This publication was part of a two-part series on overdose prevention. Click here to access 'Overdose prevention - New technology-based solutions'.

By Graham Shaw & Jean-Paul Grund / Stop Overdose Now (SON)

Fatal and non-fatal overdoses related to opiates use are on the rise in many parts of the world, with North America, Australia and Central Asia being the most affected regions. In Europe as well opioid-related overdose deaths show a continuous increase, at least since 2013. Naloxone is the centrepiece of the response to opioid overdose. This opioid antagonist medication rapidly and completely reverses the effects of opioids and thus, when timely administered, prevents opiate overdose death. Globally, about half of the countries (101 out of 196) had registered injectable naloxone by September 2017, a requirement for the drug to be legally available in the country and for licenses to be issued for the manufacture, importation and/or distribution of the drug. In Europe, by the same time, 80% of the countries (37 out of 45) had Naloxone registered by national authorities. Lack of legislation and registration can hinder Naloxone access. Policymakers and advocates can count with several guidelines to support them in drafting required policies and standard operating procedures to allow the drug’s manufacture, importation and/or distribution. Another barrier to Naloxone access is the costs. Generic and domestically produced naloxone, as well as country-collaboration for bulk purchase can help addressing this. Finally, fostering Good Samaritan Laws, positive media, community education and the meaningful involvement of people who use drugs can help broadening naloxone access, as it fights stigma and discrimination.

Good practice interventions to respond to opioid overdoses include naloxone take-home programs, peer-to-peer naloxone programs, prison and treatment pre-release programmes, and broader interventions such as drug consumption rooms and safe injecting facilities, heroin assisted treatment, and drug checking services (including fentanyl test stripes). These interventions demonstrate that Naloxone and overdose prevention must move from mainly hospital and clinical settings into the hands of people in the community (street users, carers, agency staff) to improve access and timely response. Peers can be a great asset both to improve Naloxone availability and to provide training to various actors in how to administer the drug. Training prison staff and engaging prisoners who use opiates with local health services in the weeks following their release also helps preventing overdose deaths in this population.

Overdose prevention - Status quo and challenges

This publication was part of a two-part series on overdose prevention. Click here to access 'Overdose prevention - Status quo and challenges'.

By Jean-Paul Grund & Graham Shaw / Stop Overdose Now (SON)

An innovative way of preventing opiate overdose deaths is through emerging online technologies. Online user forums as well as informative websites and mobile phone apps, are an asset in improving access to both information and naloxone itself. Web-based interventions are easily accessible from non-urban areas and across the globe, and help to circumvent stigma, punitive drug policies and harsh law enforcement. Besides, as the growing online drug market challenges traditional harm reduction service provision such as outreach work, innovative projects are using the same online channels to provide harm reduction services. High quality information websites and instructive apps increase access to information on overdose prevention, preparing PWUD and those near to them to properly respond in the event of an opioid overdose. Overall, the use of technology in support of the response to opioid overdose falls into two overlapping categories, namely communitybased networking of the response to overdose emergencies; and monitoring and research in support of risk management and response readiness. Among others, apps may offer geobased information on naloxone availability and harm reduction services to PWUD (connecting people in need of naloxone/services with those who can provide it). Other apps concentrate on post event incident reporting and monitoring of overdose only. These can potentially generate important data for overdose prevention projects and policy planning.

Innovation, however, does not come without challenges. Not all people in need possess mobile phones, and there are limits to current location technology to provide accurate geospatial location. Besides, safety, privacy and data security measures must be adapted to safeguard app users from law enforcement, hackers, and potential malicious behaviour by other app users. Finally, assuring uptake and acceptance by the PWUD community is essential, as well as securing funding to (further) develop tech-savvy initiatives to prevent overdose deaths.

Overdose prevention - New technology-based solutions

Many people who inject and use drugs experience negative interactions with the police and, as a result, are over represented in criminal justice systems, prisons and compulsory drug treatment centres. This happens because in many countries, the production, trafficking and use of some drugs is illegal and police are tasked with enforcing the law. Harm reduction programmes at their core recognize that drug use has implications for individual and public health, and these harms must be reduced as a fundamental step towards ensuring the human right to health. Despite these policy and programmatic shifts, people who use and inject drugs frequently report being targeted and searched by police, as well as experiencing harassment, humiliation, extortion, violence and arbitrary detention at the hands of the police.

In many countries, research has documented that these types of police practices increase vulnerability of HIV acquisition and onwards transmission, and are not conducive to access and retention in care for HIV and other related health services for people who use and inject drugs. In recognition of this, the World Health Organization recommends the decriminalization of drug use and possession for personal use as a critical enabler for an effective HIV response. The police have a central role in creating supportive environments where harm reduction programmes can exist and that, by fulfilling this role and becoming a partner in harm reduction, both the police and the broader communities in which they serve benefit immeasurably.

Law enforcement must work in partnership with the community, including people who use drugs, in pursuit of creating a rights- and health-affirming environment. While protecting public health is not the primary function of the police, operating within a human rights framework that improve health and well-being is part of progressive and effective policing practice.

Reducing harm: Police as partners in preventing HIV, promoting public health and protecting the rights of people who use drugs

The 45th meeting of the Programme Coordinating Board (PCB) took place in calmer waters than the previous meetings of the board. The venue was, as usual, the Executive Boardroom of the World Health Organization (WHO) in Geneva, Switzerland and the meeting was held from December 10 -12, 2019. It was the first meeting of the newly appointed third UNAIDS Executive Director in the history of the Joint Programme, and the first woman to hold that position, Ms. Winnie Byanyima from Uganda. The meeting was chaired by Ms. Li Cui from China.

Winnie’s report to the board was generally well-received, including by the NGO Delegation. Yet, as the current UNAIDS Strategy nears its expiration date in 2021, her report initiated a debate among members of the board about a possible next UNAIDS Strategy and the process involved. This discussion was closely linked with the agenda item that reflected on the report of the Joint Inspection Unit (JIU).

Just as in previous years, the first two days of the PCB discussed the report by the NGO Delegation and several other more policy and programme-driven items such as prevention, barriers to funding of community-led responses, and the Global Partnership for action to eliminate all forms of HIV-related stigma and discrimination. The third day of the meeting focused on the Thematic segment to inform the members of the PCB about possible actions to reduce the impact of AIDS on children and youth.

The PCB NGO delegation's communique: 45th Programme Coordinating Board meeting

This report enriches the information and knowledge base of harm reduction interventions in Europe from the viewpoint of civil society organisations (CSOs) that directly work for, and with, people who use drugs. This approach is a necessary, and useful, contribution to the development of drug policy in the region and C-EHRN plans to repeat this reporting on an annual basis to identify developments, changes and trends over time.

The report consists of four parts. The introduction provides background information concerning the development of the questionnaire, the data collection process, methodology used, and the nature of the data. Chapters 2-5 report on civil society involvement in drug policy and related decision-making processes as well as on hepatitis C and drug overdose prevention and management services together with the use of new drugs and new patterns of consumption. Each chapter begins with a short summary of the main results and ends by discussing conclusions and policy implications.

Most CSOs responding to the C-EHRN survey are experienced in contributing to data collection and, crucially, have close contact with many important actors in the field and have access to timely and quality information that complements the data collection mechanisms already in place. Consequently, this report reinforces the added value of the role played by CSOs in the collection of data that can inform harm reduction practice. In most countries, civil society involvement is, to some extent, enabled through dialogue and/ or information exchange but, often, the impact is regarded as unbalanced and ineffective. Permanent and formalised structures that ensure dialogue between civil society and government representatives are beneficial for such civil society involvement as structures allow for cooperation on a regular basis and oversee both the formulation of policy and its implementation. Formalised structures, however, do not safeguard meaningful involvement of civil society if they do not lead to accountable outcomes.

C-EHRN Monitoring shows that people who inject drugs (PWID) are still not allowed access to treatment of the hepatitis C virus (HCV) in 10 European countries. Although 23 countries have guidelines that include specific HCV management for PWID, many C-EHRN respondents are somewhat pessimistic about the impact of such guidelines on improving access to the HCV cascade-of-care in their country, especially to good practice, integrated, test-and-treat services at the same site. HCV testing and treatment at pharmacies remains very rare. On a more positive note, 23 European countries reported PWID organisations working actively to increase political awareness concerning HCV interventions. Compared to 2018, more attention has been paid over the past year to HCV awareness campaigns (in 15 countries), to testing at the service providers’ own premises (in 18 countries), and to treatment at the service providers own site (in 15 countries). The main barriers to address HCV among PWID include a lack of funding, knowledge, recognition, political support and skilful staff as well as weakness of civil society organisations and legal barriers.

In 15 countries of the region, the government monitors the number/proportion of people who progress through each stage of the HCV cascade-ofcare at the national level, with monitoring at the regional or local level also performed in 12 countries whereas monitoring is not performed at any level in a further 9 countries. There are still big differences within Europe as to where and how PWID can undertake a HCV test. This means PWID are in an unequal position in different European countries, regions and cities. Rapid HCV testing is available to prisoners in 21 countries.

Treatment of HCV using direct acting antivirals (DAAs) is available in all countries of the region except North Macedonia. However, 10 of 34 countries still place restrictions on access to DAA’s for those people who are active drug users. However, if access to DAA treatment is achieved, the costs are reimbursable by health insurance or through the public health service in all countries except the United Kingdom.

Consequently, to reduce the HCV-related disease burden among PWID and achieve the 2030 elimination goals as set out in the WHO Global Health Sector Strategy on Hepatitis, a radical change in the HCV response is needed in many European countries. National treatment guidelines that specifically address recommendations for treating PWID, guaranteed access by PWID to DAA treatment, improvements in the continuum-of-care and introduction of one-stop HCV testing and treatment services - including such services delivered by harm reduction organisations - needs to be further developed and adopted by all government and civil society stakeholders.

A further key contribution by civil society is collecting data on the context of drug-related overdose events and interventions at a local level, feeding into already existing data and reports. Only 5 countries reported separate overdose prevention strategies or action plans. Much improvement is needed to be able to adequately respond to overdoses in Europe. Evidence demonstrates that a range of measures – including drug consumption rooms (DCR), take-home naloxone (THN) programmes in the community, and naloxone distribution before release from prison - can reduce opioid and other drug-related overdose deaths. However, C-EHRN Monitoring shows a mixed picture of policies and measures across Europe. There is a significant disparity in how, and by whom, such overdose data is collected which can ultimately influence what is recorded as a drug-related death. To address this, the EMCDDA should encourage the respective national health authorities, their own Reitox Network, as well as others who collect such data, to collaborate more with national harm reduction networks and experts in their field of work. Furthermore, due to the uneven status of naloxone – the safe and simple response to an opioid overdose as recommended by WHO – political authorities are called upon to take appropriate legal initiatives to ensure, without delay, that naloxone is available free of charge and without prescription in pharmacies for people who use drugs; experience from Italy can be the basis for this action. In addition, to obtain a real overview of the number of doses of naloxone administered and data on the successful use of naloxone, a national reference point should be established to collect and analyse this and other data.

In general terms, the results of C-EHRN Monitoring correspond with what we know from other sources concerning new drug trends. In addition, the process of data collection as undertaken by C-EHRN Focal Points in each country has the potential of generating additional information and at a quicker pace than other methods, bringing added, qualitative value to this sector.

A review of the approach used by C-EHRN Monitoring to collect such information suggests that focus groups held several times each year would be more effective than a questionnaire as it would lead to consensus-based data. Also, a focus on drug trends, including new drugs, is preferable rather than the emergence of specific drugs. In addition, the focus should be at the city/urban level, rather than national, as this will likely provide higher quality data, and a reduction in the number of questions is recommended.

Civil society monitoring of harm reduction in Europe, 2019

This collection of case studies is an attempt by experts of the Eurasian Harm Reduction Association (EHRA) to introduce and systematise various models of alternative financing that have been implemented successfully in the current environment.

In recent years, many non-profit organisations (NPO’s) in the countries of Central and Eastern Europe and Central Asia (CEECA) have witnessed significant changes in the structure of their revenues; the volume of grant financing provided by charitable foundations has been gradually decreasing. Such a development has forced NPO’s to search for alternative sources of funding for their programmes and projects. At present, NPO’s are moving towards significantly more complex financing models, such as crowdfunding, involvement of businesses in charitable projects, and the establishment of social enterprises, amongst others. These activities are reaching a new level and becoming more mature and professional; they are now taking into consideration the interests and particularities of all stakeholders involved in the process.

This publication offers a description of various alternative financing mechanisms which NPO’s can use in their search for available financial resources, specifically the forms that such mechanisms could take; how the work should be built from the very beginning; what the motives of participating partners in such initiatives could be; and identification of the secrets of success and the possible risks, amongst other issues. This collection is prefaced with an analytical article offering a typology of alternative financing models for NPO’s. Furthermore, specific case studies are provided as illustrations of such models; the examples provided include both large and small scale projects.

Different outcomes are presented through the examples given of NPO’s utilising alternative financing mechanisms. Certain organisations are successful in their implementation of one or other of the listed approaches, whilst others may have not had such an experience but still continue to be active in this sphere while learning from their mistakes; others may just be starting their journeys and are only considering additional opportunities.

This collection is intended to provide help for both experienced and beginner NPO’s and could be of use to the leaders of such organisations, fundraisers and other specialists working with NPO’s. It may also be of interest to specialists of state bodies, business structures and also to everyone who is interested in building long term relations with NPO’s and who are willing to enhance their competencies in the fields of strategic partnership and fundraising.

A number of semi-structured online interviews with representatives of NPO’s working with vulnerable groups and implementing various alternative financing practices were conducted to collect the data introduced in this publication. Most respondents were leaders of such organisations.

In total, 20 NPO representatives from 15 countries of Western, Eastern and Southern Europe took part in the survey, including Ukraine, Georgia, the Russian Federation, Moldova, Poland, Romania, Bulgaria, Slovenia, Serbia, Armenia, Croatia, the Netherlands, Switzerland, England, and Scotland.

It is hoped that many public organisations will be able to use the experiences presented here to obtain alternative financing for the implementation of their own projects.

Alternative financing: Models of sustainable development for non-profit organisations

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.

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