This report enriches the information and knowledge base of harm reduction interventions in Europe from the viewpoint of civil society organisations (CSOs) that directly work for, and with, people who use drugs. This approach is a necessary, and useful, contribution to the development of drug policy in the region and C-EHRN plans to repeat this reporting on an annual basis to identify developments, changes and trends over time.

The report consists of four parts. The introduction provides background information concerning the development of the questionnaire, the data collection process, methodology used, and the nature of the data. Chapters 2-5 report on civil society involvement in drug policy and related decision-making processes as well as on hepatitis C and drug overdose prevention and management services together with the use of new drugs and new patterns of consumption. Each chapter begins with a short summary of the main results and ends by discussing conclusions and policy implications.

Most CSOs responding to the C-EHRN survey are experienced in contributing to data collection and, crucially, have close contact with many important actors in the field and have access to timely and quality information that complements the data collection mechanisms already in place. Consequently, this report reinforces the added value of the role played by CSOs in the collection of data that can inform harm reduction practice. In most countries, civil society involvement is, to some extent, enabled through dialogue and/ or information exchange but, often, the impact is regarded as unbalanced and ineffective. Permanent and formalised structures that ensure dialogue between civil society and government representatives are beneficial for such civil society involvement as structures allow for cooperation on a regular basis and oversee both the formulation of policy and its implementation. Formalised structures, however, do not safeguard meaningful involvement of civil society if they do not lead to accountable outcomes.

C-EHRN Monitoring shows that people who inject drugs (PWID) are still not allowed access to treatment of the hepatitis C virus (HCV) in 10 European countries. Although 23 countries have guidelines that include specific HCV management for PWID, many C-EHRN respondents are somewhat pessimistic about the impact of such guidelines on improving access to the HCV cascade-of-care in their country, especially to good practice, integrated, test-and-treat services at the same site. HCV testing and treatment at pharmacies remains very rare. On a more positive note, 23 European countries reported PWID organisations working actively to increase political awareness concerning HCV interventions. Compared to 2018, more attention has been paid over the past year to HCV awareness campaigns (in 15 countries), to testing at the service providers’ own premises (in 18 countries), and to treatment at the service providers own site (in 15 countries). The main barriers to address HCV among PWID include a lack of funding, knowledge, recognition, political support and skilful staff as well as weakness of civil society organisations and legal barriers.

In 15 countries of the region, the government monitors the number/proportion of people who progress through each stage of the HCV cascade-ofcare at the national level, with monitoring at the regional or local level also performed in 12 countries whereas monitoring is not performed at any level in a further 9 countries. There are still big differences within Europe as to where and how PWID can undertake a HCV test. This means PWID are in an unequal position in different European countries, regions and cities. Rapid HCV testing is available to prisoners in 21 countries.

Treatment of HCV using direct acting antivirals (DAAs) is available in all countries of the region except North Macedonia. However, 10 of 34 countries still place restrictions on access to DAA’s for those people who are active drug users. However, if access to DAA treatment is achieved, the costs are reimbursable by health insurance or through the public health service in all countries except the United Kingdom.

Consequently, to reduce the HCV-related disease burden among PWID and achieve the 2030 elimination goals as set out in the WHO Global Health Sector Strategy on Hepatitis, a radical change in the HCV response is needed in many European countries. National treatment guidelines that specifically address recommendations for treating PWID, guaranteed access by PWID to DAA treatment, improvements in the continuum-of-care and introduction of one-stop HCV testing and treatment services - including such services delivered by harm reduction organisations - needs to be further developed and adopted by all government and civil society stakeholders.

A further key contribution by civil society is collecting data on the context of drug-related overdose events and interventions at a local level, feeding into already existing data and reports. Only 5 countries reported separate overdose prevention strategies or action plans. Much improvement is needed to be able to adequately respond to overdoses in Europe. Evidence demonstrates that a range of measures – including drug consumption rooms (DCR), take-home naloxone (THN) programmes in the community, and naloxone distribution before release from prison - can reduce opioid and other drug-related overdose deaths. However, C-EHRN Monitoring shows a mixed picture of policies and measures across Europe. There is a significant disparity in how, and by whom, such overdose data is collected which can ultimately influence what is recorded as a drug-related death. To address this, the EMCDDA should encourage the respective national health authorities, their own Reitox Network, as well as others who collect such data, to collaborate more with national harm reduction networks and experts in their field of work. Furthermore, due to the uneven status of naloxone – the safe and simple response to an opioid overdose as recommended by WHO – political authorities are called upon to take appropriate legal initiatives to ensure, without delay, that naloxone is available free of charge and without prescription in pharmacies for people who use drugs; experience from Italy can be the basis for this action. In addition, to obtain a real overview of the number of doses of naloxone administered and data on the successful use of naloxone, a national reference point should be established to collect and analyse this and other data.

In general terms, the results of C-EHRN Monitoring correspond with what we know from other sources concerning new drug trends. In addition, the process of data collection as undertaken by C-EHRN Focal Points in each country has the potential of generating additional information and at a quicker pace than other methods, bringing added, qualitative value to this sector.

A review of the approach used by C-EHRN Monitoring to collect such information suggests that focus groups held several times each year would be more effective than a questionnaire as it would lead to consensus-based data. Also, a focus on drug trends, including new drugs, is preferable rather than the emergence of specific drugs. In addition, the focus should be at the city/urban level, rather than national, as this will likely provide higher quality data, and a reduction in the number of questions is recommended.

Civil society monitoring of harm reduction in Europe, 2019

This collection of case studies is an attempt by experts of the Eurasian Harm Reduction Association (EHRA) to introduce and systematise various models of alternative financing that have been implemented successfully in the current environment.

In recent years, many non-profit organisations (NPO’s) in the countries of Central and Eastern Europe and Central Asia (CEECA) have witnessed significant changes in the structure of their revenues; the volume of grant financing provided by charitable foundations has been gradually decreasing. Such a development has forced NPO’s to search for alternative sources of funding for their programmes and projects. At present, NPO’s are moving towards significantly more complex financing models, such as crowdfunding, involvement of businesses in charitable projects, and the establishment of social enterprises, amongst others. These activities are reaching a new level and becoming more mature and professional; they are now taking into consideration the interests and particularities of all stakeholders involved in the process.

This publication offers a description of various alternative financing mechanisms which NPO’s can use in their search for available financial resources, specifically the forms that such mechanisms could take; how the work should be built from the very beginning; what the motives of participating partners in such initiatives could be; and identification of the secrets of success and the possible risks, amongst other issues. This collection is prefaced with an analytical article offering a typology of alternative financing models for NPO’s. Furthermore, specific case studies are provided as illustrations of such models; the examples provided include both large and small scale projects.

Different outcomes are presented through the examples given of NPO’s utilising alternative financing mechanisms. Certain organisations are successful in their implementation of one or other of the listed approaches, whilst others may have not had such an experience but still continue to be active in this sphere while learning from their mistakes; others may just be starting their journeys and are only considering additional opportunities.

This collection is intended to provide help for both experienced and beginner NPO’s and could be of use to the leaders of such organisations, fundraisers and other specialists working with NPO’s. It may also be of interest to specialists of state bodies, business structures and also to everyone who is interested in building long term relations with NPO’s and who are willing to enhance their competencies in the fields of strategic partnership and fundraising.

A number of semi-structured online interviews with representatives of NPO’s working with vulnerable groups and implementing various alternative financing practices were conducted to collect the data introduced in this publication. Most respondents were leaders of such organisations.

In total, 20 NPO representatives from 15 countries of Western, Eastern and Southern Europe took part in the survey, including Ukraine, Georgia, the Russian Federation, Moldova, Poland, Romania, Bulgaria, Slovenia, Serbia, Armenia, Croatia, the Netherlands, Switzerland, England, and Scotland.

It is hoped that many public organisations will be able to use the experiences presented here to obtain alternative financing for the implementation of their own projects.

Alternative financing: Models of sustainable development for non-profit organisations

World Report 2020 is Human Rights Watch’s 30th annual review of human rights practices around the globe. It summarizes key human rights issues in more than 100 countries and territories worldwide, drawing on events from late 2018 through November 2019.

In his keynote essay, Human Rights Watch Executive Director Kenneth Roth examines the increasingly dire threat to the global system for protecting human rights posed by the Chinese government under President Xi Jinping. Deepening and increasingly sophisticated domestic repression show that China’s leaders view human rights at home as an existential threat. That, in turn, has led Beijing to see international laws and institutions for the defense of human rights as an existential threat.

As a result, Chinese authorities seek to censor criticism of China overseas, mute attention to human rights in its global engagements, and weaken global rights mechanisms. At stake is a system of governance built on the belief that every person’s dignity deserves respect—that regardless of official interests, limits exist on what states can do to people.

Noting that global institutions are built in part “on the belief that every person’s dignity deserves respect, that regardless of the official interests at stake, there are limits to what states can do to people,” Roth concludes that China is not simply a new and emerging power finding its place, but a country that poses an existential threat to the international human rights system.

The rest of the volume consists of individual country entries, each of which identifies significant human rights abuses, examines the freedom of local human rights defenders to conduct their work, and surveys the response of key international actors, such as the United Nations, European Union, African Union, United States, China, and various regional and international organizations and institutions.

The book reflects extensive investigative work that Human Rights Watch staff undertook in 2019, usually in close partnership with human rights activists and groups in the country in question. It also reflects the work of our advocacy team, which monitors policy developments and strives to persuade governments and international institutions to curb abuses and promote human rights. Human Rights Watch publications, issued throughout the year, contain more detailed accounts of many of the issues addressed in the brief summaries in this volume. They can be found on the Human Rights Watch website, www.hrw.org.

As in past years, this report does not include a chapter on every country where Human Rights Watch works, nor does it discuss every issue of importance. The absence of a country or issue often simply reflects staffing or resource limitations and should not be taken as commentary on the significance of the problem. There are many serious human rights violations that Human Rights Watch simply lacks the capacity to address.

The factors we considered in determining the focus of our work in 2019 (and hence the content of this volume) include the number of people affected and the severity of abuse, access to the country and the availability of information about it, the susceptibility of abusive forces to influence, and the importance of addressing certain thematic concerns and of reinforcing the work of local rights organizations.

The World Report does not have separate chapters addressing our thematic work but instead incorporates such material directly into the country entries. Please consult the Human Rights Watch website for more detailed treatment of our work on children’s rights; women’s rights; arms and military issues; business and human rights; health and human rights; disability rights; the environment and human rights; international justice; terrorism and counterterrorism; refugees and displaced people; and lesbian, gay, bisexual, and transgender people’s rights; and for information about our international film festivals.

Human Rights Watch - World Report 2020

By Òscar Parés-Franquero, Xavier Jubert-Cortiella, Sergi Olivares-Gálvez, Albert Díaz-Castellano, Daniel F. Jiménez-Garrido, José Carlos Bouso

In Spain, cannabis users are turning to Cannabis Social Clubs (CSCs) as an alternative for obtaining supplies of the substance, free from the risks of the illegal market. The current study aims to establish the profile of a sample (

 = 155) of Spanish CSC members and identify the impacts that these clubs have had on their consumption. To conduct the study, we developed a questionnaire structured around various issues related to the socioeconomic profile of users, their patterns of use, and the practical consequences of being a member of a CSC. The most important findings were that belonging to a CSC did not increase cannabis use and that the services that CSCs offer have favorable impacts on CSC members in terms of reducing health risks, providing legal protection, and improving their general well-being. Based on our data, the regulation of CSCs is warranted as a public health strategy regarding cannabis use.

Click here to read the full article (restricted access).

Use and habits of the protagonists of the story: Cannabis social clubs in Barcelona

This year’s International Overdose Awareness Day (IOAD) has seen our movement continue to grow and achieve real change. The final total of 874 events held in 39 countries is a new record, surpassing the previous high of 747 set last year.

And, just as in previous years, International Overdose Awareness Day is a chance to raise awareness of overdose, remember those we have lost, and call for change.

In addition to the final tally of events, there are several headline statistics which show how much our movement has grown.

As of today, the International Overdose Awareness Day Facebook page has more than 40,000 followers, while our Twitter page has more than 4,000.

This year’s campaign brought more than 273,000 visitors to the IOAD website, www.overdoseday.com Visitors to the website downloaded our online resources – posters, fact sheets, and event support kits – more than 20,000 times.

And our supporters bought and distributed close to 60,000 individual pieces of merchandise (in the form of wristbands, badges, and lanyards) – 30 per cent more than in 2018.

The other findings of the 2019 Partners’ Report are based primarily on a survey conducted by Penington Institute, the convenor of IOAD, which asked participants about their events and their experiences. Key findings gathered from responses to the survey include:

Knowledge about the IOAD community: our movement is made up of people who use drugs, loved ones of people who have been affected by drugs, harm reduction and health workers, advocates, and activists. Often, these communities overlap.

Motivations: raising awareness of overdose, reducing stigma, and commemoration or memorial of those we’ve lost were the most popular responses.

Events: almost 95 per cent of respondents had held an IOAD event before. Close to two-thirds of respondents said their event was attended by the general public, while 80 per cent said their event was attended by family and friends of people affected by overdose, and health or community workers.

Satisfaction: 95 per cent of respondents believed their event was successful or very successful, while 96 per cent were satisfied or very satisfied with the resources on offer.

Media coverage: 75 per cent of respondents said their event received media coverage, and the campaign overall generated 2,550 news stories.

Outputs and Outcomes: increased awareness, naloxone training, the creation of shareable resources, Mayoral Proclamations, and politicians promising to do more to end overdose.

The Partners’ Report concludes by reflecting on this year’s campaign and setting some ambitious targets for next year, which will be the 20th International Overdose Awareness Day.

These targets include 1,000 registered events held in 50 countries, a greater number of real-world policy outcomes, and continued growth in key target areas such as the United Kingdom, South-East Asia, South America and Africa.

International overdose awareness day: A vision to end the global overdose crisis

Policymakers in the United States increasingly recognize that drug use should be treated as a public health issue instead of a criminal issue. Most, however, continue to support harsh criminal sentences for people who are involved with drug selling or distribution. Many imagine these people are “predators” or “pushers” who force drugs on the vulnerable, contributing to addiction, overdose and violent crime.

With more than 68,000 people in the U.S. dying from accidental drug overdose in 2018 alone, many people are searching for someone to blame. Pointing the finger at people who sell drugs is, in some ways, a natural emotional response to loss of this magnitude. It is also consistent with decades of drug policies based on the assumption that people who sell or distribute drugs are responsible for causing drug use.

Politicians of all stripes have argued that long sentences for drug sellers will reduce drug availability and make remaining drugs more expensive, driving down demand. But this is not how drug markets actually work.

Imprisoning people who sell drugs does not reduce the drug supply, increase drug prices, or prevent drug use. As Mark Kleiman, a highly-regarded drug policy expert, has explained, “We did the experiment. In 1980, we had about 15,000 people behind bars for drug dealing. And now we have about 450,000 people behind bars for drug dealing. And the prices of all major drugs are down dramatically. So if the question is do longer sentences lead to higher drug prices and therefore less drug consumption, the answer is no.” When a person who sells drugs is imprisoned, they are inevitably replaced by a new recruit or by remaining sellers, as long as demand remains unaffected. A Maryland police officer once described arresting drug sellers as “playing whack-a-mole” and “banging your head against a wall,” because they can be so efficiently replaced.

Framing people who sell drugs as perpetrators and people who use drugs as victims is also misguided because there is extensive overlap between these two groups. A 2012 survey found that 43% of people who reported selling drugs in the past year also reported that they met the criteria for a substance use disorder. In addition, laws against drug selling are so broadly written that it is easy for people caught with drugs for personal use to get charged as dealers, even if they were not involved in selling at all. Politicians and prosecutors who say they want a public health approach to drug use, but harsh criminal penalties for anyone who sells, are in many cases calling for the imprisonment and non-imprisonment of the very same people.

Beyond being merely ineffective, the harsh criminalization of supply-side drug market activity may actually make drug use more dangerous, increasing overdose deaths and leading to more violence in communities. Law enforcement crackdowns on drug trafficking may incentivize the introduction of more potent, riskier drugs such as fentanyl – a synthetic opioid 30 to 50 times as potent as heroin– into the drug supply. Aggressive prosecution of people who sell drugs may undermine 911 Good Samaritan laws, making it less likely that people will call 911 at the scene of an overdose. Indiscriminately putting people who sell drugs in prison also means removing trusted sellers from communities, forcing users to buy from people they don’t know and making an already unregulated and unpredictable drug supply even less predictable.

The relationship between drug markets and violence is complicated. In some contexts, drug prohibition has fueled organized crime and been associated with horrific violence and corruption. But drug markets are much more diverse than stereotypes suggest: many of them experience little or no serious violence, while many markets that sometimes do experience violence operate relatively nonviolently most of the time. Law enforcement crackdowns may actually increase violence in these markets by disrupting the interpersonal relationships and territorial agreements that keep some drug markets operating smoothly.

While different individuals who work on the supply side of the drug economy have differing goals, priorities and knowledge levels about drug safety and harm reduction, there is evidence that some people who sell drugs take steps to ensure that their clients stay as safe as possible. Some people who use drugs report high levels of trust in the people from whom they buy, although in an unregulated drug market even the most ethical drug sellers have limited ability to know the composition of the product they are selling.

The current system of supply-side criminalization disproportionately impacts people at the lowest levels of drug supplying hierarchies. Available data suggest that the vast majority of people in prison for drug selling or distribution are not high-level suppliers or “kingpins” and have no history of violent conduct. The current system also has a discriminatory impact on communities of color, despite the fact that the available data suggest that white people are slightly more likely than either Black or Latinx people to report having sold drugs.

Our current approach to people who sell or distribute drugs in the United States does not reduce the harms of drug use or improve public safety. It is built on a foundation of stigma, ignorance and fear rather than evidence, and creates new problems while doing nothing to solve those that already exist. The Drug Policy Alliance believes it is time to rethink the “drug dealer”. We must urgently assess what type of people actually fall into this category and how we as a society can respond to them in ways that will keep people and communities safer and healthier. Despite the challenges of discussing supply-side drug policy reform in the midst of an overdose crisis, we cannot be silent while policymakers repeat the discriminatory, ineffective, expensive and dangerous mistakes of the past.

Rethinking the “drug dealer”

Coinciding with the United Nations international day to eliminate violence against women, and the subsequent 16 Days of Activism against Gender-Based Violence Campaign (25 November to 10 December), women who use drugs and their allies around the world unleashed a diverse and dynamic series of actions under the uniting themes:

The war on drugs enables violence against women

Drug use is NOT an excuse for violence and abuse.

also utilising orange (reflecting international ‘orange the world’ theme colour for eliminating violence against women. Women who use drugs are exposed to higher rates of violence than other women).

This violence includes, (but is not limited to) rape, sexual harassment, extortion, loss of child custody, imprisonment for mere personal possession, extra judicial killing, capital punishment and penalisation for drug use in pregnancy. Prohibition either directly causes or greatly exacerbates conditions for all of these violations. Gender-based violence cannot be eliminated if those most affected are not directly and meaningfully involved at all levels in relevant policy and programming.

Women who use drugs are boldly stepping out to take their place in the women’s movement and efforts to stop Gender-based violence. Collectively we and our allies call for governments to end the gendered, failed and murderous policy of drug prohibition.

The following summary features actions performed in Indonesia, Burundi, Australia, Ukraine, Nigeria, Greece, Mexico, Spain, USA, Mauritius, Nepal, Lithuania and Seychelles.

Elimination of violence against women who use drugs - Global campaign summary

According to the estimated needs to sustain HIV and TB responses in Albania, approximately US$3 million is required per year to address the two epidemics effectively. The implementation of the current Global Fund HIV and TB grant of approximately US$5.8 million is ending in December 2019. The last transition grant is expected to start in January 2020, but its level of investment will only be in the region of one-third of the value of the current grant.

This case study looks at the challenges faced in sustaining HIV prevention programmes among KAPs, implemented primarily by civil society organisations (CSO’s), as a result of the withdrawal of the Global Fund through the transition period of 2020 to 2022 and the lack of government capacity and resources to maintain the already limited services that will likely result in the re-emergence of HIV epidemics among people who inject drugs (PWID), sex workers (SW) and men who have sex with men (MSM).

Based on the issues raised in this case study, it is evident that the Global Fund, bilateral donors and private foundations need to establish a ‘safety net‘ through which sustainable bridging funds can be made available that are able to address the challenges faced in those countries, such as Albania, which can no longer rely on Global Fund grants in the future. If such a mechanism is not forthcoming, there will be a serious risk that Albania will become re-eligible for Global Fund support due to re-emerging epidemics among vulnerable groups, as has been the case in Montenegro, Serbia and certain other countries of South Eastern Europe.

The challenges of Global Fund transition in Albania: Harm reduction services on the brink of collapse

By Robert Csák, Irena Molnar, Péter Sárosi, Jovana Arsenijević, Bojan Arsenijević

Our results emphasize that drug related harms are generated in a complex system with intricate connections amongst diverse, heterogeneous actors, in an ever-changing assemblage. We tried to illustrate in this paper how the diverse everyday practices of injecting, combined with the different substances available, the social context of injecting, the physical environment where the substance use occur, could shape the risk behaviours of PWID and the risks of substance use as such. The differences in the prevalence of individual risk behaviours represent the differences in injecting practises in the two communities, and these differences underline the importance of tailoring harm reduction services to the specific needs of the local PWID community. Nevertheless if we would like to implement interventions that can effectively reduce the health risks of substance use, it is necessary to consider environmental, structural factors influencing the consequences of substance use, and aim for responses that could promote an enabling environment, despite it could be hard to transform these factors into variables affecting public health indicators directly

Some of the lessons learnt from our research:

Although the demographic characteristics of drug users were the same (mostly men in their mid-thirties, with low educational attainment, and poor labour market position), there were differences in drug use. Whilst in Belgrade most people still inject heroin, in Budapest mostly new psychoactive (cathinone-type) stimulants are injected.

Access to sterile injecting equipment declined significantly in both cities. In Belgrade 78 percent of drug users bought their clean needles in pharmacies. In Budapest, where a few NSPs remained open, this figure was only 51 percent.

The overwhelming majority of users share their equipment in both cities. The situation was more severe in Belgrade, where half of our sample practiced seven or more types of risky behaviour (compared to one quarter of the Budapest sample).

Our research confirmed that injecting drug use is a community activity, shaped by the environment and by mediated drug-sharing practices amongst the same marginalised, criminalised groups. Any future interventions should consider these environmental, structural factors.

In both cities, fewer people have access to HIV/HCV screening and counselling, vein-care products, and social services (eg. housing, employment). The closure of NSPs severely exacerbated the social isolation of their former clients: they reported significantly less access to “a place to sit for a while” or “speaking with social workers”.

The study was conducted by the Rights Reporter Foundation, in co-operation with the NGO ReGeneracija from Belgrade.

Different environments, different risk behaviours: Consequences of decreased coverage of needle exchange programmes in Budapest and Belgrade

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 conducted a research “New Psychoactive Substance Use in Moldova and Belarus”. It aimed to analyze and determine the presence of new psychoactive substances (NPS) 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 its use, and provide information to national civil society organizations for political advocacy.

In 2020, research will be expanded into 4 more countries: Kazakhstan, Kyrgyzstan, Georgia and Serbia.

New psychoactive substance use in Moldova and Belarus

MDMA is well established as a popular psychoactive substance across much of the Western world. Hundreds of thousands of people break the law to access its effects, which include increased energy, euphoria, and enhanced sociability. The categorisation of MDMA as a Class A drug in the UK and Schedule I drug internationally – categories reserved for drugs deemed to pose the highest risk to individuals and society – has never meaningfully disrupted its supply, nor its widespread use. MDMA is cheaper and purer than ever before and is available at the click of a mouse via darknet drug markets.

For several years, MDMA-related adverse events and fatalities have been increasing in the UK, with some claiming that taking MDMA today is the riskiest it has ever been. Responses are polarised between those who assert that the risks of MDMA use necessitate mitigation through prohibition and increased law enforcement, and those who perceive prohibition to be exacerbating these risks by exposing users to an unregulated market of pills and powder of unknown strength and quality. Whichever view you take, current policy is not meeting its goal of reducing harms, and greater control of MDMA production, distribution, purchase, and consumption is needed in order to prevent MDMA-related emergencies.

This report examines the acute, sub-acute, and chronic harms related to MDMA use in detail. We examine the production, distribution, purchase, and consumption of the drug; related risks and harms; and the impact prohibition has on these, as well as the potential impact of alternative policies. Crucially, our evidence shows that most harms associated with MDMA use arise from its unregulated status as an illegal drug, and that any risks inherent to MDMA could be more effectively mitigated within a legally regulated market.

Under prohibition, people purchase MDMA pills, crystal, and powder from an illegal market, with little certainty as to what these contain. Given that illegal drugs are not subject to strict production standards, consumers are exposed to the risks of poisoning or accidental overdose as a result of contamination, adulteration, and unknown strength and purity. Naïve commentators demonise the drug and simply urge young people to ‘just say no’, whilst failing to account for those who say ‘yes’. In the meantime, preventable deaths continue to occur, and otherwise law-abiding people are punished for non-violent offences such as the possession or social supply of MDMA. Governments and the mainstream media persist in perpetuating the myth that the War on Drugs is winnable if it were fought harder, and those calling for drug policy reform – as we do here – are framed as ‘radicals’ who have little or no regard for the health and wellbeing of citizens.

This characterisation could not be further from the truth. Those calling for careful reform to existing drug policy include the parents of young people whose lives have been lost or ruined by harms related to the prohibition of MDMA. We incorporate their voices in this report alongside those of academics and former police officers, highlighting the ‘broad church’ of those dedicated to fighting for reform. This includes scientists undertaking ground-breaking research into the therapeutic potential of MDMA, who work within a regulatory regime that makes such research exorbitantly expensive and time-consuming, because of the Schedule 1 status that MDMA holds in the UK.

As we enter the fourth decade of MDMA’s widespread use, new thinking is needed on how to better control production and distribution, and on how to reduce the risks associated with its consumption. There is growing evidence to support reorienting drug policy away from an ideologically driven criminal justice-led model to one rooted in pragmatic health and harm reduction principles. This is reflected in the widespread reform of cannabis laws occurring in numerous jurisdictions around the world, and the growth of treatment programmes for heroin users which include prescription heroin and supervised injecting rooms. These hard-fought policy changes acknowledge the failure of prohibition to meet its goals and produce a ‘drug-free world’. They are built on a robust and ever-growing evidence base which demonstrates how permitting or prescribing the use of legally regulated drugs improves health and safety outcomes for people who use drugs and their communities at a reduced cost to the state, whilst also providing wider employment and economic opportunities. This logic can be extended to the use of MDMA and other currently prohibited psychoactive substances.

follows this pragmatic path and pursues policy aims which many of us share, such as improvements in public health promotion, targeted harm reduction, evidence-informed policy and practice, human rights, social justice, participatory democracy, and effective governmental expenditure. For the first time, we outline detailed recommendations for drug policy reform to better control the production, distribution, purchase, and consumption of MDMA products. Reform and the reduction in MDMA-related harms this will bring cannot happen overnight. The changes we outline here, which culminate in a strictly regulated legal market for MDMA, are to be phased in gradually and closely evaluated through independent policy research to ensure health and social outcomes are properly documented, with findings folded back into the ongoing reform process.

The report is available on the Beckley Foundation's website.

Roadmaps to regulation: MDMA

In recent years, services and options for people with opiate dependence have expanded to include a range of prolonged-release buprenorphine formulations. Although these new options can represent the right solution for some individuals, a significant risk of a coercive use exists, especially in countries where people who use drugs are highly criminalised and discriminated against. In such contexts, these medications could be used as a means to reduce people’s choice with regard to their bodily integrity and their drug use. In return, this could essentially enforce prohibition and morally-driven ideas of abstinence. This paper outlines the position of the International Network of People who Use Drugs (INPUD), developed after extensive research and in consultation with people who use drugs and our allies.

Publications from IDPC Members