These guidelines serve to provide a common understanding for operating the European Union Early Warning System on new psychoactive substances (Early Warning System) by detailing the rationale, steps, procedures, roles, and responsibilities. They reflect the requirements of Regulation (EC) No 1920/2006 (as amended) and Council Framework Decision 2004/757/JHA (as amended) with respect to information exchange and the Early Warning System, as well as those for the initial report, risk assessment, and control measures with respect to accepted scientific principles and required scientific evidence.

EMCDDA operating guidelines for the European Union Early Warning System on new psychoactive substances

At the invitation of the Middle East and North Africa Harm Reduction Association (MENAHRA), and in collaboration with the United Nations Development Program (UNDP), the Joint United Nations Program on HIV/AIDS (UNAIDS), he International Development Law Organization (IDLO), the United Nations Office on Drugs and Crime (UNODC), the Law Enforcement and HIV Network (LEAHN); the third Consultative Meeting on “Law Enforcement and the Rights of People Living with and affected by HIV” was held at the Crowne Plaza Hotel in Beirut between 2 and 4 October 2019.

The meeting was attended by 28 people representing law enforcement agencies and civil society organizations in eight Arab countries: Morocco, Algeria, Tunisia, Sudan, Egypt, Jordan, Bahrain and Lebanon, in addition to representatives from UNDP, UNAIDS & IDLO. The objective of the meeting was to promote the positive engagement of law enforcement agents in the HIV response in selected countries in the region, and to create a common understanding and agreement between partners and participants on strategic human rights-based HIV programming and a roadmap to improve the legal environment in the region.

Law enforcement and the rights of people living with and affected by HIV

World Report 2020 is Human Rights Watch’s 30th annual review of human rights practices around the globe. It summarizes key human rights issues in more than 100 countries and territories worldwide, drawing on events from late 2018 through November 2019.

In his keynote essay, Human Rights Watch Executive Director Kenneth Roth examines the increasingly dire threat to the global system for protecting human rights posed by the Chinese government under President Xi Jinping. Deepening and increasingly sophisticated domestic repression show that China’s leaders view human rights at home as an existential threat. That, in turn, has led Beijing to see international laws and institutions for the defense of human rights as an existential threat.

As a result, Chinese authorities seek to censor criticism of China overseas, mute attention to human rights in its global engagements, and weaken global rights mechanisms. At stake is a system of governance built on the belief that every person’s dignity deserves respect—that regardless of official interests, limits exist on what states can do to people.

Noting that global institutions are built in part “on the belief that every person’s dignity deserves respect, that regardless of the official interests at stake, there are limits to what states can do to people,” Roth concludes that China is not simply a new and emerging power finding its place, but a country that poses an existential threat to the international human rights system.

The rest of the volume consists of individual country entries, each of which identifies significant human rights abuses, examines the freedom of local human rights defenders to conduct their work, and surveys the response of key international actors, such as the United Nations, European Union, African Union, United States, China, and various regional and international organizations and institutions.

The book reflects extensive investigative work that Human Rights Watch staff undertook in 2019, usually in close partnership with human rights activists and groups in the country in question. It also reflects the work of our advocacy team, which monitors policy developments and strives to persuade governments and international institutions to curb abuses and promote human rights. Human Rights Watch publications, issued throughout the year, contain more detailed accounts of many of the issues addressed in the brief summaries in this volume. They can be found on the Human Rights Watch website, www.hrw.org.

As in past years, this report does not include a chapter on every country where Human Rights Watch works, nor does it discuss every issue of importance. The absence of a country or issue often simply reflects staffing or resource limitations and should not be taken as commentary on the significance of the problem. There are many serious human rights violations that Human Rights Watch simply lacks the capacity to address.

The factors we considered in determining the focus of our work in 2019 (and hence the content of this volume) include the number of people affected and the severity of abuse, access to the country and the availability of information about it, the susceptibility of abusive forces to influence, and the importance of addressing certain thematic concerns and of reinforcing the work of local rights organizations.

The World Report does not have separate chapters addressing our thematic work but instead incorporates such material directly into the country entries. Please consult the Human Rights Watch website for more detailed treatment of our work on children’s rights; women’s rights; arms and military issues; business and human rights; health and human rights; disability rights; the environment and human rights; international justice; terrorism and counterterrorism; refugees and displaced people; and lesbian, gay, bisexual, and transgender people’s rights; and for information about our international film festivals.

Human Rights Watch - World Report 2020

By Òscar Parés-Franquero, Xavier Jubert-Cortiella, Sergi Olivares-Gálvez, Albert Díaz-Castellano, Daniel F. Jiménez-Garrido, José Carlos Bouso

In Spain, cannabis users are turning to Cannabis Social Clubs (CSCs) as an alternative for obtaining supplies of the substance, free from the risks of the illegal market. The current study aims to establish the profile of a sample (

 = 155) of Spanish CSC members and identify the impacts that these clubs have had on their consumption. To conduct the study, we developed a questionnaire structured around various issues related to the socioeconomic profile of users, their patterns of use, and the practical consequences of being a member of a CSC. The most important findings were that belonging to a CSC did not increase cannabis use and that the services that CSCs offer have favorable impacts on CSC members in terms of reducing health risks, providing legal protection, and improving their general well-being. Based on our data, the regulation of CSCs is warranted as a public health strategy regarding cannabis use.

Click here to read the full article (restricted access).

Use and habits of the protagonists of the story: Cannabis social clubs in Barcelona

By the Committee on Legal Affairs and Human Rights

At its meeting on 15 November 2019, the Committee on Legal Affairs and Human Rights of the Council of Europe’s Parliamentary Assembly adopted a landmark report on “Drug policy and human rights in Europe: a baseline study”. The report, submitted by British deputy Hannah Bardell, highlights that purely repressive policies have generated many human rights abuses, such as discrimination, the use of excessive force, disproportionate sentencing and prison overcrowding, with detrimental impact on public health.

On the basis of the report, the committee recommends the adoption of evaluation mechanisms, with the identification of indicators based on international human rights standards and the implementation of data collection methods on the effects of drug policies on health, crime and equality.

Furthermore, parliamentarians stress the importance for member States to prioritise education on the risks of drugs as a prevention measure, use harm reduction as well as treatment and rehabilitation services, and to ensure that criminal justice responses to drug-related crimes respect human rights, in particular by prohibiting “arbitrary arrest and detention, the use of excessive force and disproportionate sentencing against people who use drugs”.

The report was also discussed by Permanent Correspondents of the Pompidou Group at their plenary meeting held on 20-21 November 2019 in Strasbourg, where an exchange of view took place with Sunna Ævarsdóttir, deputy from Iceland and chair of the Committee on Legal Affairs and Human Rights.

Another report on “Involuntary addiction to prescription medicines” is under preparation in the Committee on Social Affairs, Health and Sustainable Development of the Parliamentary Assembly, which was also commented on by the Permanent Correspondents in an exchange of views with the Secretary of the committee.

Council of Europe parliamentarians discuss drug policy and human rights

By Taylor Fleming, Allison Barker , Andrew Ivsins, Sheila Vakharia and Ryan McNeil

Background: Occurring against the backdrop of an overdose crisis, stimulant use and stimulant-involved deaths in North America are increasing at an alarming rate. Many of these deaths are being attributed to fentanyl and related analogs, which have been increasingly found within street-level stimulant supplies. Within this, people experiencing socio-economic marginalization are at the greatest risk of overdose and other harms from adulterated stimulants. Current treatments for stimulant use disorder have limited effectiveness, and even less applicability to the lived realities of marginalized stimulant users. Emerging technologies, such as drug checking, are being implemented to support safer stimulant use, but the accessibility and utility of these technologies to stimulant users are framed by experiences of vulnerability that render them largely ineffective.

Stimulant safe supply: Solutions that provide a legal and safe supply of non-adulterated stimulants of known quality, and within a health care framework, are needed to directly address the risk of an increasingly adulterated stimulant supply. Similar innovative opioid-focused interventions are being piloted with medications that have a similar pharmacological effect as their illicit counterparts. While there are currently no approved pharmacotherapies for stimulant use, research has demonstrated a number of stimulant medications that are promising substitutes for cocaine and methamphetamine use. Much like with opioid-focused pharmacotherapies, having a consistent and safe supply of stimulants can lead to improved health outcomes and will drastically reduce overdose risk. However, for a stimulant safe supply intervention to be a success, it must provide the high and performance-enhancing effects that people seek from the illicit market, which requires doses and user agency that trials to date have not provided.

Conclusion: Efforts are needed to investigate the feasibility of pharmacological stimulant-based interventions that address safe supply needs. The promise of similar opioid-focused approaches in addressing both overdose-related risks and experiences related to vulnerability underscores the need to advance safe supply approaches targeted towards people who use stimulants. Given the current overdose crisis and rising stimulant use across North America, the implementation and evaluation of such novel stimulant-focused interventions should be a public health priority.

Stimulant safe supply: A potential opportunity to respond to the overdose epidemic

This year’s International Overdose Awareness Day (IOAD) has seen our movement continue to grow and achieve real change. The final total of 874 events held in 39 countries is a new record, surpassing the previous high of 747 set last year.

And, just as in previous years, International Overdose Awareness Day is a chance to raise awareness of overdose, remember those we have lost, and call for change.

In addition to the final tally of events, there are several headline statistics which show how much our movement has grown.

As of today, the International Overdose Awareness Day Facebook page has more than 40,000 followers, while our Twitter page has more than 4,000.

This year’s campaign brought more than 273,000 visitors to the IOAD website, www.overdoseday.com Visitors to the website downloaded our online resources – posters, fact sheets, and event support kits – more than 20,000 times.

And our supporters bought and distributed close to 60,000 individual pieces of merchandise (in the form of wristbands, badges, and lanyards) – 30 per cent more than in 2018.

The other findings of the 2019 Partners’ Report are based primarily on a survey conducted by Penington Institute, the convenor of IOAD, which asked participants about their events and their experiences. Key findings gathered from responses to the survey include:

Knowledge about the IOAD community: our movement is made up of people who use drugs, loved ones of people who have been affected by drugs, harm reduction and health workers, advocates, and activists. Often, these communities overlap.

Motivations: raising awareness of overdose, reducing stigma, and commemoration or memorial of those we’ve lost were the most popular responses.

Events: almost 95 per cent of respondents had held an IOAD event before. Close to two-thirds of respondents said their event was attended by the general public, while 80 per cent said their event was attended by family and friends of people affected by overdose, and health or community workers.

Satisfaction: 95 per cent of respondents believed their event was successful or very successful, while 96 per cent were satisfied or very satisfied with the resources on offer.

Media coverage: 75 per cent of respondents said their event received media coverage, and the campaign overall generated 2,550 news stories.

Outputs and Outcomes: increased awareness, naloxone training, the creation of shareable resources, Mayoral Proclamations, and politicians promising to do more to end overdose.

The Partners’ Report concludes by reflecting on this year’s campaign and setting some ambitious targets for next year, which will be the 20th International Overdose Awareness Day.

These targets include 1,000 registered events held in 50 countries, a greater number of real-world policy outcomes, and continued growth in key target areas such as the United Kingdom, South-East Asia, South America and Africa.

International overdose awareness day: A vision to end the global overdose crisis

In 2016 the Government published a landmark White Paper, ‘Prison Safety and Reform’, which promised to deliver much-needed changes to the prison system. It committed to address poor safety for staff and prisoners, high levels of assaults, the poor condition of the estate, poor retention in the workforce, and ultimately poor outcomes for reoffending.

Since the Government laid out its plans for “the biggest overhaul of our prisons in a generation” progress has been poor in several key areas:

Prisoner-on-prisoner and prisoner-on-staff assaults have increased by 30 per cent since 2016.

Incidents of prisoners self-harming have increased by 65 per cent since 2016.

The leaving rate for band 3-5 staff – operational prison officers – has increased by 32 per cent since 2016.

In the 12 months to March 2019, 17 per cent of drug tests on prisoners were positive.

Nearly £529 million intended for spending on the prison estate has been diverted to spending on the day-to-day running of prisons since 2016.

Significant resource pressures on prisons are likely to have held back the progress of reforms. The White Paper promised prisons the “resources, authority and tools” to address these challenges, but real-terms resource spending on prisons fell in 2016-17 and 2017-18. Her Majesty’s Inspectorate of Prisons (HMIP) has highlighted that “reduced resources, both in terms of staff and investment [has] made it extremely difficult” to run prisons.

Increasing spending is an opportunity to make progress – if targeted effectively. In 2018-19, Her Majesty’s Prison and Probation Service’s (HMPPS) resource budget rose by 4 per cent in real terms to over £3.9 billion. Several further commitments have been made: £2.5 billion for 10,000 additional prison places, £100 million for enhanced security, and £156 million for maintenance. To make the most of this increased spend the Government should focus on four priorities: more effective sentencing policies, creating a fit-forpurpose prison estate, improving prison safety, and developing the workforce.

The prison system in the UK: Priorities for investment 

By Hakique N. Virani, MD and Rebecca J. Haines-Saah, PhD

Since 2016, more than 10,300 Canadians have died of an apparent opioid-related overdose, with the majority involving fentanyl or fentanyl analogs. This unprecedented public health crisis has decreased life expectancy at birth in the country’s most affected provinces of Alberta and British Columbia. Concerned by this epidemic of overdoses, Canadian advocates for drug policy reform have welcomed the recent recommendation from British Columbia’s Provincial Health Officer that drug possession for personal use be decriminalised. Canada’s national newspaper, the Globe and Mail, published an editorial endorsement of this recommendation stating that “addiction, the compulsion to use drugs, is largely a health problem—not a criminal-law problem.” Indeed, the topic of decriminalization was also front and center at this Spring’s Harm Reduction International conference held in Portugal, a country often cited for leadership in implementing effective, health-driven policies on illicit drug use that included decriminalizing drug possession. The growing chorus of voices now calling for drug policy change is encouraging. However, the underlying reasons for a new policy direction are critically important and, on that, many well-intentioned newcomers to the chorus are somewhat offkey. The central cause for drug law reform is not its relevance to health or the present public health catastrophe. It is a matter of correcting a social injustice. Failing to articulate this in public discourse risks perpetuating harms on the people decriminalization advocates wish to help.

Public health dialogue must highlight the history, evolution, and manipulation of drug policies and should compel reformation of laws rooted in racism and subjugation as a matter of correcting injustice and inequity, not only promoting better health. In Canada, the Opium Act of 1908 was used to portray Chinese Canadians as an outside threat, despite that it was Canada’s colonizer, Britain, who drove opium use in China, smuggling enough product from British Bengal to reverse a trade deficit and create immense demand. In the U.S., Presiddent Nixon’s War on Drugs declaration of 1971 vilified those who opposed him and the Vietnam War by disproportionately criminalizing drugs popular among black Americans, student demonstrators, and anti-war pacifists. Drug policies in North America and beyond continue to achieve their original discriminatory and oppressive intents. In Canada, Indigenous people in some regions are almost nine times more likely to be arrested for drug possession, and black Canadians are more than five times as likely to be arrested despite similarities in illegal substance use across racial groups. In the U.S., between 2001 and 2010, black Americans were more than 3.73 times more likely to be arrested for cannabis possession than white Americans despite a roughly equal prevalence of use. With more than seven million arrests for cannabis possession during that period, the disparity is no small matter.

Describing substance use as a health issue suggests that solutions lie in the health domain, but this is often inconsistent with the lived experiences of people using drugs. Medical approaches that do not account for social and structural factors potentially entrench stigma and further disempower people who already experience diminished agency over their life circumstances. Especially for those experiencing social injustices that increase their risk of isolation and harm, healthcare systems that typically view illicit substance use as a hedonistic personal health behavior (without other functions or benefits) can be disengaging. Regarding healthcare professionals, one of the most concerning health outcomes of drug use is addiction, and because medicine characterizes addiction in part as using drugs despite associated problems, many quickly conclude that people who use illicit substances at all are addicted and irrational. Under this incorrect assumption, ideas like involuntary treatment and forced abstinence naturally gather momentum even though they are inconsistent with scientific evidence and the paramount medical ethic of respect for autonomy. When their presenting concerns are frequently dismissed as only drug-related, people who use drugs therefore often experience healthcare settings as stigmatizing or dictatorial. Likewise, when people using drugs encounter the view held by some medical professionals that their illicit substance use is necessarily problematic (i.e.,“disordered”) or antisocial, it should not come as a surprise that many leave health care feeling more dejected, debased, and desperate than before they sought care.

How the rationale for decriminalization is framed and the terms that are used to describe the need for drug policy reform extend beyond semantic concerns. Framing has important implications for policy responses and the allocation of resources. Just as media and governments inaccurately interchange the phrases “overdose crisis” and “addiction crisis,” health professionals commonly see“health issue”and“health problem”as the same. Yet, population studies have shown that most people who use substances do not have an associated health problem, such as addiction, and that most people with addiction eventually stop having drug problems without any medical intervention. Commonly, people describe substances as a temporary solution to problems and not as a health behavior that results in them. If the substance they choose is criminalized, however, they may only have access to more toxic illicit drug analogs that are easier to traffic, and their risk of death from accidental overdose is heightened whether they use them occasionally or compulsively.

A rising body count does present an opportunity in a callous political world to advance progressive drug policy, and portraying drug use as a health issue might evoke sympathy from voters rather than derision. But this narrative skirts necessary uncomfortable conversations about inequity and injustices, and those should be the lede. Drug law reform is a small part of addressing indefensible wrongs such as poverty, homelessness, xenophobia, gender discrimination, and the inexcusable conditions facing Indigenous peoples. These inequities are not distinct from the public health crisis of deaths from overdose, and they need to be foremost in the dialogue on policy imperatives. It should not take an epidemic of fatalities for structural injustices to be corrected, and it should not take biomedical explanations of behavioral differences to accept people as they are. If it does, just like with drug laws, by the time people get around to fixing things, unforgiveable damage will be done.

Drug decriminalisation: A matter of justice and equity, not just health

By Maciej Czachorowski, Juliana Coelho and others

Drug use in the United Kingdom (UK) is among the highest reported in Western Europe (1). In 2018-19, around 3.2 million (9.4%) 16-59 year olds in England and Wales reported using a drug in the last year (2). Current proportions are substantially lower than in the 1990s, but have changed very little in the last 10 years. The Scottish Crime and Justice Survey (2017-18) estimated 7.4% of 16-59 year olds reported using a drug in the past 12 months, an increase from 6.0% in 2014-15 but unchanged since 2008-09 (3). The estimated number of people who use opiate and/or crack cocaine aged 15-64 in England in 2016/17 was 313,971 (95% confidence interval (CI): 309,242-327,196). Within this group, there are an estimated 261,294 people (95% CI: 259,018- 271,403) who use opiates and an estimated 180,748 people (95% CI: 176,583-188,066) who use crack cocaine. The number of people who inject drugs (PWID) in England was last estimated in 2011 at 103,185 (95% CI: 100,085-107,544) (4). Work is ongoing to provide an up-to-date estimate of the number of PWID, with results expected in late 2020.

There were 192,603 individuals in treatment for drug use in England in 2017-18; 141,189 for opiate use and 51,414 for non-opiate use. Of those who newly presented to treatment for opiate use, 26% were currently injecting and 34% had previously injected drugs. Of those newly presenting to treatment for non-opiate use, 2% were currently injecting and 7% had previously injected drugs (5). Drug services across the UK are treating an ageing cohort of PWID (6-9). There are additional challenges associated with the complex and varied needs of older PWID, and additional risk factors, including for infections, that are compounded by a long history of drug use and/or injection.

PWID are vulnerable to a wide range of blood borne viral (BBV) and bacterial infections, which can result in high levels of morbidity and mortality. HIV, hepatitis B (HBV) virus and hepatitis C virus (HCV) are effectively transmitted through the sharing of injecting equipment, such as needles and syringes. Unsterile injection practices are also associated with bacterial infections such as Staphylococcus aureus and Group A streptococci (GAS), which are often worsened by poor wound care and delays in seeking healthcare. PWID are at risk of rare but life-threatening infections with sporeforming bacteria such as tetanus, botulism and anthrax which can be associated with contaminated drugs. Public health surveillance of infectious diseases, and the associated risk and protective behaviours among PWID, provides important information to understand the extent of these infections, the risk factors for their acquisition and for monitoring the effectiveness of prevention measures.

The UK has committed to the World Health Assembly’s Global Health Sector Strategy on Viral Hepatitis which aims to eliminate viral hepatitis as a major public health threat by 2030 and introduces the first ever global targets for viral hepatitis (10). In order to Shooting Up: An update, December 2019 9 achieve these targets, it is essential for us to monitor hepatitis B and C, and risk and protective behaviours among PWID.

Shooting up: Infections among people who inject drugs in the UK, 2018

Drug use continues to represent a significant problem in the Americas, and one that challenges policy makers at the highest levels. The Inter-American Drug Abuse Control Commission (known by its Spanish language acronym, CICAD), of the Organization of American States (OAS), serves as the preeminent Western Hemisphere forum for policy discussion and hemispheric cooperation on drugs. Along with other responsibilities, the Executive Secretariat of CICAD supports OAS member states by providing an evidencebased picture of the drug problem, both nationally and at the hemispheric level, so that member states can design and implement policies and programs to address the problem.

The Report on Drug Use in the Americas 2019 analyzes current drug use data in the Hemisphere. It features information on the most widely used drugs across the region, organized by drug and by population group, and highlights emerging issues of interest to policy-makers and to the public. The Report draws on data obtained primarily through national surveys using the Inter-American Uniform Drug Use Data System (known by its Spanish language acronym, SIDUC), developed by the CICAD Executive Secretariat.

The Western Hemisphere has a population of approximately one billion people, representing 35 sovereign countries. The region is ethnically, linguistically, economically, and culturally diverse. The drug problems across the Hemisphere are similarly diverse. Despite this diversity, there are a number of common themes regarding drug use.

This report highlights four specific areas of relevance to hemispheric drug policy:

As research evidence shows, the younger people begin using drugs, the greater the health risks and other consequences. Prevention programs and other interventions that can delay the age when someone first uses drugs should be accorded high priority.

Analysis of early-onset drug use is based on national secondary school student surveys. This report looks at early-onset use of a variety of licit and illicit substances, including alcohol, tobacco, cannabis, cocaine, and smokable cocaine. All of these substances show some levels of use among eighth graders. Use of any psychoactive substance—including alcohol and tobacco—among secondary school students should be a matter of concern for any country and underscores the need for preventive interventions beginning in early childhood.

Policies to control the sale and use of alcohol and tobacco have had positive results, which could provide critical lessons with regard to policies for other drugs.

Monitoring trends in drug use is one of the most important ways to evaluate the impacts of drug policies. At the national level, drug trends may rise and fall in specific populations, geographic areas, or by other variables. The evolving nature of drug use makes it difficult to identify any single common trend in drug use across the Hemisphere. Almost every drug analyzed in this report shows variations in trends between countries.

Tobacco appears to be the only substance that is showing systematic decreases in use over time. In the general population, cannabis use is increasing in most countries that have trend data, and about half the countries show increases in cocaine use. In the secondary school population, most countries with trend data available are showing increases in cannabis use, although trends for cocaine are more mixed in this age group.

While it may be difficult to draw region-wide conclusions based on trends in individual countries, the data in this report can call attention to issues of shared concern and can help to inform national policy.

Drug use has historically been seen as a male phenomenon, but recent data show that females in some countries are now using certain drugs either at the same, or at higher rates, than males. Non-medical use of prescription drugs, synthetic drugs, and opioids demonstrates how drug use patterns are changing.

Prevalence of tranquilizer use is higher among women than men in almost every country where data are available. This pattern holds true not only in the general population but in the secondary school and university populations as well.

In the case of secondary school students, the prevalence of drug use is much more similar between the sexes for alcohol and inhalants. Similar to the general population, the prevalence of non-medical use of prescription tranquilizers is higher among secondary school girls than boys. In contrast, cocaine and smokable cocaine-type substances tend to be used more by boys than by girls. In a few countries, however, girls use cocaine, cocaine base paste, and crack at higher rates than boys. While boys continue to use tobacco and cannabis at higher rates than girls, we see this gender gap closing in many countries.

The prevalence of new psychoactive substances (NPS), opioids, and benzodiazepines presents new challenges not only for drug treatment but for public health and drug policies overall. While most of the novel drugs appearing in the Americas have a low prevalence, the potential impact on health is significant. The United States and Canada are experiencing serious epidemics of opioids and NPS, resulting in some of the highest overdose rates in the history of drug use. This is costly, first and foremost in terms of the number of lives lost, but also with respect to the long-term economic impact of the problem in these countries. Signs indicate that the use of such drugs is likely to continue to spread, making them a key point of concern for OAS member states.

Previous OAS reports have highlighted the diversity of the drug problem across the Americas and the challenges this poses for international drug policy. The OAS Report on the Drug Problem in the Americas 2013 noted that this phenomenon has different impacts in different countries and therefore leads to different responses. While risk factors and determinants of drug use may be universal, the manifestation of key factors varies by country, rendering it difficult to prescribe a single set of policy recommendations.

The cross-national analysis presented in this report may be useful for shedding light on the larger context in which each country operates; however, the ability to draw conclusions on the impact of policy across countries is limited, partly because of differences in availability of data but also because of differences in the individual situation of each country and each subregion. For any given country, the data will likely prove most useful in evaluating the impact and implications of its own national drug problems and policies.

Report on drug use in the Americas

Policymakers in the United States increasingly recognize that drug use should be treated as a public health issue instead of a criminal issue. Most, however, continue to support harsh criminal sentences for people who are involved with drug selling or distribution. Many imagine these people are “predators” or “pushers” who force drugs on the vulnerable, contributing to addiction, overdose and violent crime.

With more than 68,000 people in the U.S. dying from accidental drug overdose in 2018 alone, many people are searching for someone to blame. Pointing the finger at people who sell drugs is, in some ways, a natural emotional response to loss of this magnitude. It is also consistent with decades of drug policies based on the assumption that people who sell or distribute drugs are responsible for causing drug use.

Politicians of all stripes have argued that long sentences for drug sellers will reduce drug availability and make remaining drugs more expensive, driving down demand. But this is not how drug markets actually work.

Imprisoning people who sell drugs does not reduce the drug supply, increase drug prices, or prevent drug use. As Mark Kleiman, a highly-regarded drug policy expert, has explained, “We did the experiment. In 1980, we had about 15,000 people behind bars for drug dealing. And now we have about 450,000 people behind bars for drug dealing. And the prices of all major drugs are down dramatically. So if the question is do longer sentences lead to higher drug prices and therefore less drug consumption, the answer is no.” When a person who sells drugs is imprisoned, they are inevitably replaced by a new recruit or by remaining sellers, as long as demand remains unaffected. A Maryland police officer once described arresting drug sellers as “playing whack-a-mole” and “banging your head against a wall,” because they can be so efficiently replaced.

Framing people who sell drugs as perpetrators and people who use drugs as victims is also misguided because there is extensive overlap between these two groups. A 2012 survey found that 43% of people who reported selling drugs in the past year also reported that they met the criteria for a substance use disorder. In addition, laws against drug selling are so broadly written that it is easy for people caught with drugs for personal use to get charged as dealers, even if they were not involved in selling at all. Politicians and prosecutors who say they want a public health approach to drug use, but harsh criminal penalties for anyone who sells, are in many cases calling for the imprisonment and non-imprisonment of the very same people.

Beyond being merely ineffective, the harsh criminalization of supply-side drug market activity may actually make drug use more dangerous, increasing overdose deaths and leading to more violence in communities. Law enforcement crackdowns on drug trafficking may incentivize the introduction of more potent, riskier drugs such as fentanyl – a synthetic opioid 30 to 50 times as potent as heroin– into the drug supply. Aggressive prosecution of people who sell drugs may undermine 911 Good Samaritan laws, making it less likely that people will call 911 at the scene of an overdose. Indiscriminately putting people who sell drugs in prison also means removing trusted sellers from communities, forcing users to buy from people they don’t know and making an already unregulated and unpredictable drug supply even less predictable.

The relationship between drug markets and violence is complicated. In some contexts, drug prohibition has fueled organized crime and been associated with horrific violence and corruption. But drug markets are much more diverse than stereotypes suggest: many of them experience little or no serious violence, while many markets that sometimes do experience violence operate relatively nonviolently most of the time. Law enforcement crackdowns may actually increase violence in these markets by disrupting the interpersonal relationships and territorial agreements that keep some drug markets operating smoothly.

While different individuals who work on the supply side of the drug economy have differing goals, priorities and knowledge levels about drug safety and harm reduction, there is evidence that some people who sell drugs take steps to ensure that their clients stay as safe as possible. Some people who use drugs report high levels of trust in the people from whom they buy, although in an unregulated drug market even the most ethical drug sellers have limited ability to know the composition of the product they are selling.

The current system of supply-side criminalization disproportionately impacts people at the lowest levels of drug supplying hierarchies. Available data suggest that the vast majority of people in prison for drug selling or distribution are not high-level suppliers or “kingpins” and have no history of violent conduct. The current system also has a discriminatory impact on communities of color, despite the fact that the available data suggest that white people are slightly more likely than either Black or Latinx people to report having sold drugs.

Our current approach to people who sell or distribute drugs in the United States does not reduce the harms of drug use or improve public safety. It is built on a foundation of stigma, ignorance and fear rather than evidence, and creates new problems while doing nothing to solve those that already exist. The Drug Policy Alliance believes it is time to rethink the “drug dealer”. We must urgently assess what type of people actually fall into this category and how we as a society can respond to them in ways that will keep people and communities safer and healthier. Despite the challenges of discussing supply-side drug policy reform in the midst of an overdose crisis, we cannot be silent while policymakers repeat the discriminatory, ineffective, expensive and dangerous mistakes of the past.

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