British Columbia, Canada, is experiencing a public health emergency related to opioid overdoses driven by consumption of street drugs contaminated with illicitly manufactured fentanyl. This cross-sectional study evaluates a drug checking intervention for the clients of a supervised injection facility (SIF) in Vancouver.

Insite is a facility offering supervised injection services in Vancouver’s Downtown East Side, a community with high levels of injection drug use and associated harms, including overdose deaths. During July 7, 2016, to June 21, 2017, Insite clients were offered an opportunity to check their drugs for fentanyl using a test strip designed to test urine for fentanyl. Results of the drug check were recorded along with information including the substance checked, whether the client intended to dispose of the drug or reduce the dose and whether they experienced an overdose. Logistic regression models were constructed to assess the associations between drug checking results and dose reduction or drug disposal. Crude odds ratios (OR) and 95% confidence intervals (CI) were reported.

About 1% of the visits to Insite during the study resulted in a drug check. Out of 1411 drug checks conducted by clients, 1121 (79.8%) were positive for fentanyl. Although most tests were conducted post-consumption, following a positive pre-consumption drug check, 36.3% (

 = 142) of participants reported planning to reduce their drug dose while only 11.4% (

 = 50) planned to dispose of their drug. While the odds of intended dose reduction among those with a positive drug check was significantly higher than those with a negative result (OR = 9.36; 95% CI 4.25–20.65), no association was observed between drug check results and intended drug disposal (OR = 1.60; 95% CI 0.79–3.26). Among all participants, intended dose reduction was associated with significantly lower odds of overdose (OR = 0.41; 95% CI 0.18–0.89).

Although only a small proportion of visits resulted in a drug check, a high proportion (~ 80%) of the drugs checked were contaminated with fentanyl. Drug checking at harm reduction facilities such as SIFs might be a feasible intervention that could contribute to preventing overdoses in the context of the current overdose emergency.

Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada

The legal regulation of drugs is rapidly moving from the theoretical to the practical domain. Regulation is a critical part of drug policy reform if the harms of prohibition and the illegal drug market are to be reduced but remains a particularly challenging element of the public and political debate. Progress requires engaging with legitimate public concerns about how regulation might be implemented and what its impacts will be, as well as political opposition and institutional inertia.

Regulation and management of risky products and behaviors is a key function of government authorities across the world. It is the norm in almost all areas of policy and law – except drug policy. Regulation addresses the reality of risk in our lives and our communities and is all around us: product safety regulations that require flame-retardant mattresses; food regulations that require “sell-by” dates on labels; regulation of which vehicles can be driven, how fast, and where, and so on.

This report addresses the reality that over 250 million people around the world are taking risks by consuming currently prohibited drugs. Accepting this reality and putting in place an effective regulatory strategy to manage it is neither admitting defeat nor condoning drug use. It is part of a responsible, evidence-based approach that deals with the world as it is in contrast with ideologically driven and ultimately counterproductive attempts to create a “drug free world”.

The report identifies key questions that, in the Commission’s experience, have become particular stumbling blocks in the progress of the public dialogue on regulation. By engaging with these questions directly, the report aims to facilitate and encourage the debate, thus bringing this much needed reform nearer.

Regulation - The responsible control of drugs

Since the adoption of Law 30/2000 in 2001, Portugal is frequently cited as the most important example of successful decriminalisation of drug use and of people who use drugs. Held up as the principal model of progressive drug policy, Portugal’s shift to a focus on health as opposed to criminalisation has seen a decline in morbidity and mortality related to drug use. Incidence of HIV amongst communities of people who use drugs has dropped considerably since the introduction of the 2001 law, from 1,016 cases in 2001 to 56 a decade later3 , where “there has been a large decline in the incidence of HIV and AIDS associated with injecting drugs in this risk group since 1999-2000 (though CASO argue that hepatitis C prevalence amongst people who inject drugs has remained high)”4 . Further to this, drug-related deaths have dropped considerably since 2001, from around 80 in 2001 to 16 in 2012.5 But interest in – and advocacy for – the Portuguese model of decriminalisation does not tend to go much further than analysing HIV prevalence, incidence, and drug-related deaths. Though these are, of course, extremely important and pressing considerations, the lived experiences, perspectives, and rights of the drug-using community are equally important, and these considerations are rarely taken into account in assessing the outcomes of decriminalisation in Portugal. Interactions with the state and the police, and issues of violence, social exclusion, stigmatisation, and discrimination, are often entirely omitted from discussion and analysis of decriminalisation in Portugal.

Is decriminalisation enough? Drug user community voices from Portugal

Pakistan is advancing towards a public health crisis with an estimated 133,529 people having contracted HIV/AIDS. Problematically, ‘the primary mode of HIV [and Hepatitis B and C] transmission in Pakistan continues to be the use of contaminated injection equipment among people who inject drugs’ (PWID) with prison inmates being one of the most vulnerable populations. Needle-based harm reduction programmes are non-existent in Pakistan’s prisons, in contrast to neighbouring Iran, which following a surge in prison-based HIV infections, introduced harm reduction programmes in 2003. Iran’s approach holds important lessons for Pakistan, not only because the two countries have been religiously and ideologically close, but also because the success of Iran’s harm reduction programme has been achieved through attitudinal changes by policymakers.

During the 1970s, Pakistan was a major producer of illicit opium. In 1979, the country produced an estimated 800 metric tonnes, becoming the ‘largest producer of illicit opium in the world that year.’ To fulfil treaty obligations under the 1961 Single Convention on Narcotic Drugs, authorities launched cultivation reduction efforts resulting in a sustained decrease in opium production in Pakistan after 1979; production of illicit opium in the country decreased to near zero by 1999-2001. Despite domestic supply reduction success, Pakistan has become a lucrative transit zone for drug trafficking due to its location in the so-called ‘golden crescent’, sharing a border with Afghanistan, the world’s largest producer of opium and the source of 85% of global heroin supply. The increase in Afghan opium cultivation in recent years has reduced prices and increased both demand and consumption within Pakistan, with an estimated 20 tonnes of pure Afghan opium consumed annually in Pakistan. The situation has resulted in a HIV epidemic among PWID. In 2012, HIV prevalence among this group in major urban centres in the country was close to 21%;11 by 2015, it had risen to 40% in several cities including provincial capitals.

Pakistan’s HIV epidemic and the need for prison-based harm reduction programmes

The OHCHR Working Group on the issue of discrimination against women in law and in practice launched a call for contributions for their upcoming report on 'Women deprived of liberty'. This joint contribution by IDPC, WOLA, CELS, Dejusticia and Equis focuses on the disproportionate impacts of overly punitive drug policies on women in Latin America.

This paper provides the latest available data on women incarcerated for drug offences in Latin America, highlights the key human rights challenges they face in the criminal justice system, and offers policy recommendations.

Women deprived of liberty: Joint submission to the OHCHR Working Group on the issue of discrimination against women

UN member states have agreed to hold a Ministerial Segment immediately prior to the 62nd Session of the Commission on Narcotic Drugs (CND) ‘to take stock of the implementation of the commitments made to jointly address and counter the world drug problem, in particular in the light of the 2019 target date’ set out to eradicate or significantly reduce the overall scale of the illegal drug market.

This advocacy note outlines the key issues for consideration by member states as they reflect on what has been achieved since the adoption of the 2009 Political Declaration and Plan of Action, including in light of the implementation of the UNGASS Outcome Document, and the implications for the next phase of the international drug policy regime. In addition, we analyse issues likely to come up in negotiations of the annual drugs ‘omnibus resolution’ at the UN General Assembly in New York, and offer suggestions for approaching these important negotiations. Finally, we provide recommendations to address some of the outstanding procedural questions related to the Ministerial Segment in Vienna.

On the road towards the 2019 Ministerial Segment (version 1)

New data from the ongoing Unlinked Anonymous Monitoring Survey of HIV and Viral Hepatitis among People Who Inject Drugs (PWID) have been published on the PHE website; the updated sets of tables present data for the period 2007 to 2017 inclusive. Data from 1990 to 2006 inclusive can be found in previous years’ data tables. In addition to data for the whole of England, Wales and Northern Ireland (the areas covered by this survey), the tables include data for each country and the regions of England. This article presents an overview of the trends between 2007 and 2017 for HIV, hepatitis B, hepatitis C and risk behaviours from the main Unlinked Anonymous Monitoring Survey, which is targeted at people who inject psychoactive drugs, such as heroin, crack cocaine and amphetamines. Further data from this survey related to hepatitis C will be reported in the Hepatitis C in the UK: 2018 report, to be published later this year

The HIV prevalence among “recent initiates” to injecting drug use (those who first injected during the preceding three years) is an indicator of recent transmission. The prevalence of HIV among the recent initiates taking part in the survey across England, Wales and Northern Ireland ranged from 0% to 2.6% over the time period between 2007 and 2017.

Symptoms of a possible injection site infection are common among PWID across England, Wales and Northern Ireland. In 2017, 50% (95% CI, 47%-52%) of PWID who had injected during the preceding year reported that they had experienced an abscess, sore or open wound at an injection site – all possible symptoms of an injection site infection - during the preceding year (see table 9 of the dataset). Questions regarding symptoms of injection site infections have been updated and as a result, data collected in 2017 is not comparable to previously collected data. Data from previous years can be found online [1]. The levels of possible injection site infection were particularly high among the over-35 year age group at 51%

Injecting into the groin has been associated with a number of health problems, including damage to the femoral vein and artery, infections and circulatory problems [4-5]. The proportion of current PWID who reported injecting into their groin during the preceding four weeks varied across England, Wales and Northern Ireland

Unlinked anonymous HIV and viral hepatitis monitoring among PWID: 2018 report

The Global Fund to Fight AIDS, Tuberculosis and Malaria released a report today demonstrating that 27 million lives have been saved by the Global Fund partnership. The report shows tremendous progress that has been achieved by efforts to end the epidemics, while highlighting new threats.

The Results Report 2018 includes key annual results achieved in countries where the Global Fund invests:

17.5 million people received antiretroviral therapy for HIV.

5 million people tested and treated for TB.

197 million mosquito nets distributed to prevent malaria

The progress comes against the backdrop of new threats to global health. Having reduced sharply since the peak of the epidemic, global HIV infection rates are now declining more slowly, and remain extremely high among key populations in some countries. Tuberculosis is now the leading cause of death from infectious diseases, with 1.7 million deaths per year, and the world is missing 4.1 million cases of TB every year – cases that go undiagnosed, untreated and unreported. In addition, progress against malaria has stalled. In 2016, there were 5 million more cases of malaria than 2015. With growing resistance in drugs to treat malaria and in insecticides for mosquito nets, efforts to control malaria are at stake.

Global Fund Partnership has Saved 27 Million Lives

This report argues that state ‘fragility’ metrics are inadequate. An increase in transparency and a call for new metrics are necessary to address entrenched elite corruption and organised crime in Honduras. In order to achieve these goals, donor countries must reconcile the political cost of promoting policies that address impunity and political protection against their own foreign policy agendas.

Since the 2009 coup d’etat, the United States has spent millions of dollars in Honduras, and the new Honduran government has enacted fresh policies aimed at promoting economic and security reforms. Despite these measures, Honduran political elites appear to have increased criminal activities, further consolidated sociopolitical control, and re-militarised state institutions. Consequently, the past decade has witnessed increasing government-sponsored political violence against civil society groups, and political opponents of the regime.

The November 26, 2017 re-election of President Juan Orlando Hernández signifies the continued inadequacy of international and national governance structures to curb corruption. The criminal-legal elite network in Honduras continues to impede security and justice reforms, despite the formation of the Mission Against Corruption and Impunity in Honduras (MACCIH). 1 Deeply embedded criminal-elite interests and insensitive assistance by the United States and other international donors have contributed to reform inertia

State fragility ranking organisations, like the Organisation for Economic Co-operation and Development (OECD), utilise state fragility frameworks to address issues of state instability. Yet fragility ranking organisations do not provide adequate access and transparency to their national fragility reports and related data to broaden civil society engagement

The OECD States of Fragility Framework would benefit from the inclusion of a multi-dimensional elite power fragility indicator potentially as a principle component measurement that incorporates the OECD violence lens, corruption, and elite capture across all five fragility dimensions. An elite power fragility indicator may also provide some insight into criminal-legal elite networks within donor countries, highlighting the complexity of addressing transnational elite corruption across borders

New metrics that align the United Nations Sustainable Development Goals (SDGs), drug policy, and local citizen security indicators alongside fragility metrics have the potential to provide a multi-level governance approach to guide security, economic assistance, and transparency. However, as long as international donors utilise ranking systems in silos and prioritise conflict-insensitive aid policies, aid will continue to be channelled through corrupt operating systems and efforts to support sustainable development and anti-corruption reforms will be undermined

Crime, Drugs, and Power in Honduras: Searching for Better Measures of State Fragility

Many myths surround coca. Every day press accounts around the world use the word coca in their headlines, when in fact they refer to cocaine. TNI's Drugs and Democracy Team exposes the myths and reality surrounding the coca leaf.

What is coca? Coca is a plant with a complex array of mineral nutrients, essential oils, and varied compounds with greater or lesser pharmacological effects – one of which happens to be the alkaloid cocaine, which in its concentrated, synthesized form is a stimulant with possible addictive properties.

The coca leaf has been chewed and brewed for tea traditionally for centuries among its indigenous peoples in the Andean region – and does not cause any harm and is beneficial to human health.

The traditional method of chewing coca leaf, called 

, consists of keeping a saliva-soaked ball of coca leaves in the mouth together with an alkaline substance that assists in extracting cocaine from the leaves.

When chewed, coca acts as a mild stimulant and suppresses hunger, thirst, pain, and fatigue. It helps overcome altitude sickness. Coca chewing and drinking of coca tea is carried out daily by millions of people in the Andes without problems, and is considered sacred within indigenous cultures. Coca tea is widely used, even outside the Andean Amazon region. Coca has an established use spread among all social classes, in two Northern provinces of Argentina. There is an increasing use of coca flour as a food supplement.

While the coca leaf in its natural form is a harmless and mild stimulant comparable to coffee, there is no doubt that cocaine can be extracted from the coca leaf. Without coca there would be no cocaine. The 'ready extractability' of cocaine from coca leaves is currently the major argument to justify the current illegal status of the leaf in the 1961 Single Convention. The cocaine alkaloid content in coca leaf ranges between 0,5 and 1,0 percent.

Particularly worrying is the use of smokable cocaine base paste (PBC, paco, bazuco or crack in Latin America), as distinct from free-base and crack cocaine that is produced from cocaine in the United States and Europe. Smokable cocaine base paste is harmful and highly addictive. When sharing homemade pipes, which is often part of the crack use ritual, crack users get sores on their lips and gums and are susceptible to diseases such as herpes, tuberculosis, hepatitis and HIV/AIDS.

Coca leaf: Myths and Reality

By Chamrid Kpadonou and Maria Goretti Ane-Loglo

Over the past four months, phrases such as “sweet, sweet codeine” and “end tramadol abuse now” have become very popular in Ghana and Nigeria. These terms emanated from a title of a documentary on codeine abuse in Nigeria produced by BBC - Africa’s Eye, and a campaign launched by the GHOne after a series of documentaries on tramadol abuse in the country. These documentaries have played a significant role in shaping public discourse on substance abuse.

Drug use in general is a topic that rarely features in Nigeria media outlets. The focus has mostly been on arrests and seizures of drugs by law enforcement agencies to show how well the government is doing in terms of fighting the “war on drugs”. Aside specific global campaigns such as the Support Don’t Punish Global Day of Action (26 June)1 , very few programmes and documentaries report and discuss drug use from a public health perspective.

The documentary “Sweet Sweet Codeine” is a remarkable piece of investigative journalist. The authors succeeded in exposing how large quantities of codeine-based cough syrup can be illegally bought from crooked agent of pharmaceutical companies. The documentary abetted to reinforce the need of pharmaceutical company to implement strict control procedures to ensure that such products are sold only to accredited retailers. However, the documentary displays more than a few reporting gaps, which may negatively influence the policymaking process within the region. The report claimed that the abuse of codeine causes schizophrenia. This statement is unproven and reinforces the stigma associated with people who use drugs, which further creates barriers to an effective response to the codeine crisis. Several researches concluded that there was no causal effect between substance abuse and schizophrenia. However, people suffering of schizophrenia are much more likely to have a substance or alcohol abuse problem than the general population. Stigma has a harmful effect on the psychological well-being of persons who use drugs and negatively affect their quality of life. This can lead to a complete rejection by society, discrimination or labelling of people who use drugs. In this regard, efforts must be made especially by the media to change the narrative on people who use drugs.

The documentary failed also to capture the views and perspectives of people who use drugs, and the perspectives of this community were entirely overlooked in the documentary.

Stigma has a harmful effect on the psychological well-being of persons who use drugs and negatively affect their quality of life. This can lead to a complete rejection by society, discrimination or labelling of people who use drugs. In this regard, efforts must be made especially by the media to change the narrative on people who use drugs.

Media reporting on substance use: Magnifying or reducing the harm?

By Rafaela Rigoni, Joost Breeksema & Sara Woods

This study builds and collects existing evidence on harm reduction interventions for non-injection stimulant users. Considering social, cultural, political, legislative and religious differences, it seems unlikely that one single intervention will address the many issues experienced by people who use stimulant drugs across the world. Hence, this study looks at specific drugs, routes of administration, groups of users, types of interventions and contextual variations.

Provides a global literature review of harm reduction activities for PWUS;

Documents, describes and analyses seven examples of good practices of harm reduction for PWUS in different world regions;

Contributes to guidance in supporting harm reduction for PWUS.

Stimulates a harm reduction narrative that moves beyond HIV and focuses on human rights and quality of life for PWUS.

In chapter 2 we describe our methodology. Chapter 3 gives more information on the context. This includes information on stimulants, risks and harms of stimulant use, and the risk environment in which stimulant use takes place. Chapter 3 describes the findings of our literature review, presenting twelve different forms of harm reduction interventions for PWUS. Lastly, in chapter 4, we describe seven of these interventions through in-depth case studies in different world regions.

Publications