By Sofía Aguilar, Víctor Gutiérrez, Lisa Sánchez and Marie Nougier

Although cannabis remains a prohibited substance worldwide, in recent decades a series of political, legislative and judicial processes in various parts of the world have given rise to various forms of legal regulatory regimes for the medical and therapeutic use of the plant. This trend seems to be consolidating in the Americas, in particular in Latin America and the Caribbean, where the largest number of available experiences is concentrated, and where the regulatory changes are occurring successively, in a sort of domino effect.

Although this progress is not exclusive to Latin America, and is still far from being a won battle, there is a clear shift in the global drug policy debate, particularly on cannabis. A variety of factors played a role here, including the growing availability of scientific evidence, the inability of the international drug control regime to accommodate and respond appropriately to new evidence, the emergence of a new public health paradigm in the area of drugs, the adoption of alternative policies at local level – sometimes at the expense of the international legal framework – and the growing perception that the costs of the ‘war on drugs’ far outweigh its benefits.

Unfortunately, and despite the growing number of regulatory experiences, the world has not yet reached a consensus on how to proceed, and continues to resist any possibility of activating the legal and institutional mechanisms within the scope of the United Nations to adapt the current treaty framework to this new situation. The United Nations General Assembly Special Session (UNGASS) on the ‘world drug problem’ in 2016 was the clearest example of the reluctance to openly discuss cannabis and its regulation.5 Although it occurred at a historic moment – when the legalisation of medicinal cannabis was already a reality in 16 countries (or 40 jurisdictions if US states are counted individually) – the Outcome Document of the global summit6 made no mention of the issue, or even acknowledge its existence.

It is in the midst of this contradiction that the legal regulation of medicinal cannabis is currently moving ahead. However, as with all innovative approaches, major obstacles remain in terms of its acceptance and of the restrictions imposed by the rigid international legal framework. Indeed, although medicinal cannabis per se is not prohibited under the UN drug control conventions, the inclusion of the substance in Schedule IV of the 1961 Single Convention on Narcotic Drugs restricts medical research and strict rules must be followed to allow the medicinal and scientific use of the substance. The lack of internationally sanctioned scientific consensus on medicinal cannabis is also a major issue, with no standardised or consistent products being used worldwide. These and additional factors which will be described in this paper have resulted in wide-ranging policies, requiring a certain degree of compromise (when done at the sub-national level, for example), and governed by a diversity of norms and institutions. Inevitably, the scope and impact of these policies vary greatly.

As will be discussed below, all experiences are different, and no international or regional standards currently exist. While the regulation of medicinal cannabis in Uruguay resulted from government policy and coexists with licit recreational use in a clear effort to improve public health, in countries like Argentina, Brazil and Mexico, timid legislative reforms responded to citizen initiatives which, for lack of political support, only managed to open the minimum space necessary to comply with court orders and allow the importation of pharmacological preparations produced abroad. Meanwhile, North America is silently consolidating industrial-commercial models of regulation. Although not immune to political backlash and court decisions, Canada and the United States are now at the vanguard of scientific innovation, while also meeting clear revenue-collection goals, and providing a solid basis to expand recreational and industrial systems.

This report precisely highlights this diversity of experiences, approaches and directions. The purpose of this analysis is to enhance our understanding of the current state of reforms and the lessons to be learned from them. Although the authors have done their utmost to gather as much information as possible, this paper does not claim to be comprehensive review but rather a selection of key models of medicinal cannabis being developed around the world as of March 2018. Based on the findings, we offer general recommendations, in an effort to improve public policies in areas where legislation has already changed, and inform decision-making processes in countries where reform is still pending.

Medicinal cannabis policies and practices around the world

Given the limited scientific knowledge of the day, it is understandable to a degree that the architects of the current international enforcement regime on drugs believed sixty years ago in the concept of total eradication of drug production and use. Nowadays, however, it is impossible to ignore the scientific insights and experiences that have been acquired since then in this regard: it is impossible to reduce production and trafficking in illegal drugs and their consumption on a global scale, and certainly not within the border-free European Union. In other words: the global ‘war on drugs’ launched in the 1980s cannot be won and only serves to create additional problems such as corruption, violence and illegal drug revenue in a number of countries worldwide (e.g. Paoli, Reuter & Greenfield, 2009). For decades, debate surrounding alternative regulatory models has been suppressed with the argument, among others, that international agreements and obligations do not permit it (Van Dijk, 1997). But after years of apparent immobility, several countries are presently engaged in an active search for ways to abandon the ‘war on drugs’ path – especially with respect to cannabis. A significant change of course via established international accords is unlikely in the short term because consensus is necessary in this regard and a number of traditionally exceptionally repressive countries might be inclined to obstruct already complicated procedures (Bewley-Taylor, 2003; Hall & Lynskey, 2009). Moreover, international organizations such as the United Nations (via the activities of the International Narcotics Control Board) – in addition to the European action plans – steer consistently in the direction of a uniform and strict approach to the drugs phenomenon. (Boekhout van Solinge, 2002; Roberts et al., 2005; Blom, 2006; Van Kempen & Fedorova, 2014).

In the meantime, many countries are well aware that the points of departure of the ‘war on drugs’ can only be disavowed on the basis of a policy realignment at the local and national levels, in particular when it comes to cannabis (Levine, 2003; Teurlings & Cohen, 2005; Chatwin, 2007). More and more countries, regions and cities have been testing the flexibility of the international agreements because they want to gain deeper insights into the complex character of the drugs phenomenon and potential strategies to deal with it (Bewley-Taylor, 2003; Roberts et al., 2005). They are no longer willing to wait and see what will happen in terms of the revision of international accords and agreements, but are determined by contrast to develop a policy without delay that will allow them to get a grip of the phenomenon and its problematic dimensions (Bewley-Taylor, 2003).

Uruguay and several American states (e.g. Colorado and Washington) have already opted for a regulation of the entire cannabis market, which Canada has announced that it plans to do the same in the summer of 2018. The Dutch coalition agreement of October 2017 allows for an experiment whereby a number of large municipalities are permitted to stock local Coffee Shops via government regulated cannabis production. The authoritative Global Commission on Drug Policy (members including Javier Solana, George Schultz, Kofi Annan, Richard Branson and the former presidents of Brazil, Chile, Colombia, Greece, Mexico, Poland and Portugal) has advocated uninterruptedly for an end to the global ‘war on drugs’ since June 2011 (Global Commission on Drug Policy, 2011). In Europe, countries such as Portugal, Switzerland and the Czech Republic have already implemented important reforms in terms of decriminalization.

Time for a new Belgian policy on cannabis?

Legal tensions are growing within the international drug control regime as increasing numbers of member states or jurisdictions therein move towards or seriously consider legal regulation of the cannabis market for non-medical purposes, a policy choice not permitted under the existing UN legal framework.

Reaching a new global consensus to revise or amend the UN drug control conventions to accommodate cannabis regulation, or that of other psychoactive plants and substances currently scheduled in these treaties, does not appear to be a viable political option in the foreseeable future.

The application of dubious or ‘untidy’ legal arguments to accommodate regulated cannabis markets does little for the integrity of the regime, undermines respect for international law more broadly and is not sustainable.

Appealing to human rights obligations can provide powerful arguments to question full compliance with certain drug control treaty provisions, but does not in itself resolve the arguable conflict between different treaty obligations.

States may wish to adopt a stance of respectful temporary non-compliance as they pursue legally valid and appropriate options for the re-alignment of international obligations with domestic policy.

Amongst reform options not requiring consensus, inter se modification appears to be the most ‘elegant’ approach and one that provides a useful safety valve for collective action to adjust a treaty regime arguably frozen in time.

Balancing treaty stability and change

Uruguay is the first country to legalize and regulate its domestic non-medical cannabis market. In light of this pioneering role, the choices and experiences of Uruguayan authorities hold important lessons for other jurisdictions that may consider whether and how to regulate cannabis. Uruguay’s breakthroughs and challenges related to banking, international treaties, access to the product, enforcement, medical cannabis, tourism, and research and evaluation in particular hold immense value to policymakers and analysts elsewhere. To this end, this report examines the conditions that led Uruguay’s government to pass its cannabis law in 2013, studies its progress so far, and identifies areas that policymakers should consider addressing in order to maximize the law’s potential benefits. Key findings include:

• Uruguay should consider long-term measures to ensure that cannabis business entities have access to financial institutions, including outreach to other jurisdictions shifting toward cannabis regulation, such as Canada.

• The medical and law enforcement sectors require substantial education and training, particularly regarding the aims and expected benefits of cannabis regulation, how to broaden access to medical cannabis, and the new enforcement rules under the law.

• Implementation of commercial sales so far has been marked by shortcomings in distribution. Uruguay can overcome these obstacles by widening legal points of sale to include not only pharmacies, but a new form of dispensary, which authorities are already planning.

• In order for the regulated cannabis market to displace the black market more effectively, authorities may need to reconsider rules that require users to choose only one of the three legal forms of cannabis supply: homegrowing, clubs, or commercial purchase.

• Uruguayan authorities may also need to address a growing informal market by allowing legal sales to noncitizen tourists.

• In order to better position themselves to assess these adjustments, authorities should work closer with independent researchers and civil society to ensure that they have access to key information and institutional support for their work.

Uruguay’s cannabis law: Pioneering a new paradigm

The use of drugs is not new to Nigeria, but in recent years, the country has moved from being a transit nation to a producing nation ranking as one of the largest producers of cannabis in 2 Africa and with the highest rates of drug trafficking and drug use in West Africa . In spite of this, data on the estimated number of illicit drug use in Nigeria is limited. The available data is fragmented, with one having to rely upon individual or institution research studies which tend to focus on certain drugs, population or region.

According to National Agency For Food and Drug Administration and Control (NAFDAC) , the most commonly abused drugs in Nigeria are stimulants, hallucinogens, narcotics, sedatives and tranquilizers. In National Epidemiological Network on Drug Use (NENDU) analysis of drug treatment information in Nigeria, cannabis was declared the most frequently used (36.2%) followed by opiates (28.3%) and alcohol (17.1%). The most common opiates were tramadol -71%, codeine - 15.1%, pentazocine - 9.9% and heroin and morphine representing 3.3% of the opiates declared . increase in use of injecting drugs in the country, there is a heightened risk of HIV and other blood born viruses though the sharing of needles and syringes, low risk perception and non-availability of sterile equipment at the time of use .

Injecting drugs with a contaminated needle directly into vein is actually a much more efficient way of transmitting HIV than through unprotected sexual intercourse. According to the 2014 Integrated Biobehavioral Surveillance Survey (IBBSS), the HIV prevalence among people who inject drugs is 3.4% . The HIV prevalence however varies from state to state with Kano state as high as 7% and Cross River and FCT, just over 5%. Although concerns have been raised at the community level that the national data is not a true reflection of the HIV situation among people who inject drugs which is considered to be higher. Female injecting drug users also have a higher prevalence rate than their male counterparts - seven times higher . This is consistent with data globally which states that women who inject drugs face a broad range of gender-related health risks and are less likely to access healthcare services.

Addressing barriers to effective HIV prevention and service delivery among people who inject drugs in Nigeria

Drug users are a socially hidden population with high risk behaviours, this group is one of the traditional key populations with a high HIV/STI burden. Revitalizing HIV prevention programs for drug users especially those who inject drugs is paramount. Efforts to involve drug users in programming could increase access to services to this hard to reach sub-populations. The needs and risks of people who use drugs require innovative, comprehensive and effective HIV, TB and HEPs prevention interventions.

Uganda Harm Reduction Network has conducted various activities throughout this year among which is the population size estimates and rapid assessment studies. The results of the survey data revealed that 80% of 95 respondents in Kampala and 63.3% of 30 in Mbale had tested for HIV in the past 12 months. Up to 9.2% of 76 respondents in Kampala who reported testing for HIV in the past 12 months were seropositive and none in Mbale indicating a higher HIV prevalence among the PWID in Kampala. This data suggests that the HIV prevalence for PWID in Kampala is higher than that of the general population in Uganda which is 6.0%.

Based on these results, it goes without mentioning that it is challenging to end HIV and AIDS by 2030 as required by the Sustainable Development Goals when a considerable sect of the general population; people who use and inject drugs whose specific needs with regard to HIV response are being ignored. Nationally there has been laxity in embracing essential HIV treatment and prevention strategies for people who use and inject drugs living with and affected by the epidemic thereby creating a situation of alienation of PWUIDs from the movement to end HIV and AIDs.

Uganda Harm Reduction Network therefore calls upon stakeholders to join hands, to embrace such essential harm reduction programs including Needle and Syringe Programs (NSP) and Opioid Substitution Therapy (OST) as part of the HIV prevention strategies in Uganda to cater for the specific HIV response needs of PWUIDs if Uganda as a Nation is to end HIV/AIDS by 2030.

Uganda harm reduction network- (UHRN) Annual report 2017

Effective international regimes are not static constructs. While there remains definitional variation concerning exactly what constitutes a regime – a situation that exists not only across but also within the increasingly synergistic disciplines of International Relations (IR) and International Law (IL) - there is general agreement that they operate in terms of ‘lifecycles’ and consequently ‘tend to change more or less profoundly during their lifetime.’ Still an area of relatively limited study, the concept of regime evolution takes on increasing salience in light of a significant expansion in the number of international legal instruments in operation today. As the International Law Commission noted in 2006, ‘the volume of multilateral - “legislative” – treaty activity has grown manifold in the past fifty years.’ Furthermore, observe Simmons and Steinberg, such expansion has been accompanied by an increase in ‘the scope of topics and subjects addressed by treaty law, with treaty growth being ‘especially marked in economic affairs, as well as in the areas of human welfare and the environment.’

Although various processes of regime evolution can be found across all three categories, this paper focuses on examples from the fields of human welfare (broadly defined) and the environment; more specifically the treaty regime based upon the United Nations (UN) drug control conventions and the regime of environmental regulation and its underpinning Multilateral Environmental Agreements (MEAs). With a basis in comparative analysis, our aim here is to explore how these multilateral treaty based regimes have altered and are capable of modernization over time in response to changes in circumstances and requirements of regime members. Moreover, within the context of shifts in the way that a growing number of jurisdictions are choosing to deal with the illicit use of cannabis within their territories, the paper seeks to demonstrate the extent to which the evolutionary capacity of what has been usefully called the ‘global drug prohibition regime’ (GDPR), can be considered out of step with a more dynamic regime like that dealing with transnational environmental concerns. In so doing, we hope to help move current discussions concerning the tensions presently surrounding the operation of the GDPR beyond the narrow confines of drug policy analysis and locate them within the broader context of IL, IR and wider investigation of regime evolution and modernization in general.

Beyond the fact that environmental regimes have been the subject of the most study on evolution and change, the focus on MEAs as a principle comparator to the GDPR rests on two factors. The first of these is the important, although very different, role that the advancement of scientific knowledge plays in the lifecycle of both regimes. The second relates to the regimes’ age and the associated structures and mechanisms that come with it. As will be discussed, such factors go some way to help explain why from an IL perspective the GDPR has been described as ‘Jurassic’ with its underpinning drug conventions ‘so stubbornly resistant to change compared to other treaty systems’ that they almost seem ‘“frozen in time.”’

The paper begins with an overview of the GDPR. This includes discussion of structural and normative mechanisms, processes and examples of regime ‘change’ and transformation as well as their limitations. It then moves on to an examination of MEAs and the key elements of the environmental regime that allow for change; the existence of a Conference or Meeting of the Parties and related legal structures allowing for the incorporation of far-reaching changes to environmental instruments. Examples of these mechanisms and other relevant features are explored specifically through structural analysis of the 1987 Montreal Protocol, the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES) and the UN European Commission for Europe Convention on Access to Information, Public Participation in Decision-making and Access to Justice in Environmental Matters (the Arhus Convention).

The modernisation of treaty regimes: Contrasting cases of international drug control and environmental regulation

The Senior Level Policy Dialogue "Addressing HIV and TB Challenges: from Donor Support to Sustainable Health Systems" was held in Tallinn, Estonia in December 2017 as an official event in the programme of the Estonian Presidency of the Council of the European Union.
The event, organized by the Ministry of Social Affairs and National Institute for Health Development from Estonia, WHO European Region, UNAIDS, and the Global Fund, brought together representatives of the health and financial ministries of Europe, the Balkan and Eastern Partnership countries, representatives of the European Commission, international organizations, as well as community representatives and institutions involved in funding programmes and offering services to tackle HIV and TB.
DPNSEE and 4 participating member organizations representatives (Margina, Viktorija, Cazas and Juventas) actively contributed to the meeting. Both the experiences from South East Europe and challenges we face were presented, emphasized and mentioned by many participants.
The main focus of the meeting was to:
- Present and discuss good practices at political and technical level of integrating HIV and TB services into national health systems, including challenges, risks, and opportunities;
- Present and discuss current financial and programmatic sustainability gaps and challenges, with particular focus on effective national investment to ensure universal access to health care, including key affected populations;
- Discuss roles and responsibilities of national governments, EU and international partners, as well as civil society partners in transition processes, to effectively and sustainably address HIV and TB.

DPNSEE October-December newsletter 

Since 2009, we provide harm reduction services to people who use drugs in Moscow. The political and financial climate as well as the epidemiologic situation are not very supportive for our work - Russia still has one of the fastest growing HIV epidemics in the world with more than 1 million cases being registered and more then 50 000 HIV positive people living in Moscow. Officially registered number of people who use drugs living in Moscow is over 30 000 people. Unsafe injection of drugs is still the major cause of HIV transmission in Russia (more than 60% of all new cases), HIV epidemic is escalating in the country and its capital, but the government still denies the effectiveness of harm reduction measures and provides zero support to NGOs working on HIV prevention among key affected populations. Russian drug policy is still known as one of the most conservative and repressive among those around the world - it continues to declare a zero tolerance towards drug use inflaming the stigma and discrimination towards people who use drugs because of their drug dependence and primarily they are considered not as patients who need proper treatment and support but as criminals. It restricts the access for drug users to vitally important for them information on health issues and to the health services needed such as needle exchange programs and opioid substitution treatment.

Andrey Rylkov Foundation: Provision of harm reduction services in Moscow in 2017

Drug use is criminalized in all countries of the MENA region, and a large number of PWUD are incarcerated, mostly for drug use, but sometimes even for the mere possession of syringes (UNAIDS, 2016; MENAHRA program data). Moreover, PWUD face high levels of stigma and discrimination in the region (MENA Regional Networks, 2016), which are further reinforced by their criminalization (UNAIDS, 2017a). Both the criminalization of drug use, and high stigma and discrimination faced by PWUD, negatively affect access to health services for this population. A number of studies have reported that this criminalization, manifested by punitive laws, incarceration, and prohibitions on harm reduction services, negatively affects harm reduction efforts. These negative effects include decreases in access to Needle/Syringe Programs, increased risky behaviors of sharing used injecting materials, and an increased HIV burden among PWID (UNAIDS, 2017a). Injecting drug use has been document within prisons in a number of countries in MENA, with unsafe injecting drug use being the primary mode of HIV and HCV transmission among prisoners (HRI, 2017). Furthermore within these settings, OST and ART are often unavailable, discontinued, or severely delayed - further exacerbating negative health consequences.

Police/law enforcement can also be a source of stigma and discrimination. In an Operational Research on PLHIV who inject drugs in 6 countries of the region, 7.7% of participants reported to have faced stigma and discrimination from police (MENAHRA, 2017a).

Of further concern are women who inject drugs, who remain more vulnerable and at higher risk than their male counterparts due to social stigma and gender related factors, whether within prisons or not. These vulnerabilities further hinder access to health services among women (MENAHRA, 2015). Women who inject drugs also have high risks being subjected to sexual violence from police and law enforcement agencies, as has been reported by a study conducted in 2015 (UNAIDS, 2017a).

Policy brief for law enforcement officials on the provision of harm reduction services

The last remaining DEA agents left Bolivia in January 2009, bringing to a close more than three decades of DEA-presence within the country. President Evo Morales had ordered the expulsion of the US agency in response to the harms caused by the ‘war on drugs’ and perceived US-meddling in the internal affairs of Bolivia. As part of the dispute, Morales had also expelled US Ambassador Philip S. Goldberg in September 2008, accusing the US of fomenting civil discord. ‘Without fear of the US empire, I stand before the Bolivian people today and declare United States Ambassador Mr. Goldberg persona non-grata,’ Morales announced, ‘We don't want people here who conspire against our unity. We don't want people who threaten our democracy.’ The period thus marked a nadir in US-Bolivian relations, and a turning-point for the course of counterdrug policy in Bolivia. For better or worse, the Bolivian government would now seek to cut its own path: moving away from the drug war approach of the US. But how did US-Bolivia relations arrive at this point? What were the historical antecedents of this point of fracture? Drawing on 27 oral history accounts with US and Bolivian political actors, the paper considers Bolivia’s post-transition period as a key moment in this history of fractious US-Bolivian relations and the ‘war on drugs’ in the Andes.

Many of the same themes of grievance raised by Morales were apparent during this period. Bolivia transitioned to democracy in 1982 against a background of economic crisis. The imposition of harsh-neoliberal structural reforms would bring stability to the national economy, but at a severe social cost. For large swathes of the population, the coca-cocaine economy provided a vital social-safety net during this period of crisis. Furthermore, narcodollars played a crucial role in helping to stabilise the economy: boosting national reserves and inward investment. Given these socio-economic realities and the relative absence of drug-related violence in Bolivia, there was a level of ambivalence towards the drug trade. Instead, the escalation of the US ‘war on drugs’ was, at-times, viewed to pose the greater risk to Bolivia’s social, political and economic stability. This US drug war approach included the militarisation of counterdrug operations and coca eradication. For many Bolivians, the exercise of US power in advancing its counterdrug goals invoked ‘Yankee Imperialism’ and recent memories of US-Cold War interference in Bolivia. US agencies, for example, operated in Bolivia with little local oversight, while Bolivian politicians from this period believed accusations of drug corruption were used to silence opponents of US policy. Perceptions that US counterdrug policy ran contrary to local interests, and that the US exploited the ‘war on drugs’ to exercise control in Bolivia, created an atmosphere of mistrust between the US Embassy and the Bolivian government. As evidenced by the expulsion of the DEA in 2008 and the breakdown of US-Bolivian relations, such mistrust continues to manifest itself to this day. Speaking in June 2017, Morales stated, ‘I do not regret the decision to expel the DEA. The United States used the “war on drugs” in order to control the country's politics and loot our natural resources’.

The	 coca-cocaine economy, the US	 ‘War on Drugs’ and Bolivia’s democratic	transition (1982-1993)

EQUIS is presenting the following Shadow Report for the Committee on the Elimination of Discrimination Against Women (CEDAW) in light of the pre-sessional working group meeting that will take place in Geneva in November 2017.
EQUIS is a feminist organization whose mission is to transform institutions, laws and public policies, and women’s leadership to improve women’s access to justice. EQUIS contributes to the advancement of women’s human rights and gender equality through the use of advocacy and litigation strategies at national and international level.
This document includes data EQUIS has collected through the implementation of its projects, all of which target issues that converge with recommendations made to the Mexican state.

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