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.

Redressing inequities in America’s drug policies: An evidence-grounded call for bold action

By Penelope Hill, Orsi Fehér & Jamie Bridge

Civil society, including addiction practitioners, have been actors in policy spaces since United Nations (UN) drug control debates began under the Leagues of Nations (Bruun, 1975). Since the early 1990s, prime responsibility for UN drug-related matters has been held by Viennabased institutions. Although initially experiencing limited space for engagement with UN institutions and Member States, opportunities for civil society to influence international drug policy have grown, with the recognition of the importance of collaboration with non-government organisations (NGOs) increasing across all major UN agencies and institutions managing drug-related matters.

International debates and decisions directly influence and shape on-the-ground practice in the field of addiction. Though national policies are generally made on the state-level, signatories of the drug control conventions are bound to follow their commitments to the treaties and have limited sovereignty in unilaterally regulating internationally scheduled substances. The narratives, power-dynamics and decisions on the highest levels trickle down to regional policy making, so it is very important to shift the debate from substances to people at the highest level, so drug policies can operate effectively on the national level.

Civil society engagement and attendance at CND sessions throughout the year is crucial, in order to bring “real world” issues and the voices of affected populations to the forefront of the UN debates. Addiction practitioners are critical in relaying information on evidencebased practice to these forums, to ensure that international drug policies follow scientific evidence and not preconceived ideologies, and to guarantee health-centred and rights-based approaches prevail in the global drug control framework.

International drug policy: The impact of civil society and opportunities for addiction professionals to engage

At its 47th meeting, the UNAIDS Programme Coordinating Board (PCB) adopted a new strategy to end the AIDS epidemic as a public health threat by 2030. The PCB is made of 22 Member States, elected from among the Member States of the Cosponsoring Organizations. Five non-governmental organizations, three from developing countries and two from developed or transitioning countries, are also invited to participate in meetings of the PCB but without the right to take part in the formal decision-making process and without the right to vote.

The UNAIDS 2016–2021 Strategy is one of the first in the United Nations system to be aligned with the Sustainable Development Goals, which sets the framework for global development policy over the next 15 years. The new global AIDS strategy will serve as a road map for the whole world, guiding key stakeholders to ensure effective country-led AIDS responses.

The strategy was developed through a datadriven and consultative process involving the UNAIDS staff, the Cosponsors, civil society, people living with HIV and key populations, young people, faith institutions, ministers of health, finance, and gender and parliamentarians, scientists, donors, and the private sector.

Briefing Note: Global AIDS Strategy 2021 - 2026

On 23 February, the General Assembly adopted resolution 75/260 on the organisation of the United Nations General Assembly 2021 high-level meeting on HIV/AIDS (HLM). The resolution calls for the HLM to be held on 8-10 June 2021 and invites Member States to participate. The primary goal of the HLM is to develop a clear and action-oriented Political Declaration to be agreed upon by member states towards achieving the commitment of ending the AIDS epidemic by 2030.

To promote meaningful contribution of civil society in the entire process, UNAIDS decided to contract a civil society or community-led organisation with recognised experience in the global HIV response. GNP+ and Aidsfonds were appointed to act as NGO co-conveners to work with UNAIDS to facilitate the active and meaningful participation of civil society organisations and communities in the entire HLM process. Communities and other stakeholders are encouraged to participate in the process leading up to the HLM and in the meeting itself.

The HLM is important because the outcome will be a Political Declaration that will be agreed upon by all UN member states. This document will be the point of reference for advocates to monitor and hold governments accountable to what they committed to in the Political Declaration. In order to influence the UN Member State negotiations on the Political Declaration, civil society organizations need to gain access to the people in their country’s UN Mission in New York who will be negotiating on behalf of their government. Civil society should also aim to liaise with the official country delegations who will be representing their country at the HLM, usually consisting of government officials and a civil society representative.

A civil society engagement guide to the HLM 2021

For too long public attitudes, political debate and government policy in Scotland failed to take full account of the real drivers of problem drug use. A drug problem is neither a lifestyle choice nor a personal failing; drug problems originate in a lack of support to parents, families and vulnerable young people; the failure of health and other services to engage people in need of support and in Scotland’s social, income and health inequalities that result from poverty.

Recently, a consensus has emerged that begins to recognise all this and address problem drug use and the harms caused by drug use as a public health issue.

Scotland needs a new drugs strategy that reflects this reality. Scotland’s new drugs strategy should provide a full response to our drug overdose deaths public health crisis, improve the overall quality of life of people with a drug problem and prevent problem drug use by supporting vulnerable young people and their families. This strategy needs to articulate with government poverty, equalities and other strategies.

Drugs: Policy and Aims - A Manifesto for Scotland

The global drug market is expanding and becoming more complex. Globally, opium production and cocaine manufacture remain at record levels (despite declines observed in some regions), with synthetic opioids and their analogues (for example fentanyl, Tramadol) continuing to pose a serious threat to health (UNODC Global Drug Report, 2019; 2020). Heroin continues to reach the market despite declining opium production in 2018 in Afghanistan and record levels of seizures (UNODC Global Drug Report, 2019; 2020). Methamphetamine use and related harms are of rising concern across several regions (South East Asia, North America). There has been observed diversification of cannabis products (with increased potency) consumed in some jurisdictions that permit the non-medical use of cannabis.

IDU continues to represent a key global public health issue of importance due to the associated elevated risks of drug overdose, dependence, and BBV transmission (Degenhardt et al., 2016; Larney et al., 2020; Hines et al, 2020). An estimated 15.6 million people aged 15–64 years inject drugs (Degenhardt et al., 2017). Untreated chronic HCV and opioid use disorders are responsible for most of the deaths and disability attributed to the use of drugs (UNODC Global Drug Report, 2019). Of those injecting drugs, some 1.4 million live with HIV and 5.6 million live with HCV. Patterns of HIV infection among PWID also have wide regional variations (UNODC Global Drugs Report, 2019). In 2017, 40.5 million people were dependent on opioids and 109 500 people died from opioid overdose (Degenhardt et al., 2019).

Harm reduction approaches are underpinned by the principles of pragmatism and public health, alongside dignity and human rights and focus on reducing the health, social, and economic harms associated with drug use (Harm Reduction International, 2019; Sander et al., 2019). The provision of harm reduction both in community and in prison is widely recognized as a legally binding human rights obligation (Puras, 2015).

We report here on the 2020 assessment of situation and response of drug use and its harms in the MENA region for MENAHRA. These countries are diverse in terms of geography, population size and demographics, characteristics of key populations, nature and extent of the BBV problem, and scale of harm reduction implementation. They included Afghanistan, Algeria, Bahrain, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, UAE and Yemen.

Assessment of situation and response of drug use and its harms in the Middle East and North Africa

Universal Periodic Review of Belgium (38th UPR session, May 2021) - Recommendations related to health and people who use drugs

1. Adopt a public health approach to drug use and drug addiction, and decriminalize people who use drugs:

The Belgian law on the trafficking of poisonous, soporific, narcotic, psychotropic, disinfectant or antiseptic substances provides for prison terms of three months to five years and fines of one thousand to one hundred thousand euros. While this law does not punish consumption 

, drug users are nonetheless targeted through the criminalization of drug possession for personal use.

This law dates back to February 24, 1921, and urgently requires an in-depth revision. Despite a century of prohibition, the prevalence of drug use in Belgium has only increased (more than twofold in the last 20 years), as has drug trafficking. The differentiated enforcement of this law, based on ethnic and social profiling, has also given rise to serious inequalities and injustice. But the biggest failure of criminalization lies in its inability to provide an adequate response in terms of public health, protection and empowerment of people who use drugs, and support to those with addictions and other use problems related to illegal drugs. It is therefore urgent to take into account the positive public health outcomes witnessed elsewhere as a result of the decriminalization of users.

Countries that have decriminalized use and possession for personal use for at least some drugs include Argentina, Colombia, Costa Rica, Czechia, Germany, the Netherlands, Ghana, Italy, Portugal, Spain, South Africa, Switzerland, Uruguay.

The recommendation to decriminalize drug use and ancillary activities has already been made by a plethora of international human rights bodies, including the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, the United Nations Committee on Economic, Social and Cultural Rights, as well as the guidelines for action set out in the UN System Common Position on drug matters (2018). A recent analysis of over 100 peer-reviewed studies showed criminalization has a negative effect on access to HIV prevention and treatment.

 Amend the Law of February 24, 1921 in order to adopt a public health approach to drug use and drug addiction, including through the decriminalization of drug possession for personal use.

2. Provide legal certainty to drug consumption rooms

Drug consumption rooms (DCRs) are spaces in which illegal drugs can be used under the supervision of trained staff, with the aim of reducing the risks of disease transmission through unhygienic injecting, preventing drug-related overdose deaths, and connecting high-risk drug users with addiction treatment and other health and social services. In 2018, a total of 78 DCRs operated across seven countries in the EU alone (including Denmark, France, Germany, Luxembourg, the Netherlands, Spain), as well as in other countries such as Canada, Switzerland and Australia. As shown by the EU agency on drugs and drug addiction, there is a substantial body of evidence showing their effectiveness in reducing high-risk injecting behavior. The UN Special Rapporteur on the right to health has also encouraged the establishment of DCRs.

A DCR reopened in Liège in 2018, and others are planned in Brussels and Charleroi. However, the law of February 24, 1921, which had been adopted, among other reasons, to ban opium dens, formally prohibits "providing a premise" to facilitate the consumption of a controlled substance. While city and regional authorities support and subsidize these projects, DCRs 

remain in violation of the law, and exist in great legal uncertainty.

 Amend the law of February 24, 1921 in order to provide legal certainty to health interventions such as drug consumption rooms (DCRs).

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