The 45th meeting of the Programme Coordinating Board (PCB) took place in calmer waters than the previous meetings of the board. The venue was, as usual, the Executive Boardroom of the World Health Organization (WHO) in Geneva, Switzerland and the meeting was held from December 10 -12, 2019. It was the first meeting of the newly appointed third UNAIDS Executive Director in the history of the Joint Programme, and the first woman to hold that position, Ms. Winnie Byanyima from Uganda. The meeting was chaired by Ms. Li Cui from China.

Winnie’s report to the board was generally well-received, including by the NGO Delegation. Yet, as the current UNAIDS Strategy nears its expiration date in 2021, her report initiated a debate among members of the board about a possible next UNAIDS Strategy and the process involved. This discussion was closely linked with the agenda item that reflected on the report of the Joint Inspection Unit (JIU).

Just as in previous years, the first two days of the PCB discussed the report by the NGO Delegation and several other more policy and programme-driven items such as prevention, barriers to funding of community-led responses, and the Global Partnership for action to eliminate all forms of HIV-related stigma and discrimination. The third day of the meeting focused on the Thematic segment to inform the members of the PCB about possible actions to reduce the impact of AIDS on children and youth.

The PCB NGO delegation's communique: 45th Programme Coordinating Board meeting

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

These guidelines serve to provide a common understanding for operating the European Union Early Warning System on new psychoactive substances (Early Warning System) by detailing the rationale, steps, procedures, roles, and responsibilities. They reflect the requirements of Regulation (EC) No 1920/2006 (as amended) and Council Framework Decision 2004/757/JHA (as amended) with respect to information exchange and the Early Warning System, as well as those for the initial report, risk assessment, and control measures with respect to accepted scientific principles and required scientific evidence.

EMCDDA operating guidelines for the European Union Early Warning System on new psychoactive substances

At the invitation of the Middle East and North Africa Harm Reduction Association (MENAHRA), and in collaboration with the United Nations Development Program (UNDP), the Joint United Nations Program on HIV/AIDS (UNAIDS), he International Development Law Organization (IDLO), the United Nations Office on Drugs and Crime (UNODC), the Law Enforcement and HIV Network (LEAHN); the third Consultative Meeting on “Law Enforcement and the Rights of People Living with and affected by HIV” was held at the Crowne Plaza Hotel in Beirut between 2 and 4 October 2019.

The meeting was attended by 28 people representing law enforcement agencies and civil society organizations in eight Arab countries: Morocco, Algeria, Tunisia, Sudan, Egypt, Jordan, Bahrain and Lebanon, in addition to representatives from UNDP, UNAIDS & IDLO. The objective of the meeting was to promote the positive engagement of law enforcement agents in the HIV response in selected countries in the region, and to create a common understanding and agreement between partners and participants on strategic human rights-based HIV programming and a roadmap to improve the legal environment in the region.

Law enforcement and the rights of people living with and affected by HIV

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

By the Committee on Legal Affairs and Human Rights

At its meeting on 15 November 2019, the Committee on Legal Affairs and Human Rights of the Council of Europe’s Parliamentary Assembly adopted a landmark report on “Drug policy and human rights in Europe: a baseline study”. The report, submitted by British deputy Hannah Bardell, highlights that purely repressive policies have generated many human rights abuses, such as discrimination, the use of excessive force, disproportionate sentencing and prison overcrowding, with detrimental impact on public health.

On the basis of the report, the committee recommends the adoption of evaluation mechanisms, with the identification of indicators based on international human rights standards and the implementation of data collection methods on the effects of drug policies on health, crime and equality.

Furthermore, parliamentarians stress the importance for member States to prioritise education on the risks of drugs as a prevention measure, use harm reduction as well as treatment and rehabilitation services, and to ensure that criminal justice responses to drug-related crimes respect human rights, in particular by prohibiting “arbitrary arrest and detention, the use of excessive force and disproportionate sentencing against people who use drugs”.

The report was also discussed by Permanent Correspondents of the Pompidou Group at their plenary meeting held on 20-21 November 2019 in Strasbourg, where an exchange of view took place with Sunna Ævarsdóttir, deputy from Iceland and chair of the Committee on Legal Affairs and Human Rights.

Another report on “Involuntary addiction to prescription medicines” is under preparation in the Committee on Social Affairs, Health and Sustainable Development of the Parliamentary Assembly, which was also commented on by the Permanent Correspondents in an exchange of views with the Secretary of the committee.

Council of Europe parliamentarians discuss drug policy and human rights

By Taylor Fleming, Allison Barker , Andrew Ivsins, Sheila Vakharia and Ryan McNeil

Background: Occurring against the backdrop of an overdose crisis, stimulant use and stimulant-involved deaths in North America are increasing at an alarming rate. Many of these deaths are being attributed to fentanyl and related analogs, which have been increasingly found within street-level stimulant supplies. Within this, people experiencing socio-economic marginalization are at the greatest risk of overdose and other harms from adulterated stimulants. Current treatments for stimulant use disorder have limited effectiveness, and even less applicability to the lived realities of marginalized stimulant users. Emerging technologies, such as drug checking, are being implemented to support safer stimulant use, but the accessibility and utility of these technologies to stimulant users are framed by experiences of vulnerability that render them largely ineffective.

Stimulant safe supply: Solutions that provide a legal and safe supply of non-adulterated stimulants of known quality, and within a health care framework, are needed to directly address the risk of an increasingly adulterated stimulant supply. Similar innovative opioid-focused interventions are being piloted with medications that have a similar pharmacological effect as their illicit counterparts. While there are currently no approved pharmacotherapies for stimulant use, research has demonstrated a number of stimulant medications that are promising substitutes for cocaine and methamphetamine use. Much like with opioid-focused pharmacotherapies, having a consistent and safe supply of stimulants can lead to improved health outcomes and will drastically reduce overdose risk. However, for a stimulant safe supply intervention to be a success, it must provide the high and performance-enhancing effects that people seek from the illicit market, which requires doses and user agency that trials to date have not provided.

Conclusion: Efforts are needed to investigate the feasibility of pharmacological stimulant-based interventions that address safe supply needs. The promise of similar opioid-focused approaches in addressing both overdose-related risks and experiences related to vulnerability underscores the need to advance safe supply approaches targeted towards people who use stimulants. Given the current overdose crisis and rising stimulant use across North America, the implementation and evaluation of such novel stimulant-focused interventions should be a public health priority.

Stimulant safe supply: A potential opportunity to respond to the overdose epidemic

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

In 2016 the Government published a landmark White Paper, ‘Prison Safety and Reform’, which promised to deliver much-needed changes to the prison system. It committed to address poor safety for staff and prisoners, high levels of assaults, the poor condition of the estate, poor retention in the workforce, and ultimately poor outcomes for reoffending.

Since the Government laid out its plans for “the biggest overhaul of our prisons in a generation” progress has been poor in several key areas:

Prisoner-on-prisoner and prisoner-on-staff assaults have increased by 30 per cent since 2016.

Incidents of prisoners self-harming have increased by 65 per cent since 2016.

The leaving rate for band 3-5 staff – operational prison officers – has increased by 32 per cent since 2016.

In the 12 months to March 2019, 17 per cent of drug tests on prisoners were positive.

Nearly £529 million intended for spending on the prison estate has been diverted to spending on the day-to-day running of prisons since 2016.

Significant resource pressures on prisons are likely to have held back the progress of reforms. The White Paper promised prisons the “resources, authority and tools” to address these challenges, but real-terms resource spending on prisons fell in 2016-17 and 2017-18. Her Majesty’s Inspectorate of Prisons (HMIP) has highlighted that “reduced resources, both in terms of staff and investment [has] made it extremely difficult” to run prisons.

Increasing spending is an opportunity to make progress – if targeted effectively. In 2018-19, Her Majesty’s Prison and Probation Service’s (HMPPS) resource budget rose by 4 per cent in real terms to over £3.9 billion. Several further commitments have been made: £2.5 billion for 10,000 additional prison places, £100 million for enhanced security, and £156 million for maintenance. To make the most of this increased spend the Government should focus on four priorities: more effective sentencing policies, creating a fit-forpurpose prison estate, improving prison safety, and developing the workforce.

The prison system in the UK: Priorities for investment 

By Hakique N. Virani, MD and Rebecca J. Haines-Saah, PhD

Since 2016, more than 10,300 Canadians have died of an apparent opioid-related overdose, with the majority involving fentanyl or fentanyl analogs. This unprecedented public health crisis has decreased life expectancy at birth in the country’s most affected provinces of Alberta and British Columbia. Concerned by this epidemic of overdoses, Canadian advocates for drug policy reform have welcomed the recent recommendation from British Columbia’s Provincial Health Officer that drug possession for personal use be decriminalised. Canada’s national newspaper, the Globe and Mail, published an editorial endorsement of this recommendation stating that “addiction, the compulsion to use drugs, is largely a health problem—not a criminal-law problem.” Indeed, the topic of decriminalization was also front and center at this Spring’s Harm Reduction International conference held in Portugal, a country often cited for leadership in implementing effective, health-driven policies on illicit drug use that included decriminalizing drug possession. The growing chorus of voices now calling for drug policy change is encouraging. However, the underlying reasons for a new policy direction are critically important and, on that, many well-intentioned newcomers to the chorus are somewhat offkey. The central cause for drug law reform is not its relevance to health or the present public health catastrophe. It is a matter of correcting a social injustice. Failing to articulate this in public discourse risks perpetuating harms on the people decriminalization advocates wish to help.

Public health dialogue must highlight the history, evolution, and manipulation of drug policies and should compel reformation of laws rooted in racism and subjugation as a matter of correcting injustice and inequity, not only promoting better health. In Canada, the Opium Act of 1908 was used to portray Chinese Canadians as an outside threat, despite that it was Canada’s colonizer, Britain, who drove opium use in China, smuggling enough product from British Bengal to reverse a trade deficit and create immense demand. In the U.S., Presiddent Nixon’s War on Drugs declaration of 1971 vilified those who opposed him and the Vietnam War by disproportionately criminalizing drugs popular among black Americans, student demonstrators, and anti-war pacifists. Drug policies in North America and beyond continue to achieve their original discriminatory and oppressive intents. In Canada, Indigenous people in some regions are almost nine times more likely to be arrested for drug possession, and black Canadians are more than five times as likely to be arrested despite similarities in illegal substance use across racial groups. In the U.S., between 2001 and 2010, black Americans were more than 3.73 times more likely to be arrested for cannabis possession than white Americans despite a roughly equal prevalence of use. With more than seven million arrests for cannabis possession during that period, the disparity is no small matter.

Describing substance use as a health issue suggests that solutions lie in the health domain, but this is often inconsistent with the lived experiences of people using drugs. Medical approaches that do not account for social and structural factors potentially entrench stigma and further disempower people who already experience diminished agency over their life circumstances. Especially for those experiencing social injustices that increase their risk of isolation and harm, healthcare systems that typically view illicit substance use as a hedonistic personal health behavior (without other functions or benefits) can be disengaging. Regarding healthcare professionals, one of the most concerning health outcomes of drug use is addiction, and because medicine characterizes addiction in part as using drugs despite associated problems, many quickly conclude that people who use illicit substances at all are addicted and irrational. Under this incorrect assumption, ideas like involuntary treatment and forced abstinence naturally gather momentum even though they are inconsistent with scientific evidence and the paramount medical ethic of respect for autonomy. When their presenting concerns are frequently dismissed as only drug-related, people who use drugs therefore often experience healthcare settings as stigmatizing or dictatorial. Likewise, when people using drugs encounter the view held by some medical professionals that their illicit substance use is necessarily problematic (i.e.,“disordered”) or antisocial, it should not come as a surprise that many leave health care feeling more dejected, debased, and desperate than before they sought care.

How the rationale for decriminalization is framed and the terms that are used to describe the need for drug policy reform extend beyond semantic concerns. Framing has important implications for policy responses and the allocation of resources. Just as media and governments inaccurately interchange the phrases “overdose crisis” and “addiction crisis,” health professionals commonly see“health issue”and“health problem”as the same. Yet, population studies have shown that most people who use substances do not have an associated health problem, such as addiction, and that most people with addiction eventually stop having drug problems without any medical intervention. Commonly, people describe substances as a temporary solution to problems and not as a health behavior that results in them. If the substance they choose is criminalized, however, they may only have access to more toxic illicit drug analogs that are easier to traffic, and their risk of death from accidental overdose is heightened whether they use them occasionally or compulsively.

A rising body count does present an opportunity in a callous political world to advance progressive drug policy, and portraying drug use as a health issue might evoke sympathy from voters rather than derision. But this narrative skirts necessary uncomfortable conversations about inequity and injustices, and those should be the lede. Drug law reform is a small part of addressing indefensible wrongs such as poverty, homelessness, xenophobia, gender discrimination, and the inexcusable conditions facing Indigenous peoples. These inequities are not distinct from the public health crisis of deaths from overdose, and they need to be foremost in the dialogue on policy imperatives. It should not take an epidemic of fatalities for structural injustices to be corrected, and it should not take biomedical explanations of behavioral differences to accept people as they are. If it does, just like with drug laws, by the time people get around to fixing things, unforgiveable damage will be done.

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