Harm reduction policies and attitudes in the United States have advanced substantially in recent years but still lag behind more advanced jurisdictions in Europe and elsewhere. The Obama administration, particularly in its last years, embraced some harm reduction policies that had been rejected by previous administrations but shied away from more cutting edge interventions like supervised consumption sites and heroin-assisted treatment. The Trump administration will undermine some of the progress made to date but significant state and local control over drug policies in the US, as well as growing Republican support for pragmatic drug policies, motivated in part by the opioid crisis, ensures continuing progress for harm reduction.

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Two steps forward, one step back: current harm reduction policy and politics in the United States

Background: Harm reduction interventions in Cambodia face numerous obstacles because of conflicting understanding and interests and inconsistencies in the implementation by law enforcement officials. This study aims to examine how understanding and application of Drug Control Law (DCL) and Village/Commune Safety Policy (VCSP) affects harm reduction interventions in Cambodia from the standpoints of law enforcement officials, people who inject drugs and people who use drugs (PWID/PWUD), as well as other key stakeholders.

Methods: This qualitative study was conducted in the capital city of Phnom Penh in 2015. We held five focus group discussions (FGDs) with groups of PWID/PWUD, police officers, Sangkat/commune officers, and local non-governmental organization (NGO) field staff. We also conducted ten key informant interviews (KIIs) with representatives from government agencies, donor agencies, and NGOs. FGDs and KIIs with Cambodian participants were transcribed in Khmer and translated into English. KIIs with foreign participants were transcribed in English. Transcripts were read and re-read to identify emerging themes, which were reviewed and refined to develop common and divergent patterns.

Results: There was a huge gap between what the DCL and VCSP say and how law enforcement officers and PWID/PWUD understood them. The gap was also evident in how law enforcement officers implemented the DCL and VCSP. Harm reduction services, including health- and non-health-related interventions, were limited and challenged by unsupportive attitudes, misinterpretation of the DCL and VCSP, and the lack of full engagement with NGOs in the development of these instruments. The needs of PWID/PWUD in accessing health care services were not met due to misconduct of authorities while practicing the DCL and VCSP. Further, the misconduct and enforcement of the law and policy lead to increased social discrimination and physical abuses against PWID/PWUD.

Conclusions: There is a lack of common understanding of the drug-related law and policy and their implications to harm reduction services among both law enforcement officers and PWID/PWUD. Thus, there is a need to mainstream and simplify the law and policy for better comprehension among these actors. To improve the quality and coverage of harm reduction interventions, the gap of understanding and enforcement of laws and policies should be narrowed, and coordination between the government and NGOs and other key stakeholders should be strengthened.

How understanding and application of drug-related legal instruments affects harm reduction interventions in Cambodia: a qualitative study

Across much of the world, recent decades have seen rapid and unrelenting growth in the use of imprisonment as a response to crime and social disorder. Today, well over 10 million people are imprisoned worldwide. Jurisdictions that have seen the fastest growth in prisoner numbers include the United States, where the total prison population more than quadrupled from around half a million in 1980 to its peak of over 2.3 million in 2008. Brazil has seen prisoner numbers increase twenty-fold from around 30,000 in 1973 to over 600,000 today. England and Wales provides another – albeit less dramatic – example of prison population growth: in 1975 there were around 40,000 prisoners; by 2012 the number had more than doubled to almost 87,000.

The causes of prison population growth are complex, but many of the consequences are clear. Over-use of imprisonment leads to overcrowded, inhumane and degrading conditions of detention. It disproportionately harms poor and marginalised groups in all societies. It limits the capacity of prison systems to deal effectively with the small minority of prisoners who pose serious risks to public safety, and indeed increases the risks posed by prisoners (to themselves as well as to others inside and outside prison walls). Over-use of imprisonment also imposes enormous costs on the public purse.

While there is no dispute that prison populations have risen steadily over most of the globe in recent decades, there are other strands to the story of imprisonment worldwide. Analysis of trends in the first 15 years of this century reveals a somewhat mixed picture. From 2000 to 2015, the total prison population of Oceania increased by 59%, while that of the Americas increased by 41%; that of Asia by 29%; and that of Africa by 15%. Europe, in contrast, saw a 21% fall in total prisoner numbers.

Prison: Evidence of its use and over-use from around the world

Em tempos de radicalização da violação de direitos e ameaça à democracia, é preciso defender a radicalidade da potência do cuidado. Para tanto apresentamos esta 

[1], região da cidade do Rio de Janeiro, Brasil, onde se situa a Fundação Oswaldo Cruz[2] e diversas favelas e comunidades pobres que são constantemente atingidas pela nefasta e violenta política de guerra às drogas que criminaliza e autoriza ações bélicas, neste como em tantos outros territórios periféricos de toda a América Latina.

O mundo vive um momento de avanço das forças conservadoras, que na América Latina se expressa através da fragilização dos processos democráticos; no aprofundamento das iniquidades socioeconômicas; no aumento da fragmentação e segregação social. Tais dinâmicas, em seu conjunto, põem em risco direitos fundamentais. Exemplo emblemático foi a recente intervenção no bairro da Luz, na cidade de São Paulo. Durante quatro anos sustentou-se um projeto intersetorial inspirado nos princípios da Redução de Danos que visava articular ações de garantia de direitos à moradia, trabalho/renda e cuidado na região conhecida como “cracolândia”. Em maio de 2017 foi realizada uma operação policial com a intenção de uma “limpeza social”, com utilização do pânico moral para atender a interesses da especulação imobiliária. A violência e as arbitrariedades contra pessoas em situação de extrema pobreza e vulnerabilidade social, rotuladas como “viciados em crack”, seguiram-se por dias. Assim, uma política pública de cuidado, promoção da saúde e de direitos foi substituída pela repressão e violação de direitos.

Arbitrariedades como estas não são exclusivas do Brasil, e casos similares são encontrados em muitos lugares da América Latina, onde a droga funciona como pretexto para intervenção territorial. Ocorrem também outras situações de violência estrutural, como dificuldade de acesso a políticas públicas, assassinatos, prisões, exposição a doenças infectocontagiosas, falta de acesso a medicações e a políticas que garantam a cidadania.

As políticas de Redução de Danos, em seus esforços pela promoção da saúde, cidadania, direito à cidade, justiça social e direitos humanos das pessoas que usam drogas, não está isenta dos efeitos da conjuntura conservadora. O atual modelo de política de drogas opera seletivamente, criminalizando, encarcerando e estigmatizando sobretudo as populações mais pobres, moradoras de regiões periféricas, e de modo diferenciado as pessoas em situação de rua, negras, indígenas, mulheres e jovens.

As experiências bem sucedidas de cuidado são opostas à violência intervencionista defendida pelas políticas conservadoras. As evidências e o acúmulo político da Redução de Danos rejeitam propostas que não reconhecem a diversidade da experiência humana, e que se utilizem apenas da racionalidade biomédica e da criminalização de condutas consideradas desviantes. A Redução de Danos que realizamos no cotidiano de nossas práticas, em todo o continente, se apresenta como alternativa concreta ao fracasso de concepções e intervenções dicotômicas e simplistas. Não obstante, é preciso avançar ainda mais na direção de uma Redução de Danos interseccional, capaz de articular a defesa da reforma das políticas de drogas às lutas das mulheres, da população negra, dos povos indígenas, LGBTI’s e das múltiplas juventudes.

Diante disso, propomos a formulação de uma Redução de Danos inserida num projeto despenalizador e emancipatório, em que experiências subjetivas e corporais não sejam objeto de ações repressivas e disciplinadoras. A Redução de Danos, no atual contexto, é ferramenta potente de questionamento dos modelos de controle, implicando a afirmação e respeito à liberdade e autonomia das pessoas que usam drogas.

Consideramos urgente compartilhar nossas experiências e resistências, promovendo intercâmbios que consolidem nossa articulação Latino Americana em defesa de políticas públicas de Redução de Danos conectadas a reforma da política de drogas.

Assinam a Carta de Manguinhos as seguintes organizações e instituições:

Institutional Program on Alcohol, Crack and other Drugs of Oswaldo Cruz Foundation - PACD/Fiocruz (Brazil)

International Drug Policy Consortium – IDPC

Brazilian Association of Harm Reduction Workers – ABORDA (Brazil)

Brazilian Platform on Drug Policy - PBPD (Brazil)

Brazilian Association of Collective Health – ABRASCO (Brazil)

Brazilian Association of Mental Health – ABRASME (Brazil)

Brazilian Network for Harm Reduction and Human Rights – REDUC (Brazil)

Intercambios Asociación Civil (Argentina)

Asociación Costarricense para el Estudio e Intervención em Drogas – ACEID (Costa Rica)

Acción Técnica Social – ATS (Colombia)

International Network of People who Use Drugs - INPUD

Pares en Acción-Reacción Contra la Exclusión Social - PARCES (Colombia)

Centro Cáritas de Formación para la Atención de las Farmacodependencias y Situaciones Críticas Asociadas (Mexico)

Associação Brasileira Multidisciplinar sobre Drogas - ABRAMD (Brazil)

Grupo Tortura Nunca Mais Rio de Janeiro – GTNM/RJ (Brazil)

Iniciativa Negra por uma Nova Política de Drogas – INNPD (Brazil)

Associação Redes de Desenvolvimento da Maré (Brazil)

Agência Piaget para o Desenvolvimento - APDES (Portugal)

Drug Policy Alliance – DPA (United States)

Washington Office on Latin America – WOLA (United States)

International Centre for Science in Drug Policy – ICSDP (Canada)

South Indian Harm Reduction Network – SIHRN (India)

Transform Drug Policy Foundation (United Kingdom)

Union for Improved Services, Communication and Education (Ireland)

Teenswatch Community Harm Reduction (Kenia)

Centro de Prevención de las Adicciones de Bariloche (Argentina)

Fundación Latinoamérica Reforma (Chile)

Centro de Orientación e Investigación Integral - 

Students for Sensible Drug Policy (Jamaica)

Fédération Bruxelloise Francophone des Institutions pour Toxicomane – FEDITO (Belgium)

Association de lutte contre le sida – ALCS (Marocos)

Global Call to Action Against Poverty - GCAP (Burundi)

Students for Sensible Drug Policy (Australia)

Association des Guides du Congo – AGC (Congo)

Multidisciplinary Association for Psychedelic Studies - MAPS (United States)

Washington Heights Corner Project (United States)

New York Harm Reduction Educators (United States)

Students for Sensible Drug Policy - SSDP (United States)

Elementa Consultoría en Derechos (Colombia)

Andean Information Network - AIN (Bolivia)

Puente, Investigacion y Enlace - PIE (Bolivia)

Estudiantes por una Política Sensata de Drogas (Costa Rica)

Asociación de Vecinos La Teja Barial (Uruguay)

Observatorio de cultivos y cultivadores declarados ilícitos - OCCDI (Colombia)

Corporación Humanas - Centro Regional de Derechos Humanos y Justicia de Género (Colombia)

Instituto Helena Greco de Direitos Humanos e Cidadania (Brazil)

Conselho Regional de Serviço Social do Rio de Janeiro (Brazil)

Coletivo Balance de Redução de Danos (Brazil)

Associação Brasileira de Estudos Sociais sobre o Uso de Psicoativos - ABESUP (Brazil)

Laboratório de Estudos Interdisciplinares sobre Psicoativos – LEIPSI (Brazil)

Centro de Pesquisa, Intervenção e Avaliação em Álcool e Drogas – CREPEIA (Brazil)

Centro de Referência sobre Drogas e Vulnerabilidades Associadas da UNB Ceilândia (Brazil)

Rede Nacional de Feministas Antiproibiocionistas - RENFA (Brazil)

Associação Multidisciplinar de Estudos sobre a Maconha Medicinal - AMEMM (Brazil)

Grupo Interdisciplinar de Estudos sobre Substâncias Psicoativas - GIESP/UFBA (Brazil)

Fórum Intersetorial de Drogas e Direitos Humanos de São Paulo - FIDDH (Brazil)

Fórum Estadual de Redução de Danos de São Paulo - FERD (Brazil)

Dispositivo de Abordaje Territorial Rosario - DIAT (Argentina)

New Parents for Addiction Treatment & Healing – New PATH (United States)

Carta de Manguinhos: Um apelo global para proteger a redução de danos na América Latina

At a time when rights violations and threats to democracy are deepening, it is necessary to defend the fundamental role of care. With this in mind, we present this 

, a region of the city of Rio de Janeiro, Brazil, where Fiocruz[2] and, much more drastically, many favelas and poor communities have been constantly hit by despicable and violent war-on-drugs policies that criminalize drug users and authorize warlike actions on whole populations, like in so many other marginalized regions across Latin America and the world.

The world is currently witnessing a rise in conservative forces which, in Latin America, has translated into the weakening of democratic processes; the deepening of socioeconomic inequities; and an exacerbation of social breakdown and segregation. Taken together, such dynamics risk undermining fundamental rights. One emblematic example is the recent intervention that took place in the District of Luz, in the city of São Paulo. For four years, a multisectoral project inspired by the principles of harm reduction aimed to articulate actions to guarantee the right to housing, work / income and care in the region known as "

" A police operation aimed at "social cleansing" took place in May 2017, using moral panic to serve the interests of real estate speculators. This was followed by weeks of violence and arbitrary actions against socially vulnerable people living in extreme poverty, labeled as "crack addicts." A public policy focusing on care, health and promoting rights was thus replaced with repression and rights violations.

Such arbitrariness is not limited to Brazil – similar cases can be found in many areas of Latin America, where the presence of drugs serves as a pretext for territorial intervention. Other forms of structural violence include difficulties in accessing public services, murders, incarceration, exposure to infectious diseases, lack of access to medicines and absence of policies that aim to protect citizens’ rights.

Because of their focus on promoting health, citizenship, the right to access the city, social justice and drug users’ human rights, harm reduction policies have not been exempt from the effects of the conservative juncture. The current drug policy model is implemented selectively, by specifically criminalizing, imprisoning and stigmatizing the poorest groups living in marginal regions, homeless people, black and/or indigenous people, as well as women and youth.

Successful approaches focusing on care reject the interventionist violence defended by conservative policies. The evidences, ethic and political knowhow of harm reduction reject policies that fail to recognize the diversity of human experience and only rely on biomedical rationality and the criminalization of what is considered to be divergent behaviors. The harm reduction interventions that we are carrying out in our daily lives across the continent - and perhaps in other parts of the world - represent a concrete alternative to failed binary and simplistic concepts and interventions. It is nevertheless necessary to move even further towards a multisectoral harm reduction approach that is capable of articulating support for drug policy reform with the struggles of women, blacks, indigenous peoples, LGBTI and youth.

Given this situation, we propose a harm reduction approach grounded in decriminalization and emancipation, in which subjective and corporeal experiences are no longer exposed to repressive and disciplinary actions. Harm reduction is a powerful tool to question current models of control, and includes the promotion and respect for the freedom and autonomy of people who use drugs.

We consider it urgent to share our experiences and resistance, and promote a dialogue in Latin America - and elsewhere - with the view of consolidating our argument in defense of public harm reduction policies as they relate to drug policy reform.

The following organizations and institutions sign the 

Centro de Orientación e Investigación Integral - 

Letter from Manguinhos: A global call to protect harm reduction in Latin America

In his book, Legalizing Drugs: The Key to Ending the War, Steve Rolles, author and Senior Policy Analyst at Transform Drug Policy Foundation, manages to veer away from a polarising debate and lays out what reform could actually mean. There are now almost 100 countries across the globe making use of ‘harm reduction’ interventions, a practice that turns away from the more historical crime and punishment model for drugs. In addition, 25 countries have also ended criminalisation of cannabis use. In his book, Rolles draws upon evidence gathered from these examples to ask “Why has the war on drugs proved so resilient?

Legalising drugs: The key to ending the war

In 2015 about a quarter of a billion people used drugs. Of these, around 29.5 million people - or 0.6 per cent of the global adult population - were engaged in problematic use and suffered from drug use disorders, including dependence. Opioids were the most harmful drug type and accounted for 70 per cent of the negative health impact associated with drug use disorders worldwide, according to the latest World Drug Report, released today by UNODC.

Disorders related to the use of amphetamines also account for a considerable share of the global burden of disease. And while the market for new psychoactive substances (NPS) is still relatively small, users are unaware of the content and dosage of psychoactive substances in some NPS. This potentially exposes users to additional serious health risks.

The Report finds that hepatitis C is causing the greatest harm among the estimated 12 million people who inject drugs worldwide. Out of this number, one in eight (1.6 million) is living with HIV and more than half (6.1 million) are living with hepatitis C, while around 1.3 million are suffering from both hepatitis C and HIV. Overall, three times more people who use drugs die from hepatitis C (222,000) than from HIV (60,000). However, the Report stresses that despite recent advances in the treatment of hepatitis C, access remains poor, as treatment remains very expensive in most countries.

This year marks 20 years of the World Drug Report, which comes at a time when the international community has decided to move forward with joint action. UNODC Executive Director Yury Fedotov highlighted that the outcome document of the 2016 landmark UN General Assembly special session on the world drug problem contains more than 100 concrete recommendations to reduce demand and supply, however he acknowledges that more needs to be done.

"There is much work to be done to confront the many harms inflicted by drugs to health, development, peace and security, in all regions of the world," said Mr. Fedotov.

Keep up-to-date with drug policy developments by subscribing to the IDPC Monthly Alert.

World Drug Report 2017

Medical professionals have a key role to play in managing the harms associated with illicit drug dependence. This can be in a clinical setting (ie directly managing withdrawal and relapse and in maintenance prescribing) or in advocating for the provision of evidence-based interventions in local areas with a high level of need. There are, however, a limited number of treatment options available for individuals dependent on illicit drugs. Within drug and alcohol treatment services, opiate dependence (including heroin) has the lowest rate of successful treatment, around 28% of those who access services. Despite this, there is strong and consistent evidence to support the approach of OST (opioid substitution treatment), which is routinely used in addiction services throughout the UK. Other substance use treatment options – including supervised consumption rooms and HAT (heroin assisted treatment) – are not routinely used, despite being associated with reduced levels of harm for users. This short briefing aims to raise awareness about these treatments that are being underused, by explaining what they are, what evidence exists for their effectiveness, and what their role is in a UK context.

Reducing harm associated with illicit drug use

The mandate on extrajudicial, summary or arbitrary killings has evolved over the years through various resolutions of the General Assembly and the Human Rights Commission and Council, and in response to violations of the right to life that member States have determined required a response.No international treaty explicitly defines extrajudicial, summary or arbitrary executions. However, such violations of the right to life have been commonly characterized as falling within the “public” domain, i.e., the domain of the State and its institutions, and understood to encompass killings involving State officials or private actors connected to the State, and to include armed conflict situations. While many steps have been taken over the past 20 years to broaden the reach and relevance of international human rights law, including by special procedure mandate holders, historically common characterizations have worked to exclude gender-related killings, which take place mainly in the so-called “private” sphere. When, in its application, the human rights framework fails to regard equally all loss of life, the consequences may be — however unintentionally — the perception that some arbitrary loss of life is of a lesser degree of gravity than other instances of arbitrary death.

Report of the Special Rapporteur on extrajudicial, summary or arbitrary executions 

There are more than 3,100 drug courts operating in the United States. But while the courts’ proponents say they reduce recidivism for people with substance use disorders, critics say the system abuses due process, often mandates treatment for people who don’t actually need it – people without drug dependence – and fails to provide quality care to many who do. Physicians for Human Rights (PHR) assessed the availability and quality of substance use disorder treatment through drug courts in three states – Florida, New Hampshire, and New York – and found major obstacles in all three states.

Neither justice nor treatment: Drug courts in the United States

The EU and its Member States reiterated their commitment to the fulfilment of the outcomes of the UNGA Special Session and to the UNGA resolution 71/211, adopted in December 2016; as well as to the work to be implemented by WHO in addressing and countering the world drug problem.

European Union statement at the World Health Assembly on the public health dimension of the world drug problem

The NGO Delegation brings the unique, first-hand experiences and perspectives of people living with HIV and key populations to the Joint United Nations Programme on HIV/AIDS (UNAIDS) Programme Coordinating Board (PCB). Each year, it presents a nongovernmental organizations’ (NGO) report that focuses on a critical emerging issue for affected communities and that is informed by the Delegation’s constituencies. The 2016 NGO Report is entitled An unlikely ending: ending AIDS by 2030 without sustainable funding for the community-led response. This report provides an overview of the global consensus on the need for a well-resourced community response to HIV. It outlines some of the key barriers faced by communities in terms of accessing funding from donors, and provides practical recommendations for improving financing systems so as to better support the community response.

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