By Bryce Pardo, Jirka Taylor, Jonathan P. Caulkins, Beau Kilmer, Peter Reuter, Bradley D. Stein

Deaths involving synthetic opioids in the United States increased from roughly 3,000 in 2013 to more than 30,000 in 2018. In fact, synthetic opioids like fentanyl are now involved in twice as many deaths as heroin. This book offers a systematic assessment of the past, present, and possible futures of synthetic opioids in the United States. It is rooted in secondary data analysis, literature reviews, international case studies, and key informant interviews. The goal is to provide decisionmakers, researchers, media outlets, and the public with insights intended to improve their understanding of the synthetic opioid problem and how to respond to it.

The authors conclude that (1) fentanyl and other synthetic opioids are becoming dominant in some parts of the United States and Canada, but remain less common in other parts of these countries; (2) a confluence of factors, including the dissemination of simplified and novel synthesis methods and increasing e-commerce, helps explain the surge in synthetic opioids; (3) much can be learned from other countries' experiences with synthetic opioids; (4) supplier decisions, not user demand, drive the transition to fentanyl; (5) fentanyl's spread is episodically fast and has ratchet-like persistence; (6) synthetic opioids drive up deaths rather than the number of users; (7) problems with synthetic opioids are likely to worsen before they improve, and states west of the Mississippi River must remain vigilant; (8) improving surveillance and monitoring is crucial; and (9) limiting policy responses to existing approaches seems unlikely to reverse this tide.

The future of fentanyl and other synthetic opioids

In its resolution 36/16, the Human Rights Council requested the United Nations High Commissioner for Human Rights to submit a report on violence, death and serious injury in situations of deprivation of liberty, drawing on the experience of United Nations and regional human rights mechanisms, and seeking the views of States, including on their policies and best practices, civil society, and other relevant stakeholders. It requested the report to be presented at the forty-second session of the Human Rights Council. In preparation of this report, contributions were sought from Member States; international and regional organisations; national human rights institutions; and non-governmental organisations. 1 In addition to information received from these entities, the report draws on a range of public sources, including from United Nations human rights mechanisms, and work by civil society organisations.

The issue of violence, death and serious injury was identified by the Secretary General as one of the most important challenges pertaining to the protection of persons deprived of their liberty.2 By depriving persons of their liberty, States assume the responsibility to protect the life and bodily integrity of such persons. States are thus obligated to prevent the illtreatment of, and violence against such persons and to ensure that the conditions of a dignified life are met.

The human rights of persons deprived of their liberty are enumerated in core international human rights instruments. The right to life of all individuals, including of persons deprived of their liberty is enshrined in Article 6 of the International Covenant on Civil and Political Rights (ICCPR), as is the prohibition on arbitrary deprivation of life. The right to be protected from the use of torture or cruel, inhuman or degrading treatment or punishment is found in Article 7 of the ICCPR and in the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Persons deprived of their liberty must also be treated with humanity and respect for the inherent dignity of the human person per Article 10 of the ICCPR. The United Nations Standard Minimum Rules for the Treatment of Prisoners, also known as the Mandela Rules, provide States with important and detailed guidelines for protecting and fulfilling the human rights of persons deprived of their liberty.

The present report addresses the intersection between situations of deprivation of liberty and violence, death and serious injury. The report examines the vertical, horizontal and environmental causes of violence, death and serious injury in situations of deprivation of liberty. It then considers measures which should be taken to address such incidents.

With regard to drug policy and related issues, the report:

Recognises people who use drugs as a group “facing an increased risk of torture and ill-treatment [in detention], as law enforcement officials in some cases deliberately take advantage of the pain and suffering associated with the withdrawal syndrome displayed by drug users deprived of their liberty to elicit forced confessions. Human rights mechanisms concluded that the use of withdrawal symptoms to obtain information or confessions, to punish or to intimidate or coerce may amount to torture”; (para 6)

Condemns the intentional withholding of drug treatment from a person who uses drugs as a form of punishment (para 7);

Addresses the lack of essential healthcare in prison, also touching upon drug dependence and people living with HIV, and acknowledges that “lack of healthcare or inadequate treatment in detention for persons who use drugs can also contravenes the right to health and can contribute to deaths in detention. Access of detainees to medical treatment, including access to opioid substitution therapy, is often severely restricted even if it has been demonstrated that therapy is the most effective intervention available for the treatment of opioid dependence and that it contributes to reducing mortality” (paras 29-34);

Condemns violence against people who use drugs perpetrated “under the guise of treatment when placed in mandatory administrative detention” (para. 32).

Submissions by Harm Reduction International and the Canadian HIV/AIDS Legal Network.

Earlier this year, Harm Reduction International submitted two reports to OHCHR on violence, death and serious injury in situations of deprivation of liberty – one on conditions of death row, and one on forms of violence in situations of deprivation of liberty for drug-related offences.

Human rights in the administration of justice - Report of the United Nations High Commissioner for Human Rights

The number of Australians who die from unintentional drug overdose each year continues its long-term rise. This report examines drug-induced deaths, where the death is directly attributable to the drug use, with a focus on unintentional-drug induced deaths. This report presents key statistics about unintentional drug-induced deaths in Australia from 2001 to 2017, with a snapshot of 2017 data provided in Figure 1.

Opioids (including both pharmaceutical opioids and heroin) continue to be the primary drug group associated with unintentional drug-induced deaths, though there have been significant changes in the types of opioids since 2001. While deaths involving pharmaceutical opioids have continued to rise, and comprise the largest proportion of deaths involving opioids, there have been dramatic rises in deaths involving heroin since 2012.

Benzodiazepines remain the second most common group of drugs identified in unintentional drug-induced deaths, behind opioids, though these are predominantly identified in poly-substance overdose deaths. Since 2013 there has been a significant increase in unintentional drug-induced deaths involving benzodiazepines in both Western Australia and Victoria, and to a lesser extent, New South Wales.

There has been a sharp rise in deaths involving stimulants (including methamphetamine) in Australia since 2012, which is seen in both regional and urban areas.

Deaths involving other prescription medications – such as anti-convulsant medications used as treatment for neuropathic pain, and anti-psychotics – have increased markedly in the last few years, although they account for only a small proportion of all unintentional drug-induced deaths.

Drug-induced death is not confined to either illegal drugs or those taken as medicines; alcohol may also be involved in unintentional drug-induced deaths. When used in conjunction with other drugs, alcohol may contribute to a fatal overdose, or rarely, be the sole cause of an unintentional drug-induced death. Up until recently, alcohol was the third most common drug involved in unintentional drug-induced deaths, though it has recently been surpassed by stimulants.

While a single drug may be identified in an unintentional drug-induced death, it is rare for a death to be attributable to toxicity from a single drug; deaths involving multiple drugs are the norm rather than the exception. Poly-drug deaths involving four or more substances have increased significantly in recent years.

While drug use is commonly associated with younger people, this report shows that it is middle-aged Australians (30-59 years) who have the highest incidence of unintentional drug-induced mortality. Further, the gap between this middle-aged cohort and Australians under-30 or over-60 has expanded in the last fifteen years and continues to widen. Unintentional drug-induced deaths overall are more prevalent among men, with the number of deaths for males increasing more rapidly than for women in recent years. Similarly, the rate of unintentional drug-induced death remains higher for Aboriginal Australians than for non-Aboriginal Australians, and this gap is widening. Finally, unintentional drug-induced deaths occur across all socio-economic areas, with small differences in prevalence observed between the most advantaged neighbourhoods and the most disadvantaged neighbourhoods.

Drugs and overdose also tend to be associated with urban areas; the data, however, reveal that the highest growth in unintentional drug-induced deaths is occurring in regional settings, away from capital cities. This trend poses significant challenges for responding to overdose, as regional areas tend to have less access to drug treatment and support services and may have longer delays in ambulance attendance.

Penington Institute has compiled this report based on data from the Australian Bureau of Statistics (ABS).

Australia's annual overdose report 2019

By András Költő, Alina Cosma, Honor Young, Nathalie Moreau, Daryna Pavlova, Riki Tesler, Einar B. Thorsteinsson, Alessio Vieno, Elizabeth M. Saewyc and Saoirse Nic Gabhainn

Sexual minority youth are at higher risk of substance use than heterosexual youth. However, most evidence in this area is from North America, and it is unclear whether the findings can be generalized to other cultures and countries. In this investigation, we used data from the 2014 Health Behaviour in School-aged Children (HBSC) study to compare substance use in same- and both-gender attracted 15-year-old adolescents from eight European countries (n = 14,545) to that of their peers who reported opposite-gender attraction or have not been romantically attracted to anyone. Both-gender attracted, and to a lesser extent, same-gender attracted adolescents were significantly more likely to smoke cigarettes, consume alcohol, get drunk and use cannabis, or be involved in multiple substance use in the last 30 days compared to their opposite-gender attracted peers. Those adolescents who have not been in love had significantly lower odds for substance use than all other youth. The pattern of results remained the same after adjusting for country, gender and family affluence. These findings are compatible with the minority stress and romantic stress theories. They suggest that sexual minority stigma (and love on its own) may contribute to higher substance use among adolescents in European countries.

Romantic attraction and substance use in 15-year-old adolescents from eight European countries

This is the first issue of the information digest produced by the Eurasian Network of People who use drugs.

The digest provides information about the activities of ENPUD members and updates on developments in activism and the policy landscape in the EECA region.

Infodigest from ENPUD - July 2019

The U.S. is facing an unprecedented number of opioid-related overdose deaths, and an array of other countries have experienced increases in opioid-related facilities. In the U.S., naloxone is increasingly distributed to first responders to improve early administration to overdose victims, but its cost-effectiveness has not been studied. Lay distribution, in contrast, has been found to be cost-effective, but rising naloxone prices and increased mortality due to synthetic opioids may reduce cost-effectiveness. We evaluate the cost-effectiveness of increased naloxone distribution to (a) people likely to witness or experience overdose (“laypeople”); (b) police and firefighters; (c) emergency medical services (EMS) personnel; and (d) combinations of these groups.

High distribution to all three groups maximized net monetary benefit and minimized fatal overdoses; it averted 21% of overdose deaths compared to minimum distribution. High distribution to laypeople and one of the other groups comprised the second and third best strategies. The majority of health gains resulted from increased lay distribution. In the societal analysis, every strategy was cost-saving compared to its next-best alternative; cost savings were greatest in the maximum distribution strategy. In the health sector analysis, all undominated strategies were cost-effective. Results were highly robust to deterministic and probabilistic sensitivity analysis.

Increasing naloxone distribution to laypeople and first responder groups would maximize health gains and be cost-effective. If feasible, communities should distribute naloxone to all groups; otherwise, distribution to laypeople and one of the first responder groups should be emphasized.

Click here to read the full article (restricted access)

Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and lay distribution in the United States

The “war on drugs” was first declared by U.S. President Richard Nixon in 1971, with the goal of eradicating what he viewed as the growing problem of drug addiction. Since then, it has had dire consequences, including the exacerbation of human rights violations and erosion of democratic institutions around the world. Yet human rights groups largely refrain from discussing drug policy.

Hundreds of civil society groups around the world are dedicated to investigating the outcomes of the drug war and advocating drug policy reform based on their findings. However, drug reform advocates often comment that international human rights organizations have been largely absent in these discussions. Human rights reports generally stick to noting human rights violations in affected states as a whole, without investigating the violations’ relation to drug policy and drug trafficking organizations.

Knowing this, the Human Rights Foundation initiated its War on Drugs Research Project to examine data and existing research on the global drug war’s costs and consequences in order to understand drug policy from a human rights perspective. The resulting report is organized in two parts. The first offers a high-level introduction to the drug war’s history and economics. It explains how prohibition was established, how the resulting black market functions, and how its policies have ultimately failed to decrease drug abuse.

Once we have established whether prohibition policies have created the desired outcomes, we look at the negative consequences of the policy — the human rights consequences — through three case studies: Colombia, Mexico, and the United States. These countries were selected because of their positions along the illegal drug supply chain. Colombia is a production country on the cocaine supply chain because of its position in the Andes mountain range, where coca, the plant used to manufacture cocaine, grows. Mexico is a transit country that traffickers pass through on their way to the drugs’ final stop: the United States, a destination country. Drug prohibition has taken different forms in each country because of their position on the supply chain. By examining each country, we hope to understand how different prohibition policies shape human rights outcomes.

The Human Rights Foundation (HRF) is a nonpartisan nonprofit organization that promotes and protects human rights globally, with a focus on closed societies. HRF’s focus shapes the scope of this report. The organization focuses on civil and political rights: the rights to free expression, belief, assembly, association, press; to liberty and security of the person; to access information; to political participation and to vote; and, of course, to life, among others. As many of these rights constitute the definition of liberal democracy, HRF research pays special attention to the political systems of countries in which human rights violations take place. In this report, this means that we have taken special care to understand how the drug war interacts with and affects a country’s democratic health. Colombia, Mexico, and the United States are all categorized as democratic countries under HRF’s Political Regime Research Project,i which categorizes all countries in the world into regime types using a methodology adapted from the one presented in Steven Levitsky and Lucan A. Way in Competitive Authoritarianism.


It is well established that prohibition has failed to reduce consumption and abuse. But prohibition is not just ineffective; it’s harmful. This report shows how prohibition’s policies have directly caused severe human rights violations in affected countries, especially by undermining civil and political rights to such a degree that these policies constitute a threat to democracy. Supply-centric policies have had grave consequences for individuals, communities, and the health of democratic institutions, including high rates of violence, disappearances, kidnappings, and incarceration; impacts on local communities and minority populations; state instability, lack of trust in government, and corruption; and a deterioration of rule of law and electoral competition. The report’s findings suggest that, from a human rights perspective, there must be a shift from international drug policies that focus on criminalization and supply reduction, to ones that have human rights and health at their core.

The cost and consequences of the war on drugs

The IDPC membership survey was shared with IDPC members in English, French and Spanish on 10 December 2018 and received responses until 18 January 2019. Out of IDPC’s 182 member organisations at the time, 67 eligible responses were received (i.e. 37% of IDPC’s members1 ). Responses originated from 47 individual countries, with three responses adopting a regional outlook. In terms of regional representation, Western Europe (16 responses) and Latin America (15) provided the highest amount of responses, followed by SubSaharan Africa (7), North America (6), Oceania (5), South East Europe (5), South East Asia (4), Eurasia (4) and the MENA region (1).

IDPC Membership Survey 2018: Summary of results

By Gregory Midgette, Steven Davenport, Jonathan P. Caulkins, Beau Kilmer

Substance use and drug policy are clearly in the national spotlight. Provisional data from the Centers for Disease Control and Prevention suggest that drug overdose deaths in 2018 exceeded 68,000, of which more than 47,000 involved opioids. Although heroin, prescription opioids, and synthetic opioids (such as fentanyl) receive most of the attention, deaths involving methamphetamine and cocaine are both on the rise. In addition, more than 25 percent of the U.S. population lives in states that have passed laws that allow for-profit firms to produce and sell marijuana for nonmedical purposes to adults ages 21 and older.

To better understand changes in drug use outcomes and policies, policymakers need to know what is happening in the markets for these substances. This report updates and extends estimates of the number of users, retail expenditures, and amount consumed from 2006 to 2016 for cocaine (including crack), heroin, marijuana, and methamphetamine in the United States, based on a methodology developed by the RAND Corporation for the Office of National Drug Control Policy. The report also includes a discussion of what additional types of data would help quantify the scale of these markets in the future, including the new types of information produced by the legalization of marijuana at the state level.

What users in the USA spend on illegal drugs

The research was largely based, on the one hand, on content analysis of legal and policy documents, academic journals, media reports and other state and non-state actors’ reports, and on the other hand on interviews of individuals and focus groups comprising of drug dealers, traffickers, people who use drugs and their relatives as well as clinicians, government and security officials.

This composite report summarises and brings together the main findings of each of the three country-specific reports. The main findings are grouped into five broad areas, namely: i) state of drug market ii) impacts of drugs on the state and society iii) national frameworks and actions against illegal drugs, iv) challenges and constraints, and v) actions points to effect positive change. Before delving into the research findings in each of the three countries, a brief overview of the regional perspective on how drug trade and use is addressed in the region is presented.

West Africa has become an important hub for the global trade of illegal drugs. Psychoactive drugs are substances that either stimulate (such as cocaine or amphetamines) or inhibit (such as heroin or sedative-hypnotics) the central nervous system or cause hallucinogenic effects (such as marijuana or LSD) to the effect that their use has been prohibited globally (International Encyclopedia of the Social & Behavioral Sciences, 2001). According to report of the United Nations Office on Drugs and Crime, (UNODC, 2016), Africa is the second main market for cannabis in the world after the Americas. Between 2009 and 2014, West Africa accounted for 78% of the total cocaine seizures in Africa (World Drug Report, 2016). Equally worrying is the rising number of clandestine laboratories in West Africa producing synthetic drugs including methamphetamine. It is estimated that the West African region is now producing up to 1.5 tonnes of methamphetamine every year.

This problematic situation of the drug problem was further underscored in a report produced in 2014 by the West Africa Commission on Drugs (WACD), warning against the dangers posed by the drug trade to the democratisation process, economic growth, human rights, women empowerment and rule of law across West Africa.

In view of the growing threats of the drug trade, the regional body, the Economic Community of West African States (ECOWAS) is working through its Action Plan 2016- 2020 to promote a regional approach. Other important legal documents of ECOWAS include the Conventions on Extradition and on Judicial Assistance to fight organised crime and money laundering in West Africa. At the level of the West African Economic and Monetary Union (WAEMU), member states are mandated to establish a centralised agency to address the drug trade.

Despite the progress made in terms of providing policy and legal frameworks as well as creating specialised agencies, the regional approach towards drugs faces several challenges and constraints at the regional level. These include little inter-state cross-border collaboration and operations, no centralised regional agency and database system on the illegal drug trade and organised criminal networks, and inadequate financial, material and human resources to tackle the problem. It is evident that the challenges at regional level are a reflection of the dire situation at the level of states.

Towards a new approach to address drug trafficking, production and consumption in West Africa: Case studies of Benin, Ghana & Senegal

By the National Infections Service, Public Health England

These tables present data from the Unlinked Anonymous Monitoring (UAM) Survey of People Who Inject Drugs (PWID) in contact with specialist services. This annual cross-sectional survey is co-ordinated by Public Health England, with support from Public Health Wales and Public Health Agency Northern Ireland. It is completed by people who inject psychoactive drugs. These data tables are updated annually and made available on the Public Health England GOV.UK website. Data from the biennial survey of people who inject image and performance enhancing drugs can be found in a separate set of tables published on the same webpage. The data within these tables are discussed in an accompanying report which is also available on the Public Health England GOV.UK website.

Data are presented separately for the whole of England, Wales and Northern Ireland, and sub-divided by country and PHE region. In some of these areas regional breakdowns could not be provided due to small numbers. Regional level data should be interpreted cautiously as figures may be from a small number of sites or a single site. For clarity, percentages are given to two significant figures. Confidence intervals are not presented but are available for the main findings within the accomapanying HPR.

This set of data tables presents data for the period 2008 to 2018. Data from the survey for earlier years (the survey has been running since 1990) can be found in past sets of data tables which are available via the Public Health England GOV.UK website.

This voluntary unlinked anonymous survey recruits people who inject drugs through specialist agencies within England, Wales and Northern Ireland. These agencies provide a range of services to those who inject drugs, from medical treatment to needle and syringe programmes and outreach work. People using these services that are either currently injecting drugs or who have done so previously are asked to take part in the survey by service staff. Those who agree to take part provide a biological specimen that is tested anonymously for HIV, hepatitis C and hepatitis B. Behavioural and limited demographic information is collected through a brief anonymous subject-completed questionnaire linked to the specimen but unlinked from any client identifying information. This includes questions on the uptake of diagnostic (voluntary confidential) testing for HIV and hepatitis C, hepatitis B vaccination and the sharing of injecting equipment; participants may opt out of answering any questions. The questions asked have varied over time.

Data tables of the Unlinked Anonymous Monitoring Survey of HIV and Hepatitis in people who inject drugs in the UK

Case study from: Brazil, Dominican Republic, Nicaragua & Uruguay; By Enrique Saavedra, Paula Lappado, Matilde Bango & Federico Mello

Over the past two decades, the number of people incarcerated in Latin America has skyrocketed, with more than 1.2 million prisoners overcrowding correctional facilities across the region. Accompanying this, we estimate that the number of children with an incarcerated parent in the region is currently around 1,5 to 1,9 million (see Appendix A for more details).

This marginalized and vulnerable group of young people has been neglected by, and remained virtually “invisible” to public policies, programs and civil society.

In order to assess the situation and needs of these children, and following the recommendations made by the UN Committee on the Rights of the Child during its Day of General Debate in 2011, CWS, with the technical leadership of Uruguayan NGO Gurises partnered with organizations in Brazil, Dominican Republic and Nicaragua to conduct the first regional study of children with incarcerated parents.

The participating organizations surveyed 193 children with an incarcerated parent (or adult referent), and 50 of these children and 46 of their caregivers or guardians were interviewed. 23 government officials and regional experts working in child protection were also surveyed. The results of this study demonstrate the profound impact that the incarceration of a parent has on the life of a child. Families face increased financial strains which force many children to work outside the home or assume adult roles in their household. Children undergo emotional changes, becoming sad, withdrawn or sick, and they face social stigmatization and discrimination in their communities. Their experience with police and the justice system typically creates a negative perception of these authorities, and these elements combine to alter the development of childrens’ self-identity, leading some to develop identities based on resistance to existing social structures. Research confirms that maintaining the child-parent relationship during the incarceration is one of the best ways to help children cope with such difficulties. However, it is difficult for families to maintain such relationships when their only face-to-face interaction is through prison visits, where children must endure unhealthy prison conditions, invasive body searches, and mistreatment from prison guards.

Government officials and experts working in the area acknowledge the vulnerability of this group of children, and provide important insight into their situation. They describe the justice and penal systems as “adult-centric,” looking at matters only from the perspective of the adults involved. In fact, no country in the region even systematically documents or registers the number of children of prisoners. Without any idea of the scope of the problem, it is nearly impossible to create policies and programs to address it. Likewise, the judicial system does not account for the best interests of related children when it decides appropriate punishment for those convicted of crimes.

While the legal rights and responsibilities of fathers and mothers are identical, some experts prioritize the issue of incarcerated mothers, particularly those whose children live with them in prison. It appears that the incarceration of a mother has a more dramatic impact on family dynamics and significantly increases vulnerability of children. Whether it is the mother or father that is convicted of a crime, the use of alternative punishments (eg. open and semi-open prisons) would lessen the negative impact on children. Likewise, improved coordination between state actors involved in the justice system and child protection would improve services and support to children of incarcerated parents.

It is clear that governments are the main responsible of protecting the rights of all children, and that they should, in coordination with civil society, begin to develop policies, programs and initiatives that support and empower children of incarcerated parents.

Publications