Of the four nations of the UK, Scotland had the highest population- level drug-related (DR) mortality rate in 2018 of 29.8 per 100,000 – about four times the drug poisoning mortality rate for England and Wales in 2018 (ONS, 2020) – which is potentially the highest DR mor- tality rate in the European Union (NRS, 2019), and one of the highest DR mortality rates worldwide (Degenhardt et al., 2011). Trends in an- nual deaths suggest that the situation has become markedly worse in the last few years. In Scotland the annual number of drug‐related deaths doubled between 2008 and 2018 from 474 to 1187, with a 27% rise ob- served between 2017 and 2018 (NRS, 2019). Both the magnitude of, and the observed increasing trend in, DR mortality rates constitute a public health crisis for Scotland (Nicholls et al., 2019).

Between 2001 and 2011, decreased DR mortality rates have been re- ported for males aged 15–29 years; however, rates increased in the 30– 44 year age-group (Brown, Allik, Dundas, & Leyland, 2019) – this sug- gests that the raised DR rates in later years might simply reflect a cohort of drug users becoming older, with cumulative risk behaviours and/or worsening health with age leading to premature mortality (Pierce, Bird, Hickman, & Millar, 2015) – an ’ageing cohort effect’. However, other ex- planations are possible, such as evolving drug choices amongst current users over time (for instance, changing patterns of polydrug use, such as illicit benzodiazepines in combination with heroin, or an increase in injecting relative to other modes of administration, as seen for e.g., co- caine), austerity (which impacts on provision of addiction treatment), homelessness, and (less plausibly) a changing age distribution of new users. It is therefore of importance to distinguish an ageing cohort from other possible drivers of an increasing DR mortality trend (House of Commons, 2019).

The principal objective of our study was to investigate temporal trends in DR mortality rates amongst people who inject drugs (PWID) in Scotland over the past decade (2009–2018), and to quantify associa- tions between DR mortality and factors such as age, sex, and region. We utilised the record linkage of data on individuals diagnosed with hep- atitis C virus (HCV) – a condition predominantly affecting those who inject drugs in Scotland and associated with a two-fold increased DR mortality risk (Merrall, Bird, & Hutchinson, 2012) – to examine trends in DR mortality amongst PWID diagnosed with this infection. Studying DR mortality amongst Scotland’s HCV-diagnosed cohort has the advan- tage of providing a suitable denominator to permit age and time effects on mortality rates to be distinguished, and also helps understand and improve the initiatives of Scotland’s HCV Action Plan to co-locate HCV testing and management with drug addiction services (Hutchinson et al., 2015).

Increasing drug-related mortality rates over the last decade in Scotland are not just due to an ageing cohort: A retrospective longitudinal cohort study

Synthetic cannabinoids are largely unresearched substances. There is hardly any precise information available on their effects, risks, reciprocal effects with other substances or long-term consequences. The risk of overdose with strong intoxication is generally very high with synthetic cannabinoids. This risk increases significantly through incorrect declarations made at the time of sale.

Synthetic cannabinoids are not visually recognisable, nor in terms of taste; only a complex analysis, such as those undertaken by a drug checking process, provides information about the actual substances at hand. If cannabis users do not have the possibility to use drug checking services, they can use a CBD Quick Test. While the result of a CBD Quick Test is not comparable to a drug checking result from a laboratory , it can be applied inexpensively and easily at home.

A CBD Quick Test allows cannabis users to determine whether their product is CBD cannabis (less than 1% THC content) or THC cannabis (more than 1% cannabis).

Cannabis quick tests and synthetic cannabinoids - Factsheet

By Oluseyi Kehinde and Ekanem Itoro Effiong

Achieving Universal Health Coverage (UHC) is a goal we should all be striving for. Across the world, countless people are suffering unnecessary harm and death as a result of lack of access to affordable, necessary healthcare. While all of us suffer to varying degrees when healthcare is not universally available, it is the most marginalized in our societies who are impacted the most. As a young transgender woman who uses drugs my communities are among those most impacted by lack of access to healthcare. Young Inadequately Served Populations (ISPs), particularly in the Global South, are the communities who are going to continue to be left behind if we do not achieve UHC.

In the past year, the Covid-19 pandemic has made the need for UHC all the more clear. Over the course of the past year it has become clearer than ever that a lack of access to healthcare for a minority can have a major impact on the health and wellbeing of the majority, meaning to ensure the health and wellbeing of society as a whole, we must ensure that healthcare is universally available. As this report will outline, for young ISPs, even in countries with good access to healthcare overall, this is still not the case.

As we edge closer to 2030, and the deadline set for the targets of the Sustainable Development Goals (SDGs), without UHC it is clear these targets, in particular for SDG 3 of Good Health and Wellbeing, will be all but impossible to achieve. In particular, in relation to the ISPs we work with most closely at Youth RISE; Young People Who Use Drugs (YPWUD), the target of ending AIDS by 2030 is neigh-on impossible if we do not work to ensure UHC, including for HIV, drug-related, and other harm reduction services, is reached.

UHC issues for young people who use drugs and other young inadequately served populations

Judicial and prison systems around the globe continue to face fundamental challenges that undermine the ultimate purpose of incarceration as a sentence, namely, to protect society from crime and to prevent recidivism by supporting rehabilitation and preparing prisoners for their social reintegration upon release.

Overincarceration, overcrowding, poor conditions and the serious neglect of prison services are causing prisons to be a weak link in criminal justice systems and a low priority in reform efforts. The consequences for public safety, health and human rights, as well as the financial and socioeconomic costs resulting from these deficiencies, are immense. In some countries, including those in conflict, post-conflict and other crisis situations, severe prison deficiencies have had a negative impact on peace, security and stability. The disproportionate impact of the coronavirus disease (COVID-19) in prison settings has demonstrated what can happen when already overburdened and ill-equipped prisons are confronted with crises. Addressing the challenges associated with incarceration, including its overuse, should be a key part of the effort to “build back better”.

Many problems manifested in prison settings are the result of socioeconomic disparities and systemic deficiencies in criminal justice systems. Societal, racial and other forms of discrimination may be equally reflected in criminal justice policies and practices. Effective and sustainable reform efforts therefore require a holistic reform approach aimed at addressing the root causes of overincarceration and overcrowding, and shifting policies towards prevention and alternatives to imprisonment.

The United Nations commitment to “leave no one behind” recognizes prisoners as a particularly vulnerable and marginalized group that is subject to discrimination and exclusion. Sufficiently resourced and well-managed prison services and State policies that advance noncustodial measures are important enablers of the 2030 Agenda for Sustainable Development.

United Nations system common position on incarceration

By Lela Serebryakova, Catherine Cook, & Charlotte Davies / HRI

As the COVID-19 pandemic has brought global health to centre stage, it has never been clearer that ensuring access to health care for all is paramount. People who use drugs are criminalised and marginalised in much of the world, resulting in greater barriers to accessing health services than for the rest of the population. Harm reduction services such as needle and syringe programmes (NSPs) and opioid agonist therapy (OAT) are proven to be effective and cost-effective protection from blood-borne viruses. A comprehensive package of interventions has been endorsed at the highest political level. Insufficient financial support, both for services and the advocacy necessary to garner political will at the national level, remains the major barrier to implementing at scale.

Governments have committed to ending AIDS and tuberculosis, eliminating viral hepatitis and providing universal access to health care by 2030. We will not reach these goals without the leadership of people who use drugs and a fully funded harm reduction response.

Since Harm Reduction International commenced monitoring funding for harm reduction almost 15 years ago, the findings have been consistently dire. Available funding continues to be so far from meeting estimated need that the funding ‘gap’ is more accurately described as a failure to fund. The total number of international donors investing in harm reduction remains small, and the total funds invested by international donors appears to be shrinking. At national level, more data has become available on domestic funding for harm reduction. However, spending on drug law enforcement and imprisonment continues to dwarf investment in harm reduction; with case studies showing over 600 times more spent on punitive policies.

Failure To Fund: The continued crisis for harm reduction funding in low- and middle-income countries

Across the world, thousands of people who use drugs are forcibly interned in private drug treatment centres, and subject to drug treatment against their will. From India to Guatemala to Brazil, a range of horrifying abuses are routinely reported to take place in these facilities, including inappropriate medical treatment, protracted solitary confinement, forced labour, sexual violence, and beatings, sometimes leading to death.

In this submission to the UN Special Rapporteur on Torture, IDPC draws on empirical evidence from across the world to identify four systemic drivers of torture and ill-treatment in private drug treatment centres.

The stigmatisation and criminalisation of people who use drugs, which fuel abuses, and act as an impediment to accountability;

The prevalence of compulsory drug treatment programmes;

The absence of a range of affordable, evidence-based, and rights-compliant drug treatment services provided by public authorities; and

The systematic lack of public mechanisms to authorise and monitor private centres, and to investigate and provide redress for abuses.

In order to fulfil their international human rights law obligation to prevent torture and ill- treatment, states must address these drivers. This includes decriminalising people who use drugs, and ensuring that organisations of people who use drugs participate in the creation and oversight of regulatory frameworks for private drug treatment centres.

Torture in private 'rehab’ centres: Submission to the UN Special Rapporteur on Torture

The dangers posed by COVID-19 to people detained and staff working in cramped, overcrowded conditions in prison were acknowledged in the earliest stages of the pandemic. High-level United Nations (UN) and government figures made statements highlighting the risk to life and health in prisons and, as Global Prison Trends 2021 describes, most countries implemented some form of emergency releases to reduce the prison population. As countries continue to navigate new waves of the pandemic, prisons remain hotbeds for virus transmission. Also, new offences for breaching COVID-19 regulations and the resumption of court processes have led to increases in prison numbers.

The challenges faced by prisons over the past year have been compounded by decades of inadequate funding and criminal justice reform. The pandemic has exposed the impact of overcrowding and underresourcing of prisons in the gravest of terms – through the loss of life. We mourn every death in prison, both people detained and staff, and encourage all actors to learn from the experience of the past year, as detailed in Global Prison Trends 2021, to ensure prison systems protect the human rights of those they hold.

Health crises and other emergencies are not unprecedented in prisons. This year’s Special Focus examines prisons in crises, and how authorities respond to health crises, natural hazards and extreme weather, or in fragile and conflict-affected settings. We look at how prisons and the people within them are affected, as well as the involvement of prison populations in times of such crises and consider what measures authorities can put in place for better preparedness and response.

Global Prison Trends 2021

By Suzie Roscoe et al. / Drug and Alcohol Review

Despite the wealth of evidence that alcohol and drug treatment are effective at reducing health and social harms [1–4], there has recently been substantial disin- vestment from publicly-funded treatment systems in various countries [5–9]. Worldwide each year, over 3 million lives are lost due to the misuse of alcohol and the non-medical use of opioids is associated with pre- mature deaths [4,10]. Global disability-adjusted life years attributable to alcohol and drugs are over 99 mil- lion and almost 32 million, respectively [11]. Due to the recognised burden, reducing the harm from the misuse of alcohol and drugs, through prevention and treatment, are global health priorities [12].

Public health investment provides a good return on investment in terms of health outcomes [13,14]. Effec- tive substance use treatment improves health and social outcomes for individuals, families and commu- nities [15,16]. This includes reduced consumption and abstinence [17], a reduction in risk-taking behav- iour [18], reduced offending [19,20] and reduced mortality [4,21,22].

In England, the majority of treatment services are publicly funded via the Public Health Grant [23]. The Health and Social Care Act 2012 transferred many public health responsibilities from the National Health Services, and an allocated Public Health Grant, to 152 England local government areas. Each local authority, serving a mean population of 297286 (SD 226761), were made responsible for the adminis- tration of the grant. Included within the transfer of responsibilities was the commissioning of alcohol and drug treatment services, and the protected status of the alcohol and drug budget—which prevented it being spent on other public health priorities—was removed [24].

At the same time, England experienced a national government-led austerity program, resulting in sustained reductions in total local authority funding. This amounted to estimated losses of £9.8 billion (38%) between 2009/2010 and 2018/2019 [25], including a £700 million (15%) reduction between 2015/2016 and 2019/2020 in the Public Health Grant [26].

Is disinvestment from alcohol and drug treatment services associated with treatment access, completions and related harm? An analysis of English expenditure and outcomes data

Drug checking combines chemical analysis with health consultations, with the primary aim of reducing harmful drug use and primary characteristic of direct engagement with people who use drugs. Drug checking is predicated upon a number of assumptions about drugrelated harm. Whilst drug-related deaths (DRDs) are a key harm and their prevention is a primary goal, other drug-specific and drug-related harms arise for individual users and wider society from adulteration, misselling and variations in strength, that are the focus here. For example, overdose can result from 25x-NBOMe missold as LSD (Martins et al., 2017; Measham, 2020); anxiety, paranoia and psychosis from potent cathinones such as Nethylpentylone missold as MDMA (Measham & Jones, 2017); severe toxicity from high dosage (Black et al., 2020); from mixing polydrug use and medications with pre-existing health conditions (Liamis, Milionis, & Elisaf, 2008; Wu et al., 2009); and drug-related hyperthermia and hyponatremia (Campbell & Rosner, 2008).

All can result in harm ranging from low-level adverse effects such as nausea through to acute and chronic psychological and physiological problems including permanent organ damage. Thus, drug checking aims not simply to reduce DRDs but also wider drug-related harm. Therefore its effectiveness should be measured not only by a reduction in DRDs but by successful risk communications that enhance risk management and increase harm reduction practices. By reducing adverse effects such as accidental poisoning and overdose, it is hoped that accessing emergency services, requiring medical intervention and admission to hospital will all be reduced. However, as with other harm reduction interventions, the aim is not to eliminate harm – so long as drug use remains a possibility, so too does drug-related harm – but to identify substances of concern in circulation and to increase strategies, behaviours and risk communications that could reduce that harm.

Evidence highlights the value of disseminating test results obtained from both publicly accessible drug checking and also non public drug testing (eg Johnson, Stansfield, & Hassan, 2020), for trend monitoring, public information alerts and early warning systems (eg Brunt & Niesink, 2011; Bücheli, Hungerbühler, & Schaub, 2010), However, a “limited” evidence base on individual behavioural outcomes of drug checking has been noted (EMCDDA, 2017: 139), and there is an absence of randomised controlled trials, longitudinal studies or follow-up studies. Opportunities to compare drug checking outcomes at regional and national level are also limited, with Leece (2017), Measham (2019) and Measham (2020) noting constraints such as legal, political and commercial sensitivities. A further practical obstacle to evaluation of eventbased drug checking services is the non-standardised and resourceintensive nature of collecting data from individual event management, support services and other agencies in order to monitor trends in drugrelated incidents.

Intentions, actions and outcomes: A follow up survey on harm reduction practices after using an English festival drug checking service

New psychoactive substances (NPS) started to appear on the Lithuanian drug market in 2005. However, they have gained momentum only in the last few years. For comparison, in 2012 there were 62 cases of confiscation of NPS, while in 2016 there were 433, and in 2017, 441.14 The most commonly used NPS by people who have drug use experience in Lithuania are synthetic opioids and cannabinoids, whereas young people who use drugs occasionally tend to use synthetic cathinones, as well as dissociative hallucinogen NPS and classic hallucinogen NPS.

Drug policy laws in Lithuania were changed in 2017 with the aim to decrease drug supply and demand. However, different data (see Chapter 4) show that drug use is stable or, in some populations, increasing. Meanwhile, more people are being punished for minor drug offenses, and the State is investing in the persecution of people who use drugs, while treatment and harm reduction programs are suffering and struggling to survive. There is no sustainability of funding, and existing funding is not covering the entire need.

The project “New Psychoactive Substance Use in Kazakhstan, Kyrgyzstan, Georgia and Serbia” was undertaken to generate a more accurate picture of the use of new psychoactive substances (NPS) in Kazakhstan, Kyrgyzstan, Georgia, Serbia, and additionally in Estonia and Lithuania, to assess harm reduction and law enforcement responses to the emerging issues related to the use of NPS. In 2019, similar research was conducted in Belarus and Moldova. Results from this project will supplement scarce international data on the use of NPS in these countries, present a more accurate picture of their use, and provide information to national civil society organizations for political advocacy.

The present report provides research results from Lithuania. The study was conducted in partnership between the Eurasian Harm Reduction Association (EHRA) and the School of Law, Swansea University, and supported by the Global Challenges Research Fund. The Principal Investigator for the overall project was Dr. Rick Lines of the Swansea University School of Law, and the research methodology was reviewed and approved by the Ethical Review Committee at Swansea University. This report was prepared by the coordinator and researcher for this project, Eliza Kurcevič, Senior Program Officer at EHRA.

New psychoactive substance use in the Republic of Lithuania

On 11 March 2020, the World Health Organization declared COVID-19 a pandemic. Since then, the virus has claimed millions of lives and has transformed nearly every aspect of our individual and collective reality. As with all areas of life, drug consumption, related harms and drug markets have been impacted, as have the services established to respond to drug-related problems. During the first weeks of the pandemic, the EMCDDA instigated two rapid assessment studies to identify the initial impact and implications of COVID-19. These studies identified signs of an overall decline in some forms of drug use during the first 3 months of the pandemic, largely as a result of national confinement measures. In addition, many drug services were forced to close or restrict their access, new measures for hygiene and social distancing were implemented, and there was a shift towards greater use of telemedicine.

Although from June 2020, many European countries gradually eased their lockdown measures, by the end of the year second and even third waves of COVID-19 and associated measures were experienced across Europe. As of March 2021, several European countries find themselves back in strict lockdown situations and with many national vaccination programmes experiencing delays.

The assessment is based on an established EMCDDA trendspotter methodology which is used to investigate emerging phenomenon where data is limited. It involves the use of multiple methods (survey, literature review, focus groups, etc.) and triangulation of a range of qualitative and quantitative sources. While the lack of comprehensive data means that all conclusions must be made with caution and be regarded as preliminary, it is useful to reflect on our current understanding of developments in this area.

Reports from national law enforcement experts indicate that the drug market has been remarkably resilient to disruption caused by the pandemic, with discovery of synthetic drug production sites and levels of cannabis cultivation in European countries remaining relatively stable. At wholesale level some changes in routes and methods are reported, with more reliance on smuggling via intermodal containers and commercial supply chains. While street-based retail drug markets were disrupted during the initial lockdowns, and some localised shortages were experienced, market adaptation is evident in the form of increased use of encrypted messaging services, social media applications, online sources and mail and home delivery services.

Impact of COVID-19 on drug markets, use, harms and drug services in the community and prisons

The Biden-Harris Administration has an unprecedented mandate to advance equity, which it has identified as a key priority. The advancement of equity cannot be meaningfully achieved without bold action in the domain of drug policy, as recognized by the Office of National Drug Control Policy (ONDCP) by including racial equity among its priorities for the first year of the Biden-Harris Administration. For decades, current policy approaches to drug use and addiction have been amplifying inequities across racialized and economically marginalized Americans.

This is the direct result of an overreliance on the criminal justice system and supply-side enforcement (collectively described as drug prohibition) to control drug-related harms. This continues to be the status quo despite clear scientific evidence that this approach is ineffective. To address emerging and long-standing drug-related crises, the United States needs drug policies grounded in the best available scientific evidence. This is critical to addressing three interrelated issues: the opioid overdose epidemic, the disproportionate harms of the criminal justice among racialized Americans, and the potential opportunities presented by drug decriminalization and regulation.

Below, we outline five key drug policy issues that require immediate, bold, and evidence-grounded action. These are: 

 Removing obstacles to harm reduction for overdose and infectious disease prevention; 

 Increasing access to medication for opioid use disorder; 

 Elevating the use of discretion in drug law enforcement.

Publications