By Nazlee Maghsoudi & Jeanette Bowles & Dan Werb

The increasing incidence of fatal opioid overdose is a public health crisis in Canada. While buprenorphine/naloxone and methadone are the standard first-line of opioid substitution options, limitations, including difficulty achieving long-term retention for some people who use opioids, are well known. For this group, injectable diacetylmorphine or hydromorphone can achieve positive outcomes, including high retention rates, reduced use of unregulated opioids, and reduced criminal activity. In May 2019, Health Canada announced changes to increase the accessibility of diacetylmorphine and hydromorphone, and in September 2019, the CIHR-funded Canadian Research Initiative in Substance Misuse released a national clinical guideline for diacetylmorphine and hydromorphone as additional frontline substitution options. While these developments present opportunities for scale-up, significant financial, structural, and practice barriers continue to impede access. This commentary explores the current state of policy and practice for diacetylmorphine and hydromorphone as opioid substitution options in Canada, outlines the rationale for rapid expansion of access, and highlights clinical and policy changes that must be undertaken or the death toll will continue to rise.

Expanding access to diacetylmorphine and hydromorphone for people who use opioids in Canada

: Josefina Alfonsín, Gerardo Contreras Ruvalcaba, Kenya Cuevas, Teresa García Castro, María Santos, Ari Vera Morales

Across the world, trans women have been subjected to discrimination, criminalization, and institutional violence. They often face social exclusion, violations of their human rights, and transphobia. In many cases, these factors lead to them working in highly criminalized informal economies, such as the drug trade, sex work, or sex for survival. As a result, police profile them as being dangerous, making them more vulnerable to police abuse and to being incarcerated. While data is sorely lacking, our research indicates that trans women are overrepresented in prison as compared to other groups, and they are much more likely to suffer abuse and violence behind bars than other populations. In addition to the challenges that incarceration imposes on any person deprived of liberty, trans women face particular challenges with regard to housing, their identification, body searches, access to medical services, privacy, and conjugal visits, among other issues. Despite this situation, trans women who have been deprived of liberty have demonstrated their capacity for agency and created organizations to defend their rights. In countries such as Argentina, Mexico, and Uruguay, groups of trans women are building a social movement based on different types of resistance and the development of political agendas.

Meanwhile, the absence of standards and public policies to protect the rights of trans women deprived of liberty is widespread in Latin American countries. The lack of disaggregated data, efforts to monitor this population’s situation of vulnerability, and related studies have deepened ignorance about these realities and hindered public policy design. Given the dearth of information on this issue, this report explores the framework of rights protection for trans women deprived of liberty, the statistical data available, structural inequalities existing prior to detention, living conditions in contexts of confinement, post-release social reintegration, trans women’s experiences of agency, along with good practices in the region. Furthermore, the report provides public policy recommendations to guarantee the full exercise of this population’s dignity and protection of its human rights.

: Almas Cautivas A.C, Casa Hogar Paola Buenrostro, Casa de las Muñecas Tiresias A.C., Dejusticia, Equis Justicia para las Mujeres, International Drug Policy Consortium (IDPC), Procuración Penitenciaria de la Nación de Argentina, Red Corpora en Libertad, Washington Office on Latin America (WOLA)

Trans women deprived of liberty: Invisible stories behind bars

This guide is aimed at those who work with and advocate for women who use drugs in all their diversity. It equips them with practical, evidence-based interventions which will help advance the sexual and reproductive health and rights (SRHR) of women who use drugs. It is based on the experiences of Frontline AIDS partners and others in implementing community-led harm reduction programmes in Kenya, India, Indonesia, Nigeria, Tanzania, Uganda and Ukraine from 2011 to 2020 through the Community Action on Harm Reduction (CAHR), PITCH, and Integrated Harm Reduction programmes, and others. It is informed by the recommendations of the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights 2018 report. The guide was developed in consultation with communities of women who inject drugs in select countries, and technical input was provided by the Women and Harm Reduction (WHRIN) Advisory Group.

Part 1 describes the current context for women who use drugs in relation to their SRHR. This part includes considerations of available data; the intersection of drug use with gender inequality, gender norms and stereotypes that create additional barriers to services for women who use drugs; and gender-based violence. It introduces the Guttmacher-Lancet Commission on Sexual and Reproductive Health and Rights’ 2018 definition of SRHR, and the essential service package, alongside the World Health Organization’s package for comprehensive harm reduction services.

Part 2 elaborates seven essential SRHR interventions for women who use drugs, and an additional sub-section on the sexual health and well-being of women who use drugs. Short case studies from Frontline AIDS and partners’ harm reduction programmes, as well as other NGOs, provide examples of successful interventions. In conclusion, we draw on priority recommendations from the Guttmacher-Lancet Commission for achieving SRHR that are most relevant to the context of women who use drugs.

Advancing the sexual and reproductive health and rights of women who use drugs

The criminalization of people who use psychoactive substances in the Central and Eastern Europe, and Central Asia (CEECA) region, instead of maintenance of public health and safety, increases the financial and social burden on the states. For people who inject drugs, approximately 58% will experience incarceration in their life.

Incarceration costs 2 to 6 times more than treatment from health and social service groups. However, in almost all the countries in the CEECA region, due to de facto criminalization of people who use psychoactive substances, harm reduction and other health services are severely underfunded and depend on international donors. Guidelines from the World Health Organization recommend that at least 40% of people who use opioids receive opioid substitution therapy (OST); however, most countries in the CEECA region barely reach 20%.

Governments should take evidence-based health and human rights approaches and reallocate money from policing, prosecuting, and incarceration of people who use psychoactive substances to community harm reduction and health services.

The guide contains 11 statements, followed by supporting arguments, which should be used in advocacy work. Arguments are prepared based on existing practices and evidence-based information. Arguments are created to advise on advocacy of reallocating funds from law enforcement budgets to health and harm reduction budgets for people who use psychoactive substances.

Criminalization costs in the CEECA region - A pocket guide

In 2019 EHRA together with Support, Research and Development Centre (SRDP), the Ukrainian Network of People who use Drugs (VOLNA), Drug-users Ukraine, the Drop-in Centre and the ENEY developed the methodology to access the client satisfaction with opioid maintenance therapy and conducted the pilot study in Kyiv and Kyiv Oblast region. Our approach to this study was based on the principles of equal partnership with the community of people who inject drugs and/or receive opioid maintenance therapy (OMT).

Almost from their very first days, OMT programmes in Ukraine have come under close scrutiny from the international research community. We believe that attention has been drawn to OMT programmes in Ukraine because of the low annual numbers of new patients throughout the period of the OMT implementation projects. According to UNAIDS, the estimated number of people who inject drugs in Ukraine is 346,000 individuals, of whom only 11,853 (or less than 3.5%) currently receive OMT services. The lack of attention paid to treatment satisfaction in Ukraine can probably be attributed to a shift in emphasis towards the needs of increasing service coverage, even while the quality of service is seldom included in ongoing discussions. Since OMT programmes have been operating in Ukraine for more than 10 years, the study of patient satisfaction with treatment offers opportunities for a better understanding of OMT service development prospects in the long run and of treatment trajectories and changing needs at the patient level.

As the design of this study was based on qualitative and quantitative methodological components, it was implemented in the framework of the mixed–method approach. The protocol and tools of this study were reviewed by the Ethics Review Board of the Ukrainian Institute on Public Health Policy.

The quality component of this study was implemented through semi-structured interviews with patients of OMT programmes.Within the scope of the study, the main purpose of semi-structured interviews was to highlight various aspects and criteria of satisfaction with OMT services among patients in order to develop a data-based questionnaire tool.

376 OMT patients took part in the pilot assessment, 178 structured interviews were conducted with patients who get OMT for free at state-funded OMT sites, 198 interviews were conducted with patients who buy OMT drugs in pharmacies after getting prescription at OMT sites based in private clinics. An overall satisfaction with OMT treatment is assessed as high and very high in 72% OMT patients, but the particular aspects of OMT treatment are not that highly assessed. The quality of medical care at OMT site is assessed as satisfied by 49%, 42% are satisfied with the physical environment at OMT sites and only 34 % of survey participants assess the psycho-social support as satisfied. At the same time, 89% of respondents mentioned that OMT is a vital need for them.

Based on the results of this study, we can draw the following conclusions and make some recommendations for further advocacy:

Studies like this conducted using a routine monitoring format as an integrated component of the monitoring and evaluation framework at OMT sites could help us understand the dynamics of satisfaction with treatment and treatment environment, interactions with OMT service providers and subjective treatment experiences. Which in turn could influence the long-term patient retention in OMT programmes.

For an improved understanding of the goals and outcomes of the treatment of chronic diseases like drug addiction, we recommend considering the assessment of patient quality of life as an indicator of treatment efficiency.

Survey of client satisfaction with OMT services among participants in Kyiv and the Kyiv Oblast region: A pilot study report

Venezuela’s state institutions have deteriorated and the country lacks an impartial, transparent, or even functional justice system. In this environment, armed groups and organized criminal structures, including drug trafficking groups, have thrived. But U.S government data suggests that, despite these challenges, Venezuela is not a primary transit country for U.S.-bound cocaine. U.S. policy toward Venezuela should be predicated on a realistic understanding of the transnational drug trade.

Recent data from the U.S. interagency Consolidated Counterdrug Database (CCDB) indicates that 210 metric tons of cocaine passed through Venezuela in 2018. By comparison, the State Department reports that over six times as much cocaine (1,400 metric tons) passed through Guatemala the same year.

According to U.S. monitoring data, the amount of cocaine trafficked from Colombia through Venezuela is significant, but it is a fraction of the cocaine that is sent through other transit countries. Around 90 percent of all U.S.-bound cocaine is trafficked through Western Caribbean and Eastern Pacific routes, not through Venezuela’s Eastern Caribbean seas.

There was an increase in cocaine flows through Venezuela in the period from 2012 to 2017, but that increase corresponds with a surge in cocaine production in Colombia during that same time. CCDB data suggests the amount of cocaine trafficked through Colombia rose from 918 metric tons in 2012 to 2,478 metric tons in 2017 (a 269 percent increase), and from 159 to 249 metric tons in Venezuela in that same period (a 156 percent increase). When cocaine trafficking in Colombia dropped slightly post-2017, cocaine flows in Venezuela fell as well.

U.S. CCDB data shows that cocaine flows through Venezuela have fallen since peaking in 2017. According to CCDB data, the amount of cocaine flowing through Venezuela fell 13 percent from 2017 to 2018, and appeared to continue to fall slightly through mid-2019.

A peaceful, negotiated, and orderly transition offers the best chance of allowing the reforms needed to address organized crime, drug trafficking, and corruption in Venezuela. The 2009 military coup d'etat and resulting turmoil in Honduras provides a cautionary tale for U.S. policymakers who see intervention or collapse as the best way route for a return to democracy in Venezuela.

Beyond the narcostate narrative: What U.S. drug trade monitoring data says about Venezuela

As the COVID-19 pandemic affects more people in an ever increasing list of countries, PRI has published a briefing note, 

Coronavirus: Healthcare and human rights of people in prison

. With the fast-evolving situation, there is legitimate concern at a further spread of the virus to places of detention. The difficulties in containing a large outbreak in detention facilities are clear. People in prison and the personnel who work with them are in close proximity and in many cases in overcrowded, cramped conditions with little fresh air. People in detention also have common demographic characteristics with generally poorer health than the rest of the population, often with underlying health conditions. Hygiene standards are often below that found in the community and sometimes security or infrastructural factors reduce opportunities to wash hands or access to hand sanitizer – the key prevention measures recommended by the World Health Organization.

While legitimate measures in times of such an emergency are needed to prevent further outbreaks of COVID-19 in prisons, authorities need to ensure human rights are respected. In such anxious times it is even more pertinent that people are not cut off from the outside world, they do not end up in solitary confinement, and most of all they have access to information and adequate healthcare provision – equal of that available in the community.

Our briefing outlines the key measures that criminal justice systems, including prisons and courts, have taken to prevent the spread of COVID-19 – and the impact of these in light of the UN Nelson Mandela Rules and other key standards.

Action needs to be taken now and immediately, given the risk people in prison are exposed to, including prison staff. Such action should be guided by international standards and the values of: Do no harm, equality, transparency, humanity.

Worldwide, women who use drugs are vastly underserved within health and social services and programmes. National and international research, services, guidelines, and training programmes are either gender-neutral or male-focused. As harm reduction services are primarily tailored to men, women who use drugs often find their specific needs being unacknowledged and unaddressed, leading to non gender-responsive harm reduction services.

The On the A-Gender: Community Monitoring Tool for Gender-Responsive Harm Reduction Services for Women who use Drugs aims to be a resource for community advocates to begin documenting, evidencing, and addressing this state of play. By doing so, community advocates can begin to identify areas and locales where gender-responsive services are severely lacking or identify services and programmes that can provide examples of good practice and be scaled up. The tool acknowledges the diversity and intersectionality of women who use drugs — including sex workers, lesbian and transwomen.

This tool has been developed by the International Network of People who use Drugs (INPUD) and the International Network of Women who use Drugs (INWUD), in collaboration with the United Nations Office of Drugs and Crime (UNODC) HIV/AIDS Section and Koalisi Satu Hati , a community advocacy group in Indonesia. It is based on the Policy Brief: Women who inject Drugs: Addressing Specific Needs (UNODC, UNWomen, WHO, INPUD, 2014) and its companion guidelines Addressing the specific needs of women who inject drugs: Practical guide for service providers on gender-responsive HIV services (UNODC, INPUD, 2016).

We hope this resource can be a useful and a practical first step towards developing advocacy strategies to introduce and scale up gender-responsive harm reduction services in various settings around the world. In this way, the right to health of women who use drugs can be respected and better promoted.

On the A-gender: Community monitoring tool for gender-responsive harm reduction services for women who use drugs

Smokable cocaines are commonly referred to as “the most harmful drug”, and considered not just a threat to public health, but also to public security in the urban centres of many large cities. As a result, its users are frequently subject to hostility and stigmatization.

The smokable cocaine market was established decades ago, and is definitely not a new phenomenon. Rather than disappear, it is undergoing a slow expansion: from constituting a rather localized and isolated habit in the Andean region in the 1970s, its reach has extended in all directions, throughout North and South-America, including the Caribbean and Central American regions. Societies in the Americas have coexisted with smokable cocaines for over four decades, but - surprisingly - there is a dearth of research on the development of the market, or much first-hand evidence of how this substance is actually commercialized and used by millions of people in the region.

This report reflects a study of the information collected by a network of researchers and street-corner workers assembled by TNI, and conducted from 2014 to 2018. Our objective was to understand how local markets for smokable cocaines in Latin America and the Caribbean are actually functioning. In the first phase, researchers in seven different urban locations from Mexico to Argentina were asked to collect data on the current volume and characteristics of the market, with the aim of creating an overall picture of the current situation. In a second phase, further information was solicited in order to define policy responses to stimulant use, focusing particularly on harm reduction measures.

The different forms of violence confronted by users of smokable cocaine need to be recognized and attended by public services. All policy interventions at the street level should aim to destigmatize and find concrete practical solutions to the immediate problems faced by users’ communities - initiatives inspired by the broad concept of “bed, bread and bath”.

In the design of a broader policy framework, users themselves need to be consulted and involved, enabling a form of implementation that can be checked and evaluated by its effects on the community itself. The experiences obtained in the past decade in a number of cities mentioned in this report make a strong case for developing public policy models that combine all the above features, and need to be given the appreciation and resources they deserve. A region-wide systematic evaluation of these experiences could contribute to more humane and effective polices regarding the different forms of smokable cocaine.

Smokable cocaine markets in Latin America and the Caribbean: A call for a sustainable response

By Penal Reform International, Linklaters LLP, International Drug Policy Consortium

Drug‑related offences are known to have a particular and disproportionate impact on women. Eighty-two per cent of all women in prison in Thailand are imprisoned for a drug offence; in the Philippines, the proportion of women in prison for a drug offence is 53% and in Peru and Costa Rica it is more than 60%.

This report considers five key questions relating to the sentences imposed on women for drug‑related offences across criminal justice systems in 18 jurisdictions. The research was undertaken by Linklaters LLP for Penal Reform International on a pro bono basis, and is co-published by Penal Reform International, Linklaters LLP, and the International Drug Policy Consortium. The study is instrumental in building a better understanding of the case law around women accused of drug‑related offences and forms a solid basis for the development of policy guidance and recommendations to legislators and sentencing authorities (which will be published in 2020).

The complex reasons and pathways of women’s confrontation with criminal justice systems for drug‑related offences are not adequately reflected in legislation or (where existing) sentencing guidelines, nor sentencing practices across the 18 jurisdictions.

While there is a variety of considerations mentioned in a number of jurisdictions’ legal instruments that can mitigate culpability or lessen a sentence for a woman prosecuted or convicted for drug‑related offences, the impact on their sentence received is less certain.

Factors typically include consideration of pregnancy, single-parent status, or other circumstances such as experience of violence or coercion, role in the crime, or status of vulnerability. Where such factors are explicitly mentioned, they are given weight of differing degrees or discretion is limited by the applicable law or sentencing guidelines (including mandatory minimum sentences), thus limiting their impact. In cases where they have been taken into account, it is difficult to quantify the effect on the sentence given.

In a number of jurisdictions covered, non-custodial sentences are the more common form of sentences for low‑level drug‑related offences for women (for example, in England and Wales, Germany and New Zealand). In contrast, in Russia, non-custodial sentences are only issued in about 4% of drug‑related offences cases.

Jurisdictions covered by the study are: Argentina, Australia, Colombia, Costa Rica, Ecuador, England and Wales, France, Germany, Hong Kong, Japan, Mexico, New Zealand, the Philippines, Poland, Portugal, Russia, Spain, and the United States.

Sentencing of women convicted of drug-related offences

In excess of 11 million people are in prison globally, including more than 714,000 women and girls. According to the World Health Organization (WHO), one in four people will be affected by mental or neurological disorders at some point in their lives. People in prison have a disproportionately high rate of poor mental health; research suggests that around one in seven prisoners has a serious mental health condition.

A high proportion of women in prison have poor mental health. There are many factors that can affect a person’s mental health. Many people have difficult life histories and prisons can be very tough places. This guide does not claim to solve these challenges. Instead, it gives ideas of practical steps that can help.

Prison staff have an important role to play in protecting and promoting health and well-being in prison and need adequate training as well as support from their managers. In planning and delivering prison healthcare services it is good practice to involve service users alongside health and social care professionals, relevant voluntary groups and prison staff.

This guide is written to help understand how life in prison can affect a person’s mental health, with a focus on women. It describes how to recognise the signs of poor mental health and how best to respond. The guide aims to break down the stigma and discrimination attached to poor mental health, especially for women in prison.

This guide has been written primarily for prison staff and others who work with women in prison or may be making decisions that affect them. It may also be helpful for women in prison, as well as for their families and friends. Many of the points in this guide are equally relevant to men in prison. However, there are particular approaches that should be taken to meet the specific needs of women.

At the national level, improvements in mental healthcare both within prison and the wider community need leadership from politicians and policy-makers. Aspects of prison life which have an impact on prisoners’ well-being fall within the responsibility of senior prison management and national prison administrations. In the Appendix a checklist based on international human rights standards is designed to help with the implementation of key aspects of prison reform and advocacy initiatives in line with international standards and norms.

This guide does not deal with the diagnosis and treatment of specific mental health conditions. This is the responsibility of specialised mental healthcare professionals. Neither does this guide replace mental health training for prison staff. All prison staff should receive basic and ongoing mental health training as part of their professional development, especially in relation to the prevention of suicide and self-harm.

Women in prison: Mental health and well-being – A guide for prison staff

By Luis Felipe Cruz Olivera, Teresa Garcia Castro, Kathryn Ledebur, and Isabel Pereira

In Latin America, the lives of women who grow plants destined for illicit markets are marked by several forms of discrimination: because they are women, because they are rural farmers, and because their livelihood depends on an activity that has been declared illegal. The so-called “war on drugs” and the marginalization of rural life have erected walls behind which the role of women as agents of social transformation is hidden and rendered invisible. Beyond the numerous challenges they face, women growers of coca and opium poppy have played a critical role in sustaining and improving rural livelihoods, caring for families, in community organization, and in social movements. From their fight to assert the rights of coca-grower movements in Bolivia to their contribution to peace building in Colombia, women growers have been crucial agents of change in their communities. Their active participation—whether in farmer organizations, assemblies, agrarian unions, or other collectives—has given them new tools and knowledge for interacting with government entities and achieving important local objectives. Women coca or poppy growers not only build knowledge and capacities in their territories; they also contribute on a daily basis to the transformation and improvement of their realities, and that of their families and villages. Given the silence and dearth of information regarding the role of women in community life in areas where crops declared illicit are grown, this report explores who these women growers are, their socioeconomic contexts, their involvement in the production of crops destined for illicit markets, their organizing experiences, and their participation in decisionmaking processes—taking into account case studies from Bolivia and Colombia. Furthermore, the report presents recommendations focused on ensuring the participation of women growers in political and public life at all levels of decision-making.

Publications from IDPC Members