A full range of prevention, treatment, support and care programmes for all people who inject drugs is optimal, including opioid substitution treatment, needle and syringe programmes and antiretroviral therapy for those eligible. However, evidence shows that even partial improvements can make a difference. Countries should not wait, but should start immediately to scale up harm reduction responses that are public health-based and human rights informed.

Kazakhstan, Malaysia and the United Republic of Tanzania are examples of countries that are successfully reaching people who inject drugs and reducing HIV transmission. While each continues to face challenges, their achievements
show that progress can be made.

This UNAIDS report provides successful examples of harm reduction services which have achieved a significant reduction in HIV transmission around the world.

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

Harm reduction works: Examples from around the World

In this moment, Romania is facing a new epidemiological wave of HIV infections. If in 2008 there were just three confirmed cases with HIV infection, in 2012 there were 237 new, confirmed cases (Ref: National Institute of Infectious Diseases, “Prof.Dr. M. Balş”). In September 2012, the Romanian Angel Appeal Foundation, in collaboration with the National Antidrug Agency and the Carusel Association performed a Behaviour Surveillance Study among injecting drug users in Bucharest and Ilfov, Romania.

Out of 417 participants tested with rapid test in this study 52.5% were positive to HIV, 85% with Hepatitis C virus, and 20% with Hepatitis B virus (National Anti‑Drug Agency, Report for 2013). Injecting drugs in public areas increases the risk of infections with different bacterias. Another major risk that drug users have when they are using drug in public places is the lack of sterile injecting equipment, therefore they have a big risk of getting infected with HIV, HVC and HVB. Drug consumption rooms could play an important role in preventing the risks associated with the use of drugs.

The role of drug consumption rooms in HIV prevention

This brochure highlights some of the examples of excellent practices in peer involvement in Europe. The collection of personal stories and organisation descriptions show brilliant leadership, in combining courage, perseverance and building partnerships.

25 years ago, the first peer initiatives were started as innovative means of providing HIV prevention education. Since then, the scope and capacity of peer involvement has significantly increased beyond HIV prevention and health promotion interventions. Today peer involvement is becoming a critical component in numerous types of activities that include client advisory boards, peer employment, peer-based overdose prevention initiatives, peer research units, high-profile global advocacy and internet-based networks.

Greater meaningful involvement of people who use drugs in 7 key principles and 13 examples of good practice

The burden of depressive disorders and the frequent inadequacy of their current pharmacological treatments are well established. The anaesthetic and hallucinogenic drug ketamine has provoked much interest over the past decade or so as an extremely rapidly acting antidepressant that does not modify ‘classical’ monoaminergic receptors.

Current evidence has shown several ways through which it might exert therapeutic antidepressant actions: blockade of glutamatergic NMDA receptors and relative upregulation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) subtypes may alter cortical connectivity patterns; through intracellular changes in protein expression, including the proteins mammalian target of rapamycin (mTOR) and brain-derived neurotrophic factor (BDNF); and alteration of intracellular signalling cascades. The clinical evidence demonstrates rapid improvements in mood and suicidal thinking in most participants, although study numbers have generally been small and many trials are unblinded and methodologically weak.

There is a small body of work to suggest ketamine might also augment electroconvulsive therapy and potentially have a role as a surgical anaesthetic in depressed patients. A major problem is that the effects of ketamine appear temporary, disappearing after days to weeks (although longer benefits have been sustained in some), and attempts to circumvent this through pharmacological augmentation have been disappointing thus far. These exciting data are providing new insights into neurobiological models of depression, and potentially opening up a new class of antidepressants, but there are significant practical and ethical issues about any future mainstream clinical role it might have.

Ketamine as an antidepressant: Pharmacodynamic actions, and a systematic review of efficacy 

Cocaine dependence remains a challenging public health problem with relapse cited as a major determinant in its chronicity and severity. Environmental contexts and stimuli become reliably associated with its use leading to durable conditioned responses ('cue reactivity') that can predict relapse as well as treatment success. Individual variation in the magnitude and influence of cue reactivity over behavior in humans and animals suggest that cue-reactive individuals may be at greater risk for the progression to addiction and/or relapse. In the present translational study, we investigated the contribution of variation in the serotonin (5-HT) 5-HT2C receptor (5-HT2CR) system in individual differences in cocaine cue reactivity in humans and rodents.

We found that cocaine-dependent subjects carrying a single nucleotide polymorphism (SNP) in the HTR2C gene that encodes for the conversion of cysteine to serine at codon 23 (Ser23 variant) exhibited significantly higher attentional bias to cocaine cues in the cocaine-word Stroop task than those carrying the Cys23 variant.

In a model of individual differences in cocaine cue reactivity in rats, we identified that high cocaine cue reactivity measured as appetitive approach behavior (lever presses reinforced by the discrete cue complex) correlated with lower 5-HT2CR protein expression in the medial prefrontal cortex and blunted sensitivity to the suppressive effects of the selective 5-HT2CR agonist WAY163909. Our translational findings suggest that the functional status of the 5-HT2CR system is a mechanistic factor in the generation of vulnerability to cocaine-associated cues, an observation that opens new avenues for future development of biomarker and therapeutic approaches to suppress relapse in cocaine dependence.

Variation within the serotonin (5-HT) 5-HT2C receptor system aligns with vulnerability to cocaine cue reactivity

During the sixth summit of the Americas (April 2012, Cartagena), leaders of various countries ofthe Americas issued a mandate to the Organization of American States (OAS) to analyze current drug policies and explore new approaches, with a view to developing viable alternatives that would effectively regulate the production, trade, and consumption of drugs of illicit substances while alleviating the violence and harm associated with current approaches to this issue.

Since then, the hemispheric response to the “World Drug Problem” has been a changing landscape, and many more leaders have since called for reform of international and national-level drug policies to include more effective and humane alternatives to dealing with this global crisis. Previous measures to suppress drug production and consumption have been extreme, and have often proved ineffective. Methods such as aerial fumigation to suppress cultivation or mass incarceration as a response to drug consumption and small scale trafficking, have taken governments and societies further away from their original objective of preventing drug misuse and guaranteeing universal access to health and treatment for addiction, as set out in the 1961 convention on narcotic drugs. These first UN conventions of 1961 and 1971, prepared primarily from a punitive and prohibitionist perspective, created and sustained a ‘War on Drugs’ mentality.

This paper by the OAS Inter-American Commission on Women (CIM) offers a country-by-country review and analysis of available information on illicit drugs and the consequences of current drug control policies.

Women and drugs in the Americas

The United States (U.S.) approved use of federal funds for needle and syringe programs (NSPs) in December 2009. This study compares syringe disposal practices in a U.S. city with NSPs to a U.S. city without NSPs by examining the prevalence of improperly discarded syringes in public places and the self-reported syringe disposal practices of injection drug users (IDUs) in the two cities.

We found eight-fold more improperly disposed syringes on walkthroughs in the city without NSPs compared to the city with NSPs, which was corroborated by survey data. NSPs may help IDUs dispose of their syringes safely in cities with large numbers of IDUs.

A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programmes

The Arab region is comprised of 22 countries with a population of 367 million out of the 7 billion in the world which accounts for about five per cent of world population. According to the medium variant projection, the Arab Region will have 598 million inhabitants by 2050, an increase of two-thirds by 20101 . In addition, Arab countries have received more than 10% of the world’s migrants and the United Nations Economic and Social Commission for Western Asia (UN-ESCWA) estimates that there are more than 25 million migrants in the region. The Gulf region hosts the largest proportion of guest workers to indigenous populations in the world.

Drug-related HIV transmission is driving the epidemic and people who inject drugs (PWID) are one of the population groups most severely affected by HIV infection in many Arab countries. Throughout the region, there is a convergence of high-risk behaviours among PWIDs, where unsafe injecting practices are accompanied by unsafe sexual behaviours, and overall risk of exposure increases.

Available evidence indicates that the Arab countries are far from being on track in achieving the global target for people who inject drugs. Significantly stronger commitment is urgently needed to bring evidence-informed responses to scale programmes targeting PWID. Arab countries with documented epidemics among PWID and which do not currently address the needs of PWID in their national AIDS strategies, should take immediate steps to rectify this10. Governments must urgently commit major new resources to comprehensive, evidence-informed prevention programmes for PWID and intensify efforts to increase the scale of HIV testing, and harm reduction programmes.

This document aims to support Arab States to achieve the goals and targets of the 2011 United Nations General Assembly High Level Meeting on HIV and AIDS.

Arab Strategic Framework to Respond to HIV and AIDS (2014-2020)

Growing numbers of doctors are calling for a health-based approach to be adopted as a cornerstone of global drugs policy as a high-level UN conference highlights what critics say are continued failings in international bodies’ strategies for dealing with global drug problems.

The High-Level Review at the latest annual session of the UN Commission on Narcotic Drugs (CND)—the chief policy-making body for international drug control—in Vienna earlier this month assessed how the UN is meeting goals for dealing with the global drug problem ahead of a UN General Assembly Special Session on Drugs in 2016.

A high-level UN meeting on international drug policy came to a close last week with doctors lamenting the lack of progress on health issues.

Doctors criticise UN’s approach to global drugs control

Research confirms legalizing medical marijuana does not increase crime.

Researchers at the University of Texas Dallas published an article in 

today that indicates that despite opponents’ fears, legalizing medical marijuana does not increase crime and may actually lower some types of violent crime. The study examined FBI Uniform Crime Report statistics on murder, rape, assault, robbery, burglary, larceny and auto theft from all 50 states, including 11 states that legalized medical marijuana during the course of the study, over a 17 year period from 1990-2006. Controlling for confounding factors, they found no increases in any category of offense and even saw a slight decrease in homicides and assaults.

The study is reminiscent of a University of Chicago study that came out last year showing that, despite opponents’ warnings about increases in unsafe driving behaviors, legalizing medical marijuana was associated with a drop in traffic fatalities. In addition, preliminary figures in Colorado and Washington, the two states to have legalized and regulated marijuana for recreational use, show traffic fatalities in those states have slightly decreased the first year of full legalization.

“It must be difficult to be an opponent of marijuana reform. They can’t make arguments against legalization based on logic and facts so they must constantly resort to fear-based hypotheticals and anecdotes that keep getting proved wrong by systematic study. I feel for them. I really do,” said Major Neill Franklin (Ret.), a police officer for 34 years who now heads Law Enforcement Against Prohibition, a group of law enforcement officials opposed to the war on drugs.

This study is based on U.S. state panel data and suggests that medical marijuana legalisation is not predictive of higher crime rates and may be related to reductions in rates of homicide and assault.

The effect of medical marijuana laws on crime: Evidence from state panel data

Under Russian control, opioid substitution therapy for hundreds of Crimeans could come to an abrupt end. Ed Holt spoke to patients and providers in the peninsula about their concerns.

Russia's annexation of Crimea is threatening to force hundreds of people who use drugs back into addiction or turn them into refugees as opioid substitution treatment (OST) programmes in the region seem set to end.

People who inject illicit drugs in Crimea, which, following a controversial March 16 referendum, will become part of Russia possibly within months, have had access to OST in Ukraine for years. Indeed, Ukraine's recent reduction of new HIV infections has been put down to the widespread implementation of harm reduction programmes.

But Russian law forbids the provision of OST and organisations working to provide services to people who use drugs in Crimea say there is now a question mark over the fate of the more than 800 people receiving OST in the region. Irina Potapova, coordinator for OST for the International HIV/AIDS Alliance in Ukraine, which runs harm reduction programmes in Crimean cities, tells 

: “In the worst-case scenario, hundreds of patients would be forced to become refugees and seek treatment in mainland Ukraine.”

Fears over future of opioid substitution therapy in Crimea

South-Eastern Europe has long served as a corridor for several drug-trafficking routes to Western and Central Europe. Owing to its geographical position between Afghanistan, the world’s most important opiate-producing country, and the large and lucrative markets for opiates in Western and Central Europe, South-Eastern Europe is a crucial stage on one of the world’s most important heroin trafficking routes, the “Balkan route”.

Diverse drug flows come from multiple directions. Externally, cocaine arrives from South America. Internally, South-Eastern Europe produces relatively large amounts of cannabis, most notably in Albania, and the region also has a recent history of producing and trafficking amphetamine-type-stimulants (ATS). Of all these drug flows, however, only heroin flows can be considered strategically significant to consumption markets in Western and Central Europe.

This report shows how South-Eastern Europe countries serve as a corridor for several drug-trafficking routes to Western and Central Europe.

Publications