponentially and the vast majority of these women come from situations of poverty and social exclusion, lending greater urgency to the need for alternatives to incarceration with a special focus on women. The report is the result of a collaboration between human rights and advocacy groups including the Center for Legal and Social Studies (

, CELS), Dejusticia, Equis: Justice for Women, the Institute for Judicial Investigations at the Autonomous University of Chiapas (

Instituto de Investigaciones Jurídicas de la Universidad Autónoma de Chiapas

), the International Drug Policy Consortium (IDPC), the Prison Ombudsman’s National Office in Argentina, Instituto Pro Bono, and the Washington Office on Latin America (WOLA).

Testimony by women held under house arrest sheds light on how some of the challenges associated with home detention often remain hidden. When house arrest is implemented without accounting for an individual’s right to access education, work, healthcare, or food, it is worse than being in prison, some women said. Nora Laura Calandra, a formerly incarcerated woman from Argentina who now works as an advocate, described a case in which a woman who had gone into labor was told she couldn’t leave her house and go to the hospital without first receiving court authorization. Others noted that at least in prison, they were guaranteed something to eat.

If house arrest is implemented in overly harsh conditions, it’s counterproductive.

 For house arrest to be effective, it needs to be implemented in such a way that women can meet their basic needs, improve their living situation and resolve the underlying problems that led them to come into contact with the criminal justice system.

The report examines house arrest legislation in seven countries across the Americas—Argentina, Brazil, Colombia, the Dominican Republic, Ecuador, Mexico, and Peru—and includes case studies on the challenges for implementing house arrest effectively. Especially amid the COVID-19 pandemic, states are facing the critical task of reducing the population in prison—this will likely necessitate increasing the number of people under house arrest. But if authorities do not consider combining home detention with educational or job-training programs, evidence-based drug treatment programs, or other forms of community support, this severely limits the benefits of house arrest over incarceration, the report states.

More often than not, across the Americas house arrest is being used to harshly punish people when what’s needed are policies that actually protect the health and welfare of communities.

 Should COVID-19 make house arrest a more popular option as states look for ways to reduce prison overcrowding, it’s critical that authorities implement house arrest in a humane, rights-respecting way.

Imprisoned at home: Women under house arrest in Latin America

The need to change our language in relation to people who use drugs has become an increasing topic of discussion, but there is still a long way to go. People who use drugs are highly diverse and their relationship with drug use takes many different forms. Current prohibitionist approaches to drug use and ‘war on drugs’ rhetoric does little to encourage language that acknowledges this diversity. Instead, it promotes and maintains negative stereotypes that construct people who use drugs as morally flawed, inferior, unreliable, and dangerous.

Language does not stand still. It is dynamic, and the language and words we use are always changing. This makes it difficult to be absolute in the way we use language. Nevertheless, there are times when certain language and words used in relation to people who use drugs can be disempowering, divisive, confusing, or give offence.

Compiled by INPUD and the Asian Network of People who Use Drugs (ANPUD), this guide aims to explain our current position on the use of language and to provide clear advice on what is acceptable to us as communities of people who use drugs. We want to encourage all people to be thoughtful about the language and words they use, and have therefore provided a reference guide that identifies stigmatising language and gives non-judgemental, strengths-based, and respectful alternatives.

Publications from IDPC Members