By Anna Olsen, Gabriel Wong, and David McDonald, Australian National University

In summary, our evaluation found that the ACT Pill Testing Trial was implemented as planned, that the service was well received by patrons and stakeholders, and that the service impacted positively on patron knowledge, attitudes and behaviours. The 2019 Groovin the Moo festival Pill Testing Trial, implemented by Pill Testing Australia, was the second government-sanctioned trial of its type in Australia. It was designed and implemented collaboratively between the key stakeholders, primarily Pill Testing Australia, Cattleyard Promotions, and key ACT Government agencies ACT Health and ACT Policing. Enough lead time was available to develop the trial carefully, with the result that it was implemented as planned and produced the types of outputs that the key stakeholders expected to see. The service provided harm reduction information to 234 patrons and identified seven substances containing a potentially dangerous substance, N-ethyl pentylone. The experience of testing and the accompanying harm reduction brief interventions produced a number of positive results in terms of participants' self-reported drug harm reduction knowledge, their trust of health providers and other written sources of harm reduction information, and stated behavioural intentions regarding drug use.

Overall, the evaluation produced no strong arguments against the development of further services that provide pill testing and harm reduction information for people who use illicit drugs. The findings are supportive of such initiatives.

Australian Capital Territory pill testing trial 2019: Program evaluation

By Robert Csák, Irena Molnar, Péter Sárosi, Jovana Arsenijević, Bojan Arsenijević

Our results emphasize that drug related harms are generated in a complex system with intricate connections amongst diverse, heterogeneous actors, in an ever-changing assemblage. We tried to illustrate in this paper how the diverse everyday practices of injecting, combined with the different substances available, the social context of injecting, the physical environment where the substance use occur, could shape the risk behaviours of PWID and the risks of substance use as such. The differences in the prevalence of individual risk behaviours represent the differences in injecting practises in the two communities, and these differences underline the importance of tailoring harm reduction services to the specific needs of the local PWID community. Nevertheless if we would like to implement interventions that can effectively reduce the health risks of substance use, it is necessary to consider environmental, structural factors influencing the consequences of substance use, and aim for responses that could promote an enabling environment, despite it could be hard to transform these factors into variables affecting public health indicators directly

Some of the lessons learnt from our research:

Although the demographic characteristics of drug users were the same (mostly men in their mid-thirties, with low educational attainment, and poor labour market position), there were differences in drug use. Whilst in Belgrade most people still inject heroin, in Budapest mostly new psychoactive (cathinone-type) stimulants are injected.

Access to sterile injecting equipment declined significantly in both cities. In Belgrade 78 percent of drug users bought their clean needles in pharmacies. In Budapest, where a few NSPs remained open, this figure was only 51 percent.

The overwhelming majority of users share their equipment in both cities. The situation was more severe in Belgrade, where half of our sample practiced seven or more types of risky behaviour (compared to one quarter of the Budapest sample).

Our research confirmed that injecting drug use is a community activity, shaped by the environment and by mediated drug-sharing practices amongst the same marginalised, criminalised groups. Any future interventions should consider these environmental, structural factors.

In both cities, fewer people have access to HIV/HCV screening and counselling, vein-care products, and social services (eg. housing, employment). The closure of NSPs severely exacerbated the social isolation of their former clients: they reported significantly less access to “a place to sit for a while” or “speaking with social workers”.

The study was conducted by the Rights Reporter Foundation, in co-operation with the NGO ReGeneracija from Belgrade.

Different environments, different risk behaviours: Consequences of decreased coverage of needle exchange programmes in Budapest and Belgrade

Drug checking (or ‘pill‐testing’ as it has been referred to in Australia and as a result is the term used herein) is a harm reduction intervention aimed at providing information to people intending to consume drugs, regarding the contents of their drugs, and providing information to reduce the potential harms from drug consumption. While most of the public focus has been on pill‐testing at music festivals, there are many models of pill‐testing available. This includes fixed sites in central locations (such as at transport hubs, or in community centres providing other health‐care check‐ups and support services), pop‐ups at festivals and music events, postal services and in clubs. Mostly, they target people who use drugs recreationally, although more recently the appearance of fentanyl in the USA and Canada has prompted calls to expand pill‐testing to include testing opioids in street‐based drug markets.

There has been an exponential increase in the number of pill‐testing services across developed nations in the last 5 years. Research evidence on its feasibility and effects has been widely documented. It appears to be a highly acceptable intervention amongst Australian festival goers. Australia is a federated nation, with drug policy implementation occurring largely at state level. Two pilots of pill‐testing have been successfully undertaken in one Australian jurisdiction, the Australian Capital Territory (ACT).

Despite these successful pilots, pill‐testing has remained a highly controversial harm reduction intervention in Australia, and particularly in one state, New South Wales (NSW). The public debate in NSW has not resulted in policy change thus far, with the current conservative NSW government unwilling to trial pill‐testing at time of writing. This is despite an environment in the last 18 months theoretically conducive to policy change, including a state election, high levels of advocacy for pill‐testing, a window of opportunity created as a result of the summer festival season in NSW, and the focussing events of deaths at festivals. In this paper, I explore ways to understand the nature of the debate, with a view to looking for new accommodations and ways of conducting a more productive and less divisive policy debate.

Making drug policy in summer — drug checking in Australia as providing more heat than light

On 5th December 2019 the Civil Society Forum on Drugs (CSFD) will host a seminar for Members of European Parliament (MEPs), along with other European policy makers on ‘The Future of European Drug Policy – Seminar organised by the Civil Society Forum on Drugs’ at the European Parliament. The seminar is specifically targeted at MEPs that have a clear interest and mandate in the area of drug policy, such as members of the LIBE, DROI and ENVI Committees. Through its legislative, budgetary and political oversight powers, the European Parliament has a critical role to play in policy formation and support, including on key issues related to drug policy.

Historically, the European Parliament has played an active role in the area of drug policy. It was instrumental in the creation of both the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), and the Drugs Prevention and Information Programme (DPIP) which marked the first time that funding was ringfenced for drug-related issues. This programme has existed for the previous two financial frameworks, but is scheduled to end in 2020.

As European policy makers move towards 2020 in a Europe that faces significant political, social and economic challenges, and in the context of global drug policy challenges, this event aims to:

Highlight why drug policy should remain a key priority for Europe and why MEPs and other European policy makers need to keep it on their political agendas, and

Help MEPs navigate the implications of the new phase of global and European drug policy.

With these aims in mind, this event will highlight ongoing challenges in drug policy at European and global levels and provide insight into how civil society can assist policy makers and legislators in tackling these issues. Speakers will provide inputs on the contributions of civil society to the EU and European Commission (EC) on current drug policy issues, and raise awareness of the value of civil society participation – and in particular the CSFD – in drug policy processes. This briefing paper has been prepared for participants to provide background and context to the seminar.

The future of European drug policy: A briefing paper for members of the European Parliament 

By the Select Committee into Alternate Approaches to Reducing Illicit Drug Use and its Effects on the Community / Legislative Council, Western Australia

The Legislative Council established the Select Committee into Alternate Approaches to Reducing Illicit Drug Use and its Effects on the Community (Committee) on 17 October 2018. The Committee inquired into approaches to reducing harm from illicit drug use in other jurisdictions and compared their effectiveness to the approaches currently used in Western Australia (WA).

The inquiry is specifically about illicit drugs, although the Committee heard about the high levels of harm associated with alcohol and prescription drugs. Importantly, the inquiry is concerned with drug users, and not people involved in the drug trade. The Committee inquired into approaches to addressing the use and possession for personal use of drugs, and not possession with intent to sell or supply, or the distribution of drugs.

People always have, and always will, use drugs. Prohibition has not stopped this. In 2016, 43% of Australians had illicitly used a drug at some point in their lives. There is a growing recognition across the world that drug prohibition has increased the harms associated with drug use. Under prohibition, black markets have thrived, prisons have filled with drug users and those committing drug-related offences, and stigma is experienced by people who use drugs.

The Committee has distinguished between non-problem and problem drug use. Most people who use drugs do so in an occasional, recreational way that does not adversely affect their lives or the community. The minority suffer from drug use disorder, and require treatment or support. Some people are more likely to develop drug problems than others. Factors including childhood trauma, economic disadvantage, unemployment, unstable housing and mental health issues are linked to problematic drug use. People living in regional and remote areas, and particularly Aboriginal Australians, are at greater risk of experiencing drug-related harm.

Drug use is associated with health, social and economic harms to the people who use drugs, their family and friends, and the wider community. Drug use itself causes some of these harms, such as death, disease and drug-fuelled violence. Other harms are caused by the criminalisation of drug use or possession for personal use. A criminal record can affect employment, housing and educational opportunities. Prohibition also increases stigma, as people are less likely to seek help when they fear criminal action. These impacts can compound existing social disadvantage. The Committee found that all of these harms are present in WA, particularly given our high rates of problematic methamphetamine (meth) use.

Help, Not Handcuffs: Evidence-based approaches to reducing harm from illicit drug use in Western Australia

By the Afghanistan Research and Evaluation Unit

The Afghanistan Research and Evaluation Unit today launched a research synthesis paper titled “The Helmand Food Zone: The Illusion of Success”. The study is supported by the EU’s three-pronged research in Natural Resources Management in Afghanistan. This study documents how the Helmand Food Zone was developed, its origins and architects, as well as the different actors involved in the implementation and the subsequent challenges of delivery. Initially presented as a drug control project, the Helmand Food Zone came to be accredited for supporting stabilisation and governance in the Helmand province between 2008 and 2012. Driven by political demands rather than evidence, the program became a flagship in Helmand, and lauded as a success, despite evidence to the contrary.

Speaking about the report, AREU Director Dr Orzala Nemat said, “This is timely research as we are heading towards the formation of a new government and a possible peace deal in the coming year. In both of these contexts, addressing the issue of drugs is a key challenge that the future Afghan leadership will have to tackle, in light of the lessons drawn from past practices.”

The study reports that the short term success of the Helmand Food Zone with regards to its association with reducing poppy was far outweighed by the role the programme played in: (i) creating the conditions for unprecedented amounts of land to be brought under poppy cultivation than ever before; (ii) institutionalising forms of corruption that further alienated the rural population from the authorities; and (iii) helping set in motion a process of agricultural intensification that is likely to lead to the displacement of at least half a million people in the next decade.

The paper argues, “However, as yields recovered in 2016 and the Afghan National Defense and Security Forces lost control over larger tracts of rural Helmand, farmers returned to poppy cultivation in ever greater numbers,” adding that “So much so that by 2017, UNODC estimated that there were 144,000 hectares of opium poppy in Helmand as a whole; and the United States Government's estimates of poppy cultivation for the Helmand Food Zone indicated that there was even more poppy within its boundaries than when the programme began in 2009.”

According to the study, the Governor’s reliance on donor patronage from funds to transport and logistics and his pursuit of an opium ban regardless of the impact on rural lives and livelihoods increased the perception amongst farmers that he did not act in the interests of the local population, but of his foreign benefactors. As such, the Helmand Food Zone served to further embed a growing sense of hostility to the provincial authorities and undermine the state-building objectives proffered by the donors as a reason for supporting the intervention.

In fact, from a governance perspective, the study concludes that the Helmand Food Zone worked through and consolidated existing systems of power and patronage, empowering the Governor, officials and village elders to solicit rent and favours from farmers in exchange for development assistance or to avoid eradication. Of particular concern, the Helmand Food Zone turned a blind eye to repeated reports of corruption with regard to the distribution of wheat seed and fertilizers and continued to support the production of unverifiable village lists by district officials and elders with all the problems that this entailed. By doing so, the programme helped institutionalise forms of corruption and fueled the frustration and anger that many rural households felt towards the government and its representatives. By operating through mechanisms that siphoned off support to the wealthy, the Helmand Food Zone helped undermine the very goal that it set out to achieve – the idea that the governor and the government could deliver services to the population

The study builds on in-depth fieldwork and high-resolution satellite imagery collected before, during and after the implementation of the Helmand Food Zone, as well as interviews with some of the main protagonists in the donor community. In total, 4,122 household interviews took place with farmers over an 11-year period in either all or some of the 28 research sites in Helmand province, in areas both north and south of the Boghra canal. The latest body of fieldwork was conducted in spring 2018 and consisted of 310 interviews in the same research sites, supplemented with a further 52 interviews with women who resided in former desert areas.

The Helmand Food Zone: The illusion of success

By the Canadian Association for Safe Supply

In regions of Canada where the tainted drug supply being a significant factor in overdose deaths, safe drugs can prevent overdose death.

“Safe Supply” refers to legal and regulated drugs such as heroin and hydromorphone that perform as a substitute for illicit drugs. Unlike traditional substitution treatments, such as methadose, suboxone,and kadian, safe supply still provides the mind-altering properties that drug consumers seek in illicit drugs.

Safe supply is not just a treatment for an individual at risk of overdose, but for the systemic issues that impact individuals and increase overdose risk (criminalization, contaminated drugs).

Similar to how the Canadian government controls and distributes alcohol, providing a regulated safe supply of opioid and/or stimulant drugs reduces overdose death.

People that use stimulant drugs like cocaine, crack, and methamphetamine are also at risk of overdose from fentanyl contaminants. Safe supply means providing pharmaceutical grade cocaine and methamphetamine, not just opioids.

Safe Supply means that service providers re-conceptualize safe use practices (using sterile equipment, narcan) to include using a safe substance of known potency.

For it to be effective it has to be available: barriers reduce accessibility.

Safe supply is a catalyst to getting people in touch with harm reduction, housing, and healthcare services.

Safe supply fact sheet

By the Canadian Association of People who Use Drugs

This report is a general outline of the “safe supply” concept, of what safe supply is, and the role of safe supply in drug policy. The purpose of this document is to provide clarity to what is meant by the term “safe supply” with a mind to keeping conversations on point when safe supply and drug policy are being discussed.

The safe supply ideas set out in this report are meant to be examples of how they could be provided and are not meant to form a comprehensive guideline for designing a safe supply system. Safe supply program designers should be creative and thoughtful to the needs/wants of the drug using population being served. The thoughtful approach to safe supply requires thinking as economists to imagine policies and programs that will truly appeal to those who would otherwise prefer to consume drugs purchased on the illicit market.

Safe supply refers to a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market.

Drugs included are opioids such as heroin, stimulants such as cocaine and crystal methamphetamine, hallucinogens such as MDMA and LSD, and marijuana.

Safe supply concept document

People who inject drugs (PWID) are at high risk of acquiring and transmitting blood-borne viruses, including HIV, from unsafe injection practices and risky sexual behaviors. The United Nations Office on Drugs and Crime (UNODC) estimates that around 29.5 million people suffer from drug use disorders worldwide of the estimated 15.6 million PWID in the world, subSaharan Africa has 1.4 million. The Southern and Eastern coasts of Africa are important routes for global heroin trafficking originating from Asia, and the region is fast becoming a final destination for these drugs, with a growing number of African consumers.

HIV prevalence among PWID is 18% globally, nearly 28 times higher than HIV prevalence among the general adult population. A systematic review determined that HIV prevalence among PWID in subSaharan Africa was 56%, but estimates in the region vary widely.

Adverse health outcomes among PWID are further intensified by punitive legal environments, a variety of human rights abuses and poor access to services. Few harm reduction programs and PWID-specific HIV prevention, care and treatment services are available in sub-Saharan Africa. As of 2017, only seven countries had publicly funded syringe exchange and medication-assisted opioid treatment programs. In Mozambique, publicly funded harm reduction and HIV care and treatment programs for PWID did not exist prior to this study.

An estimated 13.2% of the adult population in Mozambique are living with HIV; the percentage of PWID living with HIV was unknown. Information on blood-borne disease burden and demographic and behavioral characteristics of PWID are necessary to assess the unique prevention, care and treatment needs of this population. For this purpose, we conducted the first biological and behavioral survey (BBS) among PWID in two urban areas of Mozambique. PWID are one of five priority populations surveyed as part of the national HIV behavioral surveillance system, which include men that have sex with men, female sex workers, long-distance truck drivers, and mine workers. This manuscript presents the main findings of the PWID BBS survey.

High prevalence of HIV, HBsAg and anti-HCV positivity among people who injected drugs: Results of the first bio-behavioral survey using respondent-driven sampling in two urban areas in Mozambique

The phenomenon of new psychoactive substances (NPS) started decades ago with the growth and production of drugs that replicate the effects of controlled drugs (such as amphetamines, cocaine, cannabis and heroin) but avoid legislative control based on different chemical structures.

In recent years, the increasing use of NPS has led to new threats for health of people who use drugs (PWUD) – including overdose, psychotic reactions, high HIV risks due to multiple injections and increased number of sexual contacts. However, in many countries service providers such as harm reduction, drug treatment programs and ambulance services are not prepared to provide PWUD with quality support and counselling to reduce risks of NPS.

In the Central and Eastern Europe and Central Asia (CEECA) region the situation with NPS is truly alarming and has become one of the major challenges for the national public health systems, local NGOs, communities PWUD.

EHRA in partnership with School of Law, Swansea University conducted a research “New Psychoactive Substance Use in Moldova and Belarus”. It aimed to analyze and determine the presence of new psychoactive substances (NPS) 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 its use, and provide information to national civil society organizations for political advocacy.

In 2020, research will be expanded into 4 more countries: Kazakhstan, Kyrgyzstan, Georgia and Serbia.

New psychoactive substance use in Moldova and Belarus

MDMA is well established as a popular psychoactive substance across much of the Western world. Hundreds of thousands of people break the law to access its effects, which include increased energy, euphoria, and enhanced sociability. The categorisation of MDMA as a Class A drug in the UK and Schedule I drug internationally – categories reserved for drugs deemed to pose the highest risk to individuals and society – has never meaningfully disrupted its supply, nor its widespread use. MDMA is cheaper and purer than ever before and is available at the click of a mouse via darknet drug markets.

For several years, MDMA-related adverse events and fatalities have been increasing in the UK, with some claiming that taking MDMA today is the riskiest it has ever been. Responses are polarised between those who assert that the risks of MDMA use necessitate mitigation through prohibition and increased law enforcement, and those who perceive prohibition to be exacerbating these risks by exposing users to an unregulated market of pills and powder of unknown strength and quality. Whichever view you take, current policy is not meeting its goal of reducing harms, and greater control of MDMA production, distribution, purchase, and consumption is needed in order to prevent MDMA-related emergencies.

This report examines the acute, sub-acute, and chronic harms related to MDMA use in detail. We examine the production, distribution, purchase, and consumption of the drug; related risks and harms; and the impact prohibition has on these, as well as the potential impact of alternative policies. Crucially, our evidence shows that most harms associated with MDMA use arise from its unregulated status as an illegal drug, and that any risks inherent to MDMA could be more effectively mitigated within a legally regulated market.

Under prohibition, people purchase MDMA pills, crystal, and powder from an illegal market, with little certainty as to what these contain. Given that illegal drugs are not subject to strict production standards, consumers are exposed to the risks of poisoning or accidental overdose as a result of contamination, adulteration, and unknown strength and purity. Naïve commentators demonise the drug and simply urge young people to ‘just say no’, whilst failing to account for those who say ‘yes’. In the meantime, preventable deaths continue to occur, and otherwise law-abiding people are punished for non-violent offences such as the possession or social supply of MDMA. Governments and the mainstream media persist in perpetuating the myth that the War on Drugs is winnable if it were fought harder, and those calling for drug policy reform – as we do here – are framed as ‘radicals’ who have little or no regard for the health and wellbeing of citizens.

This characterisation could not be further from the truth. Those calling for careful reform to existing drug policy include the parents of young people whose lives have been lost or ruined by harms related to the prohibition of MDMA. We incorporate their voices in this report alongside those of academics and former police officers, highlighting the ‘broad church’ of those dedicated to fighting for reform. This includes scientists undertaking ground-breaking research into the therapeutic potential of MDMA, who work within a regulatory regime that makes such research exorbitantly expensive and time-consuming, because of the Schedule 1 status that MDMA holds in the UK.

As we enter the fourth decade of MDMA’s widespread use, new thinking is needed on how to better control production and distribution, and on how to reduce the risks associated with its consumption. There is growing evidence to support reorienting drug policy away from an ideologically driven criminal justice-led model to one rooted in pragmatic health and harm reduction principles. This is reflected in the widespread reform of cannabis laws occurring in numerous jurisdictions around the world, and the growth of treatment programmes for heroin users which include prescription heroin and supervised injecting rooms. These hard-fought policy changes acknowledge the failure of prohibition to meet its goals and produce a ‘drug-free world’. They are built on a robust and ever-growing evidence base which demonstrates how permitting or prescribing the use of legally regulated drugs improves health and safety outcomes for people who use drugs and their communities at a reduced cost to the state, whilst also providing wider employment and economic opportunities. This logic can be extended to the use of MDMA and other currently prohibited psychoactive substances.

follows this pragmatic path and pursues policy aims which many of us share, such as improvements in public health promotion, targeted harm reduction, evidence-informed policy and practice, human rights, social justice, participatory democracy, and effective governmental expenditure. For the first time, we outline detailed recommendations for drug policy reform to better control the production, distribution, purchase, and consumption of MDMA products. Reform and the reduction in MDMA-related harms this will bring cannot happen overnight. The changes we outline here, which culminate in a strictly regulated legal market for MDMA, are to be phased in gradually and closely evaluated through independent policy research to ensure health and social outcomes are properly documented, with findings folded back into the ongoing reform process.

The report is available on the Beckley Foundation's website.

Roadmaps to regulation: MDMA

By Richard Stranz (Aides), Eurosider Project

Drugs users and community health workers (CHW) in France both expressed the need to have their reality of their work around injection practices legitimised and formalised as interventions being beneficial to the health of drug users (DU).

As a result back in 2009, a community-based research study, called AERLI (Accompagnement et éducation à la réduction des risques liés à l’injection), was instigated in France between AIDES, Médecins du Monde and the INSERM research institute. Its aim was to identify how CHW by being present at the moment of injection could improve DU health outcomes.

One aspect of this research was that the CHW were trained implement the research protocol. This protocol also standardised the steps of the intervention. These were transformed into a training manual.

The results of AERLI 1 published in 2016 proved that interventions at the time of injection reduced risky behaviour for infectious diseases (HIV and Hep C particularly) and also in the long term both as one off and if repeated (ref).

Since then, through training workshops very similar to the one laid out in this manual AIDES has been reinforcing the capacities of its own volunteers and salaried staff as well as from other organisations to implement this intervention adapting. It has also trained staff from other organisations.

The EUROSIDER project, a lighter version of the AERLI study, was carried out with the support of EU funding via DG JUSTICE call: JUST-2016-AG-DRUG.

The main objective of this project was to contribute to reducing the risk of HIV-HCV transmission and to better international Hepatitis C policy and practice by studying the transferability of an effective community-based, Individually-Tailored Support and Education for Safer Injection (ITSESI) intervention in four different political and epidemiological contexts.

As one of the deliverables of the project, this training manual resembles the one used during the training sessions implemented during the project.

It has been enriched with the feedback from the trainers in the four target countries Bulgaria, Greece, Portugal and Romania.

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