The plight of children affected by intractable epilepsy and the efforts of the families of Alfie Dingley and Billy Caldwell to access to medicinal cannabis led to a change in Government policy. In November 2018 medicinal cannabis was changed from Schedule 1 to Schedule 2 of the Misuse of Drugs Regulation 2001, allowing specialist doctors to prescribe it and for products to be available for further research to be conducted.

This rescheduling was widely welcomed but there was a failure to communicate what this would mean in practice for the availability of medicinal cannabis. Expectations were raised that these products would become widely available and there needs to be far clearer communication that this is not the case.

Very few prescriptions have been issued for medicinal cannabis since the rescheduling in November 2018. This is because most of these products are not licensed by the Medicines and Healthcare products Regulatory Agency (MHRA) or the European Medicines Agency (EMA) and neither have they been approved by the National Institute for health and Care Excellence (NICE).

There are major gaps in the research base for medicinal cannabis in part because research was very difficult under the previous scheduling. There were restrictions on accessing products to conduct the robust clinical trials necessary to test efficacy and safety. Without a thorough research base products remain unlicensed and may only be prescribed if the individual prescribing doctor is satisfied that there is sufficient evidence for the product’s safety and efficacy for an individual patient.

Drugs policy: Medicinal cannabis

 Classification of Drugs: when science was left

, the Global Commission on Drug Policy explains how the biased historical classification of psychoactive substances has contributed to the "world drug problem". It is the first-ever comprehensive report providing a political reading of the current evaluation and classification, or "scheduling" of drugs according to their harms.

Psychoactive substances should be classified with regard to their potential for dependence and other harms. This is not the case today, where some substances are legally available because they are considered beneficial (medicines) or culturally important (alcohol), while others are seen as destructive, and are strictly prohibited. The classification of drugs is at the core of the international drug control system. As such, governments must ensure that such a classification is pragmatic and based on science and evidence, makes clear the benefits and harms of drugs, and allows for responsible legal regulatory models to control drugs.

Classification of psychoactive substances: When science was left behind

WHO estimates that 71 million people worldwide were chronically infected with hepatitis C virus (HCV) in 2017. Globally, 23% of new HCV infections and one in three HCV deaths are attributable to injecting drug use (PWID). HCV is also a major concern for people detained in prisons and other closed settings – available data demonstrate that one in four detainees are HCV positive.

This policy brief highlights the current landscape of country hepatitis policies for harm reduction and HCV testing and treatment in PWID and people in prisons. It aims to capture how governments are translating the WHO 

Global health sector strategy on viral hepatitis, 2016-2021

 into national plans, and provides a summary of the enablers and barriers to HCV testing and treatment in these populations.

Access to hepatitis C testing and treatment for people who inject drugs and people in prisons — a global perspective

The title of this report, ‘We Fight, We Hide and We Unite’, reflects the survival strategies we identified amongst resilient harm reduction non-governmental organisations (NGOs) and community networks of people who use drugs (PWUD) in Eastern Europe and Central Asia (EECA). This report details our findings from the situation assessment, ‘The Shrinking Space for Civil Society in Eastern Europe and Central Asia: Coping strategies amongst resilient harm reduction organisations and community networks in the context of a shrinking space for civil society in Eastern Europe and Central Asia’, conducted in the summer of 2017. This assessment forms a part of the regional approach of the AFEW Network within the ‘Bridging the Gaps: health and rights of key populations’ programme (hereafter, the ‘Bridging the Gaps’ programme), financed by the Ministry of Foreign Affairs of The Netherlands. Furthermore, within this programme, the AFEW Network implements four country programmes, namely, in Georgia, the Kyrgyz Republic, Tajikistan and Ukraine.

In EECA, we have observed a diminishing space for civil society organisations (CSOs), perhaps best exemplified by the ‘Foreign Agent Law’ in the Russian Federation. The shrinking civil society space threatens the effectiveness of the response to HIV and other public health issues, particularly as it pertains to the health and rights of key populations. This pillar of the regional approach seeks to build upon progress made and support strategies that work, thereby reclaiming that space for civil society involvement (CSI). In this way, we work towards an effective HIV and public health response that respects the human rights of key populations and the survival of a healthy civil society.

We fight, we hide or we unite: Coping strategies amongst resilient harm reduction organisations and community networks in the context of shrinking space for civil society in Eastern Europe and Central Asia

Across the world people living with HIV, activists, lawyers, health care providers and other allies are trying to bring an end to HIV criminalisation. HIV criminalisation is about using criminal or similar laws to punish or control people living with HIV based on their HIV-positive status. HIV criminalisation usually focuses on the sexual lives of people living with HIV. It places them at risk of arrest when they: (1) don’t disclose their HIV-positive status to a sex partner (or can’t prove they have disclosed); (2) potentially expose their sex partners to what the law considers to be a risk of transmission; or (3) allegedly transmit HIV.

The work activists are doing to end HIV criminalisation is wide-ranging. We are supporting people who are facing HIV-related criminal charges or who have been convicted of HIV-related criminal offences. We are running campaigns to reform or repeal HIV criminalisation laws. We’re reaching out to legislators, government officials and policy makers, and we’re fighting stigmatizing news coverage. Some of us are organising demonstrations, educating our communities and sharing skills and information with scientists, HIV communities, and human rights allies. Others are working hard to end police brutality, gender-based violence and racialized, sexual, and class-based oppression. We are also conducting our own communitybased research and using research published by others to learn about the effects of HIV criminalisation and to support our efforts to change or end the unjust use of laws against people living with HIV.

The purpose of this guide is to help advocates who want to use research in their activism. It is not a guide about how to conduct original research. Instead, it focuses on how to use the results of existing research in the fight against HIV criminalisation.

 ‘‘Using research in the fight against HIV criminalization: a guide for activists’

The NAHRPP project (New Approaches in Harm Reduction Policies and Practices) is a joint project of the Transnational Institute (TNI), based in the Netherlands, ICEERS (Spain), Forum Droghe (Italy) and Diogenis (Greece), supported by the European Union. The project addresses recent drug policy developments in Europe. One section of this project, led by TNI, is focused on the role of local authorities in cannabis regulation. Local and regional authorities across Europe are confronted with the negative consequences of a persisting illicit cannabis market. Increasingly, local and regional authorities, non-governmental pressure groups and grassroots movements are advocating for regulation of the recreational cannabis market, rather than prohibition. This project analyses the possibility of cannabis market regulation models, alongside political, policy, and legal steps under exploration by local authorities in Belgium, Spain, Switzerland, Germany, Denmark and the Netherlands. It is hoped that the information collected through this initiative will help to improve the understanding of regulating drug markets as a means to reduce the negative consequences of illicit drug markets on individuals and society. In order to better understand the situation around, and possibilities for, local and regional cannabis regulation, a series of six country reports were developed, providing background for an overarching analytical report. The country reports provide detailed information about the state of cannabis policy, and the possibilities for change, within each country. These reports address the past, present, and future of cannabis policy domestically accross the EU.

Cannabis regulation in Europe - Country reports

Is drug checking a valuable tool to reduce the harm of drug use? In many countries this is still an ongoing debate, one often hampered by lack of empirical evidence and practical experience. In the Netherlands, government-licensed drug checking has occured for over the past two decades and has grown from a small scale project into a nationwide scientific monitor.

As one of the world’s oldest drug checking services, the ‘Drugs Information and Monitoring System’ (DIMS) can provide advice and insight from lessons learned on how to set up and operate a drug checking service to all international collaborators, many of whom are taking their first steps in providing national drug checking programs.

This factsheet offers an overview of the history, organisation, common practice and strategies for warning campaigns of DIMS, and aims to serve as an objective insight into the ins and outs of drug checking as being executed in the Netherlands. While political and public opinion on the subject differs from country to country, sharing information will have its value for public health for certain.

The Drugs Information and Monitoring System (DIMS) - Factsheet on drug checking in the Netherlands

Since the 1960s, the “War on Drugs” had started to take shape, not just in the US, but globally. By 1988, the United Nations Member States had ratified 3 major conventions that have fuelled criminal and repressive approaches to many forms of drug use. The War on Drugs has become a conflict of enforcing prohibitionist policies on the manufacture, distribution, and consumption of “illegal drugs.” However, now, after more than forty years of a militaristic approach to a public health problem, there continues to be an increase in narcotics production in the so-called “global south” and rising rates of consumption particularly in northern economies. Even more importantly, in recent years, there have been grave concerns about the global response to drugs; it has become more than clear that the War on Drugs not only perpetuated, but fuelled, severe human rights abuses towards people who use drugs, was not effective in its stated goals to curb drug use, and only worsened public health issues, especially in the context of HIV.

In the past decade a growing movement for reform of the outdated punitive approach has started to gain traction. Not only local, regional, and global civil society organisations, but also UN agencies are speaking out more and more in favour of drug policy reform and the need to provide people centred and rightsbased harm reduction services to people who use drugs. The harms of a continuing punitive approach that effectively criminalises people who use drugs are inconsistent with basic human right principles. In 2019 the UN System Task Team’s published a report entitled “What we have learned over the last ten years” speaks out strongly against the violent consequences of the War on Drugs.

Unexpectedly, global drug policy has influenced the African region significantly. Criminalisation of the possession of drugs for personal use remains across the southern African region and in many places harm reduction policies are not available; in places where policies are available to provide harm reduction services, implementation is often still lacking. In 5 countries where this report has done focus groups with people who use drugs it shows clearly that repressive policies lead to an environment of impunity of violence by the police, government stakeholders, and the wider community. Extreme levels of stigma are fuelled by criminalisation f drug use and possession within the communities that people who use drugs live. Even more worrying is the added burden of people who use drugs who live with HIV, who struggle to access ART, and of women who use drugs who face added issues of gender-based violence. Through linking the prevailing laws and policies with the lived experiences of people who use drugs this report provides clear evidence of the dehumanising effects of the continuing repression.

"Don't treat us as outsiders" - Drug policy and the lived experiences of people who use drugs in Southern Africa

By Trimbos, Mainline, Correlation and NIHR

In the Netherlands, for many years drug consumption rooms (DCRs) are one of the harm reduction interventions run by addiction treatment and social relief services. The first formal drug consumption room was run by an addiction treatment service2 and opened its doors 10 June 1994 in Maastricht. Since then, the number of drug consumption rooms increased, primarily aiming for the reduction of drug-related nuisance in the streets and public spaces. In the 21st century, the need for specific drug consumption rooms decreased, due to the many initiatives that took place in the field of housing of homeless people who use drugs (PWUD) (such as hostels and ‘around the clock (24/7) shelters’). Changes in the objectives of DCRs were noted over time, as more facilities now have included health promotion for PWUD as a main target. And since the 2010s, addiction care services are shifting their objectives towards recovery, which includes societal, social and personal recovery.

When describing and defining a DCR, a number of key aspects always pop up: safer drug use, nuisance control and reduction of adverse health effects. In this inventory, we use the following definition: “Drug consumption rooms are facilities where (homeless) people struggling with a drug addiction can use their drugs in a hygienic and quiet environment, with social workers present in the background. Drug consumption rooms aim to reduce nuisance in the neighborhood and to reduce the adverse health effects of drug use“ (Standard of Care Opiate Addiction3 , 2017) (Zorgstandaard Opiaatverslaving, 2017). Aside from drug consumption rooms, there are also a number of alcohol consumption rooms in the Netherlands, aiming to reduce nuisance caused by drinking in public. However, in this report we focus on DCRs.

Drug consumption rooms in the Netherlands were last monitored in 2013 (Laghaei et al., 2013). In 2013, for the first time since the monitoring of DCRs since 2000 (Linssen et al, 2002), a decrease in number was noted; 31 DCRs in 2013 compared to 37 in 2010 (Havinga & Van der Poel, 2011). In order to keep track of DCR developments over the years, a periodic inventory is needed. Therefore, Trimbos Institute, Mainline and Correlation/ European Harm Reduction Network initiated this new inventory.

Drug consumption rooms in the Netherlands

By the National Institute for Health Research (NIHR)

Handy little pocket-sized booklet explaining the issue of syringe dead space, and why it makes a difference.

DEAD SPACE is the space between the needle and the plunger when the plunger is pushed all the way down. Blood and drug remain in the dead space after injecting. Some works have a higher dead space than others so there’s more blood and drug left. This blood could contain viruses like HIV or Hepatitis C. The lower the dead space, the smaller the amount of blood left inside and the lower the risk of catching viruses if works are accidentally shared. Low dead space needles and syringes have less space, so there is less risk. If you use low dead space needles and syringes:

• Less chance of catching viruses if you accidentally share works

• No need to flush as flushing damages veins

• Easier to clean out any viruses from low dead space needles and syringes

Low dead space needles and syringes: What and why?

This paper provides an overview of established and emerging cannabis products in Europe. For each type of product, major issues in its production, distribution, use and effects on health are detailed. In doing so, the paper seeks to inform a discussion of the new challenges that may emerge in the monitoring of these products and the consequences of their use. At the time of writing, regulated markets for recreational cannabis had yet to emerge in Europe, though the policy in some countries in the Americas is rapidly shifting towards the legalisation of the recreational and medical use of cannabis. It is therefore timely to provide an overview of the diversification of cannabis products in Europe, to contribute to the available knowledge on cannabis market changes and their implications for policy and practice. While there are other aspects of relevance, including the modus operandi of organised crime groups and traffickers, prevalence and other consumption metrics, these are not addressed in this report, as detailed information is provided in other European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) publications.

Cannabis is by far the most widely used illicit drug in the European Union (EU), accounting for 38 % of all money spent on the illicit drug retail market (EMCDDA and Europol, 2016). Among adults (aged 15-64), it is estimated that 24.7 million (7.4 %) have used cannabis in the last year (EMCDDA, 2019). The two main cannabis products used in Europe are herbal cannabis (marijuana) and cannabis resin (hashish). In Europe, these are typically smoked in joints (rolled cigarettes) containing tobacco (Hindocha et al., 2016).

The cannabis plant synthesises at least 144 unique compounds known as cannabinoids (Hanuš et al., 2016). The most abundant of these is ∆9-tetrahydrocannabinol (THC). THC produces the effects that people who use cannabis seek from the drug, such as feeling ‘high’ and relaxed with changes in the perception of colours and sounds. THC can also cause unwanted effects such as memory impairment, anxiety and paranoia. These adverse effects become more severe with higher doses of THC. Concentrations of THC in cannabis products have risen in recent years, and evidence suggests that users only partially adapt to changes in THC (Curran et al., 2016). As a result, people who use cannabis may have been exposed to rising doses of THC over time. These changes may have increased the level of adverse health effects related to cannabis use. In Europe, the number of first-time admissions to drug treatment for cannabis problems increased by 76 % from 2006 to 2017 (EMCDDA, 2019). It is possible therefore that an increase in the concentration of THC in cannabis is associated with this increase in admissions to treatment. These differ from synthetic forms of THC (e.g. dronabinol) and from synthetic cannabinoid receptor agonists, or ‘synthetic cannabinoids’, which are discussed later in this report. (Freeman et al., 2018). However, conclusions in this regard need to be made with caution, as other factors — such as a greater awareness of cannabis-related treatment needs, an overall increase in the level of provision and changes in referral practice, including direct referrals from the criminal justice system in some countries — could also explain this increase.

Cannabidiol (CBD) is typically the second-most abundant cannabinoid produced by/in the cannabis plant. CBD is nonintoxicating and has shown promise as a treatment for several medical conditions including epilepsy, psychosis and anxiety disorders (Bergamaschi et al., 2011; Devinsky et al., 2017; McGuire et al., 2017; EMCDDA, 2018b). CBD has been found to offset some of the harmful effects of THC, such as memory impairment and paranoia, without influencing the ‘high’ sought by users (Englund et al., 2017). Some evidence also suggests that the balance of THC to CBD may contribute to the level of harm experienced from long-term cannabis use. While frequent use of cannabis with high THC to CBD ratios has been associated with a greater risk of psychosis and dependence, it has been argued that this is less commonly observed with the use of cannabis with a more balanced THC to CBD ratio (Di Forti et al., 2015; Freeman and Winstock, 2015). It has also been suggested that encouraging the use of cannabis with a more balanced THC to CBD ratio may therefore be a strategy for harm minimisation (Englund et al., 2017).

THC and CBD are both synthesised by/in the cannabis plant in the glandular trichomes. These structures are resinous and sticky, helping to defend the plant against herbivores and environmental stresses. They differ from non-glandular trichomes, which occur in either cystolithic (found on the upper surface of the cannabis leaves) or non-cystolithic (appearing mainly on the lower side of the leaves and bracts) form. Capitate-stalked trichomes (Figure 1) are most abundantly distributed around the female flowers and produce the highest quantity of cannabinoids (Turner et al., 1978). Maximising the production of these capitate-stalked trichomes (and/ or improving the efficiency of extracting THC from them) is a key method for increasing the potency (2) of cannabis products. Bulbous trichomes are also glandular but are smaller in size and produce fewer cannabinoids. In addition to the cannabinoids, glandular trichomes also contain essential oils known as terpenes, which give cannabis its distinctive odour. Variations in the terpene profile affect the experience of using cannabis by influencing its taste and smell, and may influence its pharmacological effects (Russo, 2011).

Developments in the European cannabis market

狱自成立以来，毒品政策全球委员会一 直呼吁对非法毒品消费去罪化，并对低 层次非暴力犯罪者采用监禁以外的替代方 式。今日，全世界被监禁的人数量已经过 千万。其中五分之一是因为毒品相关犯罪 被监禁，而且其中83%的人仅因为持有个 人使用的毒品 。委员会认为监禁是基于禁 制的毒品政策的没能达成目标的体现，也 表明实施的政策没能将个人与社群的健康 和权利放在刑法手段前面。

狱监狱是毒品政策失败的后果：没能减 少毒品需求、毒品供应或削弱跨国有组 织犯罪的力量。当国家采取剥夺自由的手 段，就有义务为被拘禁者提供关怀，担负 特殊责任。很多国家却没能做到这些。

Publications