The World Health Organization (WHO) international meeting on prisons and health, held in Lisbon, Portugal, on 11–12 December 2017, brought together more than 100 experts in the field of prison and public health from 30 countries worldwide; besides the WHO Regional Office for Europe and WHO Headquarters several other international and European agencies were represented, including the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the Council of Europe’s Pompidou Group, the European Centre for Disease Prevention and Control, the United Nations Office on Drugs and Crime, and the Ministry of Health and the Ministry of Justice of Portugal; support was provided by Public Health England (PHE), the UK Collaborating Centre for the WHO Health in Prisons Programme (HIPP).

The meeting participants propose the following conclusions for wider dissemination to all those who could improve the current position worldwide with respect to drugs and drug-related harms in prison, which continue to challenge prison systems and the wider community.

The WHO international meeting on prisons and health contributes to sharing good practice internationally, maintaining and improving professional development and capacity in the prison health system; it also allows discussion of the challenges currently facing the prison setting with respect to public health and health service delivery and encourages debate on the scientific evidence that supports policy and intervention.

The meeting’s conclusions aim to fully acknowledge the role of prisons as important settings to address health inequalities and to recognize the status of people in prison as a disadvantaged group in terms of health and well-being. These conclusions direct the attention of policymakers, professionals and prison administrators to the necessity, in terms of both public health and social well-being, of enhancing knowledge and understanding of effective interventions on drugs and drug-related harms in prison (including tobacco- and alcohol-related health harms), and of ensuring that interventions to reduce drug use and drug-related health harms are evidence-based, particularly in a setting as sensitive as a prison, where people have been deprived of their liberty. Applicable also to people in youth detention settings, these conclusions recognize that – in order to achieve lasting improvements in the health of people who experience incarceration – treatment and prevention efforts in prison and youth detention settings must be sustained after these individuals return to the community.

Conclusions of the WHO international meeting on prisons and health Lisbon 2017

Globally, cannabis is the most commonly used illicit substance and for a long time, a topic of interest within the international drug control regime (Davis, 2017; Bewley-Taylor, Blickman, & Jelsma, 2014). The psychoactive substance is governed by the international drug control convention, which is signed by most of the world’s nations. The commitment of the nations to the international drug control convention, also known as the 1961 Convention on Narcotic Drugs, has led to the implementation of national prohibition laws that extend to both cannabis use and production (Rehm & Fischer, 2015).

Today, the international drug control regime faces challenges as it turned out that under a system of prohibition, the enforcement of cannabis laws results in extensive costs, high levels of arrests and criminal records in the population (Rehm & Fischer, 2015). In order to avoid these effects of cannabis prohibition, some nations choose a more tolerated approach towards their regulation of cannabis (Bewley-Taylor, Blickman, & Jelsma, 2014). The Netherlands is one of those nations; the monarchy maintains a tolerated attitude regarding the regulation of cannabis. The Dutch tolerate the buying and selling of small amounts in strictly controlled locations (coffee-shops), although the production and import of cannabis remains illegal (Spithoff, Emerson, & Spithoff, 2015; Monshouwer, van Laar, & Vollebergh, 2011; MacCoun, 2011). This remarkable regulation has resulted in the so-called backdoor problem of an illegal supply chain; as coffee-shop owners cannot obtain their stock supply legitimately, they are forced to buy their cannabis supply at the illegal market.

Currently, the backdoor problem remains unsolved in the Netherlands, leading to high pressure on the police and juridical system as the current policy is not considered as easy to control (Trimbos Instituut, 2009). As a solution to this, the Dutch parliament debated a bill that aims to legislate cannabis from seed to smoke. This regulation can solve the controversies of the current cannabis policy, as removing the cultivation and distribution of cannabis for commercial purposes from criminals and shoving it into the hands of licensed entrepreneurs or the government will undercut the black market and corresponding harms from corruption and violence (Armentano, 2010). Hence, Dutch coffee-shop owners can legitimately obtain their supplies. In addition, crimininal justice resources will save time and can be redirected towards other priorities, as the burden of cannabis-related crimes will be downsized (Caulkins et al., 2011).

If the bill passes the parliament, the Netherlands can take multiple models into account regarding the design and implementation of the cannabis legalization policy. Namely, the road to the legalization of recreational cannabis is not unknown; in 2012, Colorado became one of the first two jurisdictions of the United States of America that approved the legalization of cannabis (Ghosh, et al., 2017). Not short after, Uruguay followed in 2013, being the first country in the world that legalized cannabis from seed to smoke (Hoffman, 2016).

The success and failures of both Colorado and Uruguay can be a source of great information for researchers and policy makers who consider the legalization of cannabis. Therefore, the aim of this study is to create insight into the recreational cannabis policy of Uruguay and Colorado by conducting a comparative literature study. Consequently, this literature review can contribute to future research regarding the design and implementation of the legalization of cannabis in the Netherlands. The following research question is put central in this literature review: What lesson can be learned from Uruguay and Colorado regarding the legislation of recreational cannabis?

How to legislate recreational cannabis

Recent deaths of young Australian music festival attendees from ‘party-drug’ overdoses have sparked debate about the effectiveness of drug policies. Australia is widely lauded for its harm minimisation approach to drugs, and yet, over the last 30 years, it can be argued its policies have been fragmented, sometimes inconsistent and contradictory. The present article examines the root of this inconsistency, using it as a foundation to advocate for drug policy reform. In keeping with the goals of the National Drug Strategy to promote policy innovation, there is an opportunity to learn from international studies which have shown promising findings in the reduction of party-drug use and its harms through application of pill testing.

This paper evaluates Australia’s National Drug Strategy and pill testing through a lens of pragmatism, to determine whether there is space for testing practices in contemporary policy. Specifically, the paper analyses current drug policy literature and research studies, examining a range of key drug use indicators, social and political debate and research evidence.

The need for policy reform, attitudinal and cultural shifts and development of stronger cross-sectoral partnerships is highlighted, to ensure a rational and logical approach that genuinely tackles drug policy-making and strategy from a broad public health perspective.

Using a theoretical frame of pragmatism and drawing from national and international research evidence, this paper recommends the integration of pill testing into Australia’s harm minimisation strategy.

‘Worth the test?’ Pragmatism, pill testing and drug policy in Australia

All public policy should be informed by open debate. I organised the West Midlands Drug Policy Summit as an opportunity to invite open thinking and create a space for that sensible and mature discussion. On 15th December 2017, organisations involved in drug policy from across the region attended the summit. They were also given the opportunity to share their views and shape the agenda through a prior consultation.

The following recommendations are based on ideas proposed to us in our consultation and at the summit. There was consensus that, at the very minimum, these ideas were worthy of being closely looked at for their ability to reduce crime and prevent harm.

As background to the summit, my offi ce produced a hard-hitting ‘cost of drugs’ report in September 2017.1 It revealed that £1.4bn is the estimated annual cost of substance misuse to the West Midlands region. This is the cost to society of drug-related crime, health service use, drug-related deaths and social care.

Half of all burglary, theft, shoplifting and robbery is committed by people who use heroin, crack cocaine or powder cocaine regularly. This represents one in fi ve crimes reported to West Midlands Police and tens of thousands of victims. Every three days in the West Midlands somebody dies from drug poisoning, with a death every four hours in England.

Despite the good work being done by many, collectively drug policy is failing. This failure means the public put up with more crime, public services are put under more strain, and not enough is done to reduce the harm of those suffering from addiction.

The effective provision of mainstream treatment and harm-reduction services is the foundation of good drug policy. These services, like the police and wider public sector, have faced signifi cant cuts to their funding in recent years. The knock on effect of these cuts is becoming clear, with drug related deaths at an all-time high for the fourth year in a row, burglary and violent crime on the rise, and an estimated 22,500 children in the West Midlands growing up with a parent or parents suffering from serious drug problems.

Reducing crime and preventing harm: West Midlands drug policy recommendations

Harm reduction refers to “policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption”. As such, harm reduction sits alongside other pillars of drug policy such as demand reduction and supply reduction. It is a pragmatic, evidence-based, highly effective and cost-effective component of drug policies around the world — and has been a central component of Germany’s national approach since the late 1980s, being one of the four pillars of the German National Strategy on Drug and Addiction Policy (2012). Core harm-reduction interventions — such as needle and syringe programmes, opioid substitution therapy and naloxone distribution — were also referred to in the Outcome Document of the United Nations General Assembly Special Session (UNGASS) on the World Drug Problem in April 2016.

The Global Partnership on Drug Policies and Development (GPDPD) is a programme implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ) and under the political patronage of the Federal Government’s Drug Commissioner. Under the auspices of this Partnership, an Expert Group Meeting (EGM) on harm-reduction responses for people who use stimulant drugs was held from 4th to 6th October 2017 in Bangkok, Thailand. EGM was co-hosted by the Thai Office of the Narcotics Control Board (ONCB), the International Drug Policy Consortium (IDPC), the Transnational Institute (TNI) and Harm Reduction International (HRI). It brought together 52 participants from around the world, comprising representatives from Member States, United Nations agencies, civil society as well as academics, and people who use drugs. This was the second EGM on harm reduction within the framework of GPDPD, following a first Meeting in Berlin in 2016 whose results were fed into the UNGASS 2016 preparation process.

Over recent decades, the consumption of stimulant drugs has proliferated: according to the United Nations Office on Drugs and Crime (UNODC), 37 million people used amphetamines and prescription stimulants in 2015, and 17 million used cocaine — placing this category of drugs second only to cannabis. The exponential growth in stimulant use presents new challenges to the practice and principles of harm reduction, which have gained prominence over the last 30 years with a focus on opioid use, the injection of drugs and the transmission of HIV and other blood-borne diseases. EGM sought to discuss and explore how harm reduction could be better applied to protect the health of people who use stimulant drugs, within a human rights framework in line with the UNGASS Outcome Document Chapter IV.

This conference room paper outlines the most relevant findings of the Expert Group Meeting.

Conference room paper submitted by the Federal Republic of Germany on the importance of harm reduction for people who use stimulant drugs

National consultations undertaken by AIVL in 20171 reveal a number of systemic and service level barriers that contribute to increasing rates of sharing and reuse of injecting equipment, such as experiences of stigma and discrimination, limited and inconsistent range of injecting equipment and laws that restrict the availability of equipment.

Barriers to accessing sterile injecting equipment contribute to decisions to share injecting equipment, which latest data from the Australian Needle and Syringe Program (NSP) Survey2 illustrates has been on the rise over recent years, increasing the risk of new hepatitis C and HIV transmissions.

Australia has long been at the forefront of hepatitis C and HIV responses, yet our goals of eliminating these viruses cannot be achieved without a strong and responsive prevention system.

Outlined below are best practices for NSP service provision that are defined by and responsive to the needs of people who inject drugs. AIVL calls for these best practices to be implemented to ensure that Australia can achieve its hepatitis C and HIV elimination goals:

- Diversity of options with consistency of experience People who require NSP services should have an expectation that wherever possible and regardless of service site, a consistent range of injecting equipment is available that goes beyond basic fit packs, and that the experience is non-judgemental and creates an environment where additional health information is available when requested.

- Ensuring that all parts of Australia’s NSP system are welcoming and non-judgemental Experiences of stigma were identified as playing a role in decisions to use a particular service type or to engage with service staff. All parts of the NSP system should be focused on creating welcoming, non-judgemental environments, either through staff training or, in the case of syringe dispensing machines (SDMs), ensuring the location is not stigmatising with unnecessary surveillance.

- Ensuring consistency of equipment across all service types AIVL’s 2017 literature review on NSP service provision noted the variability of equipment availability across jurisdictions, with some types of equipment available in particular jurisdictions but not in others. Different types of injecting require different equipment, therefore a consistent range of basic equipment should be provided across all NSP service types.

- Creating an enabling environment that maximises the widest availability of injecting equipment Inconsistencies in legislation and regulation, such as the varying legality of peer distribution of injecting equipment across jurisdictions, should be addressed to ensure that these barriers to injecting equipment access are removed. Legislative amendments in the ACT and Tasmania that enable provision of injecting equipment for non-medical professionals provide positive examples of leadership.

- Position NSPs as a core part of Australia’s health system NSPs, particularly primary NSPs, need to be recognised as a core part of Australia’s health system and embedded into broader health networks in order to create service and referral pathways between NSPs and other health services. Supporting partnerships through local Primary Health Networks provides a first step towards embedding fixed site NSPs into local health systems.

- Create pathways for employment of peers and encourage peer-employment outside of primary NSPs, and ensure that peer workers are adequately supported in the workplace Findings from AIVL’s consultation demonstrate the benefits that peer workers in NSPs can provide, however this is largely restricted to primary NSPs in metropolitan areas. Creating pathways to employment for peers in other NSP service types and outside of metropolitan areas will support additional engagement in the health system by people who inject drugs as well as building of peer networks that play a key role in information dissemination. The role of people with lived experience of drug use is critical in Australia’s response to blood borne viruses because of the trust that exists within peer networks and their reach into communities of people who may not frequently engage with the health system.

- Ensuring funding allows for flexibility of service delivery Allowing for greater funding flexibility will allow NSP services to better cater for local populations, such as providing outreach services in communities with dispersed populations, establishing operating hours that align with community needs or provision of a broader range of equipment that matches the community’s pattern of usage.

- Creating greater service awareness and managing expectations Underpinning best practice relating to NSP service provision also requires awareness raising and management of expectations amongst people who inject drugs around service types and service availability. Developing and implementing peer-led best practice principles within the NSP service system will help service delivery match service expectations however wider promotion of service availability may also help increase service access and overall needle and syringe coverage.

- Creating consistency in data collection with a focus on collecting what is required Concerns over privacy and confidentiality were raised through AIVL’s 2015 National NSP Forum and by a minority of participants in these consultations. Although it is not clear if data collection has any significant impact on decisions to access injecting equipment from a particular site, a best practice approach would suggest that only data that is absolutely necessary be collected.

Needle and syringe programs in Australia: Peer-led best practice

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?

Millions of children and adults around the world, afflicted with terminal or life-threatening illnesses, suffer from severe physical pain, screaming out and begging for help. There is an effective treatment available that is easy and cheap to produce. And yet, for various reasons, including government regulations based on disproportionate concerns about misuse, and a historical neglect of suffering even within medical systems, most people are unable to access this treatment.

The lack of access to morphine and similar opioids is a reality specific to most low- and middle-income countries, and it is a critical issue from an ethical, human rights, medical and humanitarian perspective. It is urgent to effect rapid change through effective, compassionate, evidence-based policies. Every delay means more people suffering needlessly.

While each country has its own specific issues and bottlenecks, policymakers can make real progress in solving the problem by implementing some basic principles and measures, based on successes achieved in other parts of the world.

There are remarkable individuals who have taken the initiative, overcoming bureaucracy and facilitating access to morphine and palliative care in specific regions and countries. So much more could be achieved, and more quickly, if central health authorities made this a top priority, loosened regulatory hurdles, ensured widespread training and education on palliative care, and facilitated the procurement, production, distribution and prescription of oral morphine. Dr. Faith Mwangi-Powell, founding Executive Director of the African Palliative Care Association, has said that the success story of Uganda shows what’s possible when different groups come together, but that the “most important thing is good political will.”

This short guide summarises some of the key issues and solutions, including an emphasis on the fundamental ethical principles from which all else flows. The many organisations working on the subject of pain relief have developed country-specific recommendations and solutions through painstaking work on the ground. This guide offers an additional voice in support of these efforts.

Ending the agony:  Access to morphine as an ethical and human rights imperative

Drug law reform is an incredibly complex area of public policy. This is due to the interweaving nature of the relevant issues and the challenges arising from drug use and its consequences. This complexity is also due to conflicting views about how best to address the use of drugs in the community.

Historically, the approach to drugs both internationally and in Australia was based on prohibition of recreational drug use, although there is growing recognition that a dominant focus on law enforcement strategies has not eradicated the supply or demand for such substances, but has contributed to increased harms such as overdoses and black market crime. Now more than ever, there is also greater availability of new and often more harmful substances on the illicit market. Related to this, is the rising misuse of approved pharmaceutical drugs within the broader community.

It is in the context of these issues that the Law Reform, Road and Community Safety Committee received the Terms of Reference for this inquiry. A key focus was to consider how effective current drugs laws are and whether they are successful in reducing health and social harms associated with their use. The Committee was also asked to examine best practice in this area from other jurisdictions and their suitability for implementation in Victoria. These terms of reference provided the Committee with the unique opportunity to examine drug use as a whole, rather than focus on individual substances as has been done in previous inquiries.

While the title of the inquiry relates specifically to law reform, the Committee’s investigations were largely informed by the evidence received in submissions and public hearings, which called for a broader examination of drug-related laws, policies, procedures, programs and initiatives. The result is a report that comprehensively explored the key areas of prevention, law enforcement, treatment and harm reduction, and acknowledges the need for a more effective drug response framework, one that prioritises health and community safety.

A common theme throughout the inquiry was the need for honest and open discussions to understand why people may use drugs and to work towards more compassionate and balanced responses. The Committee was committed to providing a platform for this dialogue throughout the inquiry. The report and recommendations reflect the outcomes of these discussions, including that while people continue to use substances, whether illicit or pharmaceutical, more should be done to keep people safe.

Parliament of Victoria, Australia: Inquiry into drug law reform

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

Drug checking services invite members of the public to anonymously submit psychoactive drug samples for forensic analysis and then provide individualised feedback of results and counselling as appropriate. These services are known under many names, including: drug checking (services), street drug analysis, pill testing, adulterant screening, multi-agency safety testing, and drug safety testing. Here, we use the term ‘drug checking services’, while acknowledging that a lack of agreement about terminology persists.

The rationale for the operation of these services is to inform people who decide to use currently illegal drugs or new psychoactive substances (NPS) about the content and purity of the products, so they can make a more informed decision about whether to use them or how to use them (Brunt et al., 2017). These services also monitor drug market changes and when particularly dangerous drug samples are identified, they can issue tailored public alerts and inform specific harm reduction interventions (Vidal Giné et al., 2017).

In recent times, we have seen the emergence of hundreds of NPS, as well as a rise in purity of substances typically used in nightlife settings, including MDMA and cocaine. In parallel, we have seen the emergence of drug checking services globally. The last time a substantive review of drug checking services was undertaken was in 2001 (Kriener et al., 2001) and this review only covered European countries. A brief updated report released by the EMCDDA recently profiled some aspects of drug checking services, but it again covered the main European services only (Brunt, 2017).

This bulletin is the first time a global perspective has been taken. This work sought to identify and document the features of drug checking services operating across the globe as at 2017.

Publications