By Aileen O’Gorman and Eberhard Schatz / Harm Reduction Journal

In recent decades, a range of civil society organisations (CSOs) (such as drug user groups, non-governmental or third sector organisations, and networks of existing organisations) have sought to shape the development of drugs policy at national and international levels. Tese CSOs engage in peer, professional, and public policy advocacy and seek to efect change mainly through legislation, resource allocation, and service provision.

Civil society involvement in drug, and other, policy making has been enabled by the expansion of ‘democratic spaces’ for civil society participation at national and supranational level. By participating in such spaces (e.g. by writing submissions, or contributing to government committees and consultative fora) and seeking to infuence the formal policy making process, many CSOs have shifted focus from their traditional ‘outsider’ activist role to adopt an ‘insider’ strategy in the belief that social change occurs through politics.

However, the capacity for civil society to infuence harm reduction discourses and drug policies from the inside is shaped by the contexts in which they operate. At a national level, the level of ‘enabling environment’ for civil society is key. So too are the prevailing views regarding drug use and harm reduction, the extent and range of public health services to address drugrelated harms; and the local level of drug regulation and law enforcement. At a supra national level, there are spaces with varying levels of scope for infuencing drug policy. For example, the Vienna NGO committee (VNGOC) facilitates CSO access to the United Nations Ofce of Drugs and Crime and the Commission on Narcotic Drugs (CND); and the EU Civil Society Forum on Drugs provides a platform for dialogue and interaction with the European Commission and for feeding grassroots experience, expertise, and recommendations into European drug strategies and action plans.

Civil society involvement in harm reduction drug policy: Reflections on the past, expectations for the future

By Marie Nougier (IDPC) and Adrià Cots Fernández (IDPC)

For centuries, criminal laws, justice systems, and prisons have been designed for, and by, men. The 2010 United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders, also known as the ‘Bangkok Rules’, break away from this history by establishing the first set of international human rights standards that focus on the specific needs and experiences of women deprived of liberty.

Ten years after the adoption of the Bangkok Rules by the 193 countries represented at the UN General Assembly, states across the world have largely failed to implement them, while the number of women in prison has continued to raise dramatically. By 2020, an estimated 741,000 women were incarcerated worldwide, compared to 636,000 in 2010. The global female prison population is estimated to have increased by about 59% from 2000 to 2020.

This worrying trend has been fuelled by the harshly punitive drug laws adopted at the end of the 20th century. In many countries in Asia and Latin America, drug offences are the main cause for the incarceration of women. In most cases, women are detained for carrying out low-level drug activities, such as transporting drugs, that are characterised by high risk, a high degree of replaceability within illegal drug organisations, and very little financial reward.

Although theoretically ‘gender-blind’, punitive drug policies such as the disproportionate use of pretrial detention, mandatory minimum prison sentences, and the dearth of harm reduction and evidence-based treatment in prisons, have impacted women disproportionately. They have also ignored the causes for women’s involvement in illegal drug activities, which include the intersection of poverty and caretaking responsibilities, and coercion or influence at hands of a male relative or partner. In other words, they have undermined the application of the Bangkok Rules.

For advocates across the world, the 10-year anniversary of the Bangkok Rules is an opportunity to remind states that 

gender equality policies, criminal justice rights and drug laws are not isolated from each other

. If states want to implement a genuine agenda for gender equality, they need to review the laws and policies that undermine it – including drug legislation.

This briefing paper provides analyses the concrete ways in which punitive drug legislation has impacted upon the achievement of the Bangkok Rules, and offers several recommendations on how to translate the commitments set in the Bangkok Rules into drug policy. These include the following urgent recommendations:

Address prison overcrowding by immediately releasing all women incarcerated for minor or non-violent drug offences, including but not limited to drug use and possession for personal use, and non-violent drug supply offences committed by women in situations of vulnerability, and ensure adequate support to transition into the community.

In the context of COVID-19, it is especially urgent to release women with health risks, and women in situation of vulnerability, such as older women, disabled women, pregnant women, women with children, and women responsible for other dependants.

Urgently amend existing laws and policies to ensure that women charged with, indicted for, or convicted of minor or non-violent drug offences are eligible for diversionary measures and alternatives to incarceration and punishment.

Ensure that women who remain in prison during the pandemic have access to strictly voluntary evidence-informed, rights-based, gender-sensitive drug services, including drug dependence treatment, harm reduction and additional support services focusing on addressing past histories of trauma, gender-based violence and mental health.

Punitive drug laws: 10 years undermining the Bangkok Rules

There is an increasing tendency to get service users, such as Drug Users (DU’s) involved in health services and health policies. Participation is seen as an indispensible ingredient for good and effective policymaking and there exist numerous best practice examples of peer involvement in the field of health promotion and prevention. Health policies and health interventions are considered to be more effective and supported, when all relevant parties and communities (including civil society and the final target group) are being involved equally. In addition, policy makers and professionals realise that it is no longer appropriate to talk about and not with the final target group. All kind of communities and also DU’s demand their rights: they want to be heard and they want to be taken serious.

There are numerous ways and forms of participation and also the purpose varies from case to case. One could think of information sharing and consultation or focus on empowerment and joint decision-making. Saying this, it can be assumed, that participation is not only a tool and a method, but also a process and a principle. Yet there are numerous drawbacks which jeopardize the process and make it difficult to respond appropriately. DU’s are often poorly represented in service provision and decision making, although there is evidence that their knowledge and expertise is important and most useful for the development of tailored responses and policies.

‘Nothing about us, without us’ - Participation and involvement of drug users in health services and policy making 

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

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

The elimination of violence against women who use drugs (EVAWUD) - 2020 campaign report

During the lockdown that followed the arrival of COVID 19, many local drug services closed their doors to clients, contacting them instead by internet or telephone. Alongside this, People Who Use Drugs who had attended pharmacies to collect their prescriptions were permitted to cut visits to the pharmacy and being observed by the pharmacist or staff, they visited on a weekly or two-weekly basis. The reduction in attendance at the pharmacy has proved to be useful for drug users, offering a more humane, dignified and therapeutic arrangement.

This fits in with the overall goals of good drug Opioid Substitution Therapy, which should involve a therapeutic partnership between drugs services and those who use them. Therapeutic arrangements should be negotiated and agreed upon, not forced upon clients by the drug service.

Senior policy makers and managers and professional leaders in OST have acknowledged that people on OST in the UK have responded overwhelmingly with responsibility to the opportunity of take-home doses. EuroNPUD has been assured that OST services will focus on reaching the 50% of people with opioid dependence who are not currently accessing OST rather than reintroducing take home dispensing.

Take-home opiate substitute therapies (OST) - EuroNPUD advocacy brief

Medications like buprenorphine, methadone, and morphine bind to the opioid receptors and stop the withdrawal symptoms and cravings. These medications are known as Opioid Substitution Therapies or OST for short. If you have developed a dependence on short-acting opioids, such as heroin, you will get sick about 6-8 hours after you last used. However, OST is longacting and buprenorphine and methadone both work for at least 24 hours. With the right dose, someone with opioid dependence will usually only need to take OST once a day and with the new long acting depot buprenorphine only once per week or per month.

OST is a life-saving medication that takes you away from the challenges of raising money and the risk of going into withdrawals. It also reduces your risk from viruses like HIV and hepatitis and your vulnerability to opioid overdose and police arrest.

We're in this together - All about treatment for opioid dependence from people who have lived it - Client guide

In their Global State of Harm Reduction: 2019 updates, HRI note that the spread of harm reduction services is still stalling globally in continuation of a trend observed since 2012. The 2018 Global State of Harm Reduction 2018 briefing, highlights that although women are estimated to account for one third people who use drugs globally and are consistently reported to have less access to harm reduction services and to be at higher risk of HIV and hepatitis C infection, robust data on this subject is scarce, and research on drug use and related health issues rarely produces information about women.

While tools exist to enable harm reduction services to institute a gender lens and gender mainstreaming in their programming in order to improve relevance and reach to women who use drugs, services that have introduced such approaches are thin on the ground. Where they do exist, there is not necessarily scope to document and promote experience. In order to leverage greater accountability from governments that have endorsed UN guidelines and resolutions around provision of services for women who use drugs, it is important to document and promote such services where they do exist, so that models of replication can be resources and established at other harm reduction programmes, while pressure builds to reverse the stalling of actions that improve respectful access to health for women who use drugs. With this in mind, WHRIN undertook a survey, in order to attempt a ‘mapping’ of women friendly services around the world.

Mapping harm reduction services for women who use drugs - WHRIN regional survey results

By Ernst Wisse et al. / International Journal of Drug Policy

COVID-19 holds the world in a tight grip. In these unprecedented times, health and health-system capacities have been on the top of the global agenda for several months. Many countries have rolled out far-reaching prevention measure such as physical distancing and ‘lock- downs’ to prevent (further) overwhelming of health system capacities.

In many contexts, people who use drugs are a vulnera- ble population, prone to poor access to health services com- pounded by criminalization, and stigmatisation in health-care settings.( UNAIDS, 2019 ) , ( Van Boekel, Brouwers, Van Weeghel & Garretsen, 2013 ) This is illustrated in poor health outcomes and persisting high risk of infectious diseases. For instance, people who inject drugs are left behind in the progress of the global HIV re- sponse with less than 1% living in a country with high level of critical prevention services, such as access to sterile syringes and low-threshold opioid treatment programmes or opioid agonist therapy (OAT).

Marginalised and criminalised communities have greater challenges accessing health services.( UNAIDS, 2019 ) Consequently, a health sys- tem under too much pressure would likely disproportionally impact peo- ple with already established barriers, such as people who use drugs. Looking back at the conceptual building block framework, the notion of equity has been explicitly integrated in the goals of improved health outcome. This underlines that perhaps health systems have a tendency to ‘serve the mass’, and additional attention is needed to ensure equi- table access for all, including criminalised and marginalised communities such as people who use drugs.

COVID-19 and people who use drugs; seizing opportunity in times of chaos

By Correlation European Harm Reduction Network

Harm reduction centres are often the only point of access to health and social services for many PWUD. Preliminary research on the effects of the COVID-19 pandemic on drug services and PWUD has noted decreases in available harm reduction services.

European harm reduction services needed to be innovative and adapt very rapidly in response to the fast-changing landscape of the pandemic and its associated national control measures.

Frontline harm reduction workers play a crucial role in public health response during COVID-19 and are instrumental in implementing these rapid-scale changes required to keep vital services operational.

Their experiences during the pandemic provide critical data to understanding the effect of the pandemic on the vulnerable population of PWUD and the health services they depend on.

Voices of frontline workers: Harm reduction responses in the European region during the COVID-19 pandemic

By Rafaela Rigoni et al. / Harm Reduction Journal

Civil society organisations (CSOs) is assumed to function as intermediaries between citizens and policymakers. CSOs can act as transmission belts that filter societal preferences and channel them to policymakers. In practice, however, their capacity to effectively interact with policymakers varies considerably. In the field of harm reduction, CSOs play an essential role in developing and implementing effective measures to address the negative consequences of drug use. They work directly for, and with, people who use drugs (PWUD) and have a good understanding of their daily needs.

Due to the provision of low-threshold services, civil society-based harm reduction agencies are usually the first contact point for PWUD. For this reason, a functioning relationship between CSOs and decision-makers is crucial in ensuring that the public policy responds to the actual needs of PWUD. The inside knowledge and information of communities and grass-root organisations are critical in developing adequate drug policies and practice. Currently, however, a constructive and respectful relationship between policymakers and CSOs is missing in several European countries. In these countries, decision-makers may have minimal knowledge about what PWUD need, resulting in a lack of adequate, inclusive policies, based on mutual understanding and real needs.

Civil society is increasingly assuming the role of holding governments and donors, among others, accountable, by engaging in independent monitoring and evaluation of services and programmes. It has long been shown that community monitoring can play an essential role in improving service delivery. Moreover, in combination with advocacy, monitoring tools are crucial strategies to hold governments accountable and to improve the implementation of policies and programmes in line with the needs of PWUD and their environments.

Harm reduction in Europe: a framework for civil society-led monitoring

World Report 2021 is Human Rights Watch’s 31st annual review of human rights practices around the globe. It summarizes key human rights issues in more than 90 countries and territories worldwide, drawing on events from the previous year.

In his keynote essay, “Biden’s Challenge: Redeeming a US Role for Human Rights,” Human Rights Watch Executive Director Kenneth Roth addresses the shortcomings and human rights violations of the outgoing Trump administration, while setting forth recommendations for how the incoming Biden administration may help the US reclaim its role as a world leader through global partnerships and recommitting to human rights at home.

One step, as Roth suggests, is to set such commitments to upholding human rights via legislation. Narrow Democratic majorities attained in both houses of Congress from the 2020 election will be invaluable to Biden as he hopes to hit the ground running in his first 100 days. Other commitments, however, such as the ratification of core human rights treaties, will require a degree of bipartisanship not seen during Trump's term in office, since they will require the support of two-thirds of the Senate in order to be passed. As Roth summarizes, "Biden’s task is to find a way, through policy and practice, to make upholding human rights more central to US government conduct in a way that has a better chance of surviving the radical changes in policy that have become a fixture of the US political landscape."

Perhaps the greatest challenge before Biden, is the task of reframing how fundamental human rights are understood in the US. In Trump's final year at the helm, thousands of families seeking asylum at the US-Mexico border were forcibly separated from each other and children were segregated into cages, systemic racism was brought into the spotlight once again as deep-seated racial injustices continued to act with apparent impunity, and the COVID-19 pandemic revealed glaring deficiencies in the country's ability to provide universal access to health care and other basic necessities during a crisis.

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.

More specifically in relation to drug policy, the report highlights numerous human rights violations, including:

Drug policy shortcomings disproportionally punishing those who have the smallest influence in sustaining the illicit drug trade (in Azerbaijan, Georgia, Mexico, the Philippines, Russia, Saudi Arabia, Singapore, Thailand, and the United States).

False drug charges and police raids weaponised for political purposes (in Azerbaijan and the Philippines).

Racial disparities in policing (in the United States).

Widespread violence and killings perpetrated by state and non-state actors (in Colombia, Democratic Republic of Congo, and Syria).

Lack of access or limited access to essential medicines due to conflicts, global health crises, or stigma (in Argentina, Brazil, Bangladesh, Indonesia, Iran, Israel and Palestine, and the United States).

Human Rights Watch: World Report 2021

By Orsi Féher (SSDP) and Juan Fernández Ochoa (IDPC) / Support. Don't Punish

The latest UNODC World Drug Report estimates that the number of drug-related deaths reached 585,000 in 2017. That’s over 65 deaths every hour. Most of these deaths are related to overdose and untreated hepatitis C, which speaks volumes of the multiple health crises at the heart of drug-related harm. Only 1% of people who inject drugs lives in countries where basic harm reduction services are within adequate reach.

Moreover, these tragic numbers do not account for the trail of pain and death resulting from other forms of violence fuelled by the “war on drugs”: disappearances, police and extra-judicial killings, death penalty executions, arrests, incarceration, lack of access to controlled medicines, among many others.

These harms and these deaths disproportionately impact communities already targeted by intersecting forms of oppression. And they can be reduced and prevented through responses that prioritise health and welfare. These include diverse, effective and accessible harm reduction initiatives and services that respond to community needs.

For the last eight years, Support. Don’t Punish campaigners across the globe have mobilised with this purpose, advocating for drug policies and narratives that centre human rights and dignity. For the benefit of all in our communities.

Publications from IDPC Members