作者: Daniel O’Keefe, Ricky N Bluthenthal, Alex H Kral, Campbell K Aitken and Angus McCormacka & Paul M Dietzea / Bulletin of WHO 

为注射吸毒者提供无菌注射设备时，覆盖率是衡量注 射针头和注射器方案是否有效的重要因素之一。世 界卫生组织 (WHO)、联合国毒品和犯罪问题办公 室 (UNODC) 和联合国艾滋病毒 / 艾滋病联合规划 署 (UNAIDS) 目前建议采用基于人口的方法来测量覆 盖率，即在指定的地理区域内估计注射毒品的人口数 量。然而，基于人口水平的覆盖率测量方法高度依赖 不确定的预估人口数量，并且无法捕捉到个体使用者 获取注射器和注射阶段的不同水平。因此，这些措施 只能宽泛地评估此服务方案普及的范围，并不能反映 注射毒品的个人和小团体是如何接触使用注射针头和 注射器的。为了解决此类限制，一些研究人员建议， 以个人为单位，根据注射阶段与获得的无菌注射针头 和注射器数量的百分比来测量覆盖率。这些措施会根 据个体的需求情况评估覆盖率，为减少伤害方案的规 划和监测提供了增强信息，现已在多项国际性研究中 得以使用。我们建议世界卫生组织、联合国毒品和犯 罪问题办公室和联合国艾滋病毒 / 艾滋病联合规划署 在减少伤害方案的国际监测准则中增加测量个人覆盖 率的方法。这样的话，就可以制定出更具反响性、更 有效的方案，从而更好地减少注射吸毒者之间的注射 风险行为和血源性病毒的传播。

为注射吸毒者提供减少伤害服务的措施

By Daniel O’Keefe, Ricky N Bluthenthal, Alex H Kral, Campbell K Aitken and Angus McCormacka & Paul M Dietzea / Bulletin of WHO

Coverage is an important dimension in measuring the effectiveness of needle and syringe programmes in providing sterile injecting equipment for people who inject drugs. The World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) currently recommend methods for measuring coverage at the population level, that is, across an estimated population of people who inject drugs within a given geographical area. However, population level measures of coverage rely on highly uncertain population estimates and cannot capture the different levels of syringe acquisition and injecting episodes among individual users. Consequently, such measures only broadly evaluate the extent of programme service delivery, rather than describe how people who inject drugs as individuals and sub-groups interact with needle and syringe programmes. In response to these limitations, several researchers have proposed measuring coverage at the individual level, by the percentage of injecting episodes in relation to the number of sterile needles and syringes acquired. These measures evaluate coverage according to each individual’s needs. Such measures provide enhanced information for planning and monitoring of harm reduction programmes and have now been used in multiple international research studies. We advise that WHO, UNODC and UNAIDS add individual-level coverage measurement methods to their international monitoring guidelines for harm reduction programmes. By doing this, more responsive and effective programmes can be created to better reduce injecting risk behaviours and blood-borne virus transmission among people who inject drugs.

Measures of harm reduction service provision for people who inject drugs

By Liz McCulloch & Scarlett Furlong / Volteface

In this report, Volteface aims to bridge the gap in understanding of how social media is being used as a marketplace for illicit drugs and the impact this is having on young people – social media’s primary user group.

This report examines how prevalent this phenomenon is, which platforms are most likely to host this activity, what drugs are being advertised, how the platforms are being used, and what impact this is having on young people’s wellbeing, as well as the challenges facing social media regulators and law enforcement.

This research used a mixed methodology of both qualitative and quantitative research. To ascertain the prevalence of this phenomenon, Volteface commissioned Survation in January 2019 to conduct a nationally representative poll of 2,006 16-to-24 year olds.

An unrepresentative ethnographic trawl was conducted on Facebook, Instagram and Snapchat – the platforms on which the poll suggested that drug distribution activity is most prevalent. This involved setting up accounts that observed and recorded evidence of drugs being advertised and sold through these platforms. The researchers did not communicate with any social media users during the trawl and all published screenshots have been anonymised.

Volteface also invited relevant stakeholders to take part in interviews, an online survey and focus groups to evaluate the impact of drug selling and buying through social media platforms. A total of 24 interviews were conducted, five online survey responses were received and 30 young people aged 13 to 17 participated in four focus groups.

One in four young people (24%) reported that they see illicit drugs advertised for sale on social media – a significant figure considering how recent a phenomenon this is.

Of those who reported seeing illicit drugs advertised for sale on social media:

56% saw drugs being advertised on Snapchat, 55% on Instagram and 47% on Facebook.

63% saw cannabis being advertised – making it the most commonly seen drug advertised for sale.

Cocaine was the second drug most commonly seen advertised (26%), followed by MDMA/Ecstasy (24%), Xanax (20%), Nitrous Oxide (17%) and Codeine/Lean (16%).

72% said that they see illegal drugs advertised for sale on social media sites or apps once a month or more.

36% were not concerned by seeing drugs advertised for sale on social media. Worryingly, this percentage increased the younger the respondent. 33% aged 18+ were not concerned, but this jumped to 48% for under-18s.

The data indicated that there is an association between frequency of social media use and the likelihood of seeing drugs advertised for sale. The baseline of seeing drugs advertised for sale on social media is 24%. This increases to 29% of respondents who use social media every hour, compared to 14% of respondents who use social media once a day.

Social media is providing drug dealers with easy-to-use and familiar platforms that they can utilise to find and build trust with customers, advertise their business, and disguise their activities. Concerningly, Volteface’s research has shown that dealers have been quick to take up this opportunity, with one in four young people now seeing drugs advertised for sale on social media.

The emergence of drug markets on social media is not simply a transfer of harmful activity from the offline world onto the online world. It is a new problem which presents new threats. Regulators and enforcers will not be able to tackle this new, illicit online drug market and minimise the harms associated with it unless innovative approaches are put in place.

DM for Details: Selling drugs in the age of social media

This brief provides an overview of opioid overdose prevention and treatment approaches as well as barriers to accessing treatment.

Availability and accessibility of Naloxone

Opioid overdose prevention and treatment approaches

Potential future approaches to opioid overdose prevention and treatment

Technological approaches to prevent or respond to an opioid overdose

Barriers to accessing opioid overdose treatment and opportunities to overcome them

Medicalisation of harm reduction programmes

For legislators, policy makers and advocates

For networks/groups of people most affected by opioid use

This is the third publication in the IAS Policy Brief Series on inclusive care services and policies for people who use drugs.

Access saves lives: Opioid overdose treatment 

By Dr Katherine Morley, Dr Emily Finch, Ms Dee Cunniffe / London Joint Working Group on Substance Use and Hepatitis C

Hepatitis C is a blood borne virus that can cause cirrhosis, liver cancer and death. However, NICE approved treatments can cure the virus in around 95% of patients. The responsibility for testing people at risk of having hepatitis C, and treating people who are infected, lies across different services including GP practices, drugs services, prisons, pharmacies and hospitals.

In order to ensure that people at risk are tested, and that people with hepatitis C can access treatment, effective data sharing pathways must be developed between services. This report explores current barriers and solutions to join the dots and improve data pathways between testing, treatment and care for hepatitis C patients.

We identified two major obstacles to effective data sharing in relation to hepatitis C diagnosis and treatment:

Confusion about who data can be shared with and under what circumstances;

A lack of computer systems that enable care providers to easily share patient data. In particular, we found that obtaining written consent from patients was often considered the ‘best’, if not the only, basis on which data could be shared. This is at odds with the Health and Social Care (Safety and Quality) Act 2015 and General Data Protection Regulation, which create an obligation to share data for patient care and provide a legal basis for doing so that does not require explicit patient consent.

We made three recommendations to address these obstacles:

Development of clear guidance and training for care providers, particularly those from community drug and alcohol teams, regarding: 

when explicit patient consent is, and is not, needed to share data;

who data can be shared with and under what circumstances.

Provision of additional support for hepatology outreach, particularly in community drug and alcohol teams, but potentially also in other community contexts such as pharmacies.

Development of informatics solutions that help care providers to share data, via joint working of Operational Delivery Networks and commissioners.

Joining the Dots: Linking pathways to hepatitis C diagnosis and treatment

By Matayo Baluku, Twaibu Warnala & Denis Muhangi

Globally, an estimated 275 million people used drugs at least once in 2016, 10.9 million of whom injected their drugs. Injecting drugs carries a high risk of human immunodeficiency virus (HIV) and viral hepatitis transmission if sterile injecting equipment is not easily accessible and injecting equipment is shared among users. In 2016, more than half of the people who inject drugs (PWID) worldwide were living with hepatitis C virus (HCV); one in eight was living with HIV, and 82.4% were co-infected with both HIV and HCV. The risk of acquiring HIV for PWID in 2017 was 22 times higher than that for people who did not inject drugs.

Whereas hepatitis B virus (HBV) and HIV are transmitted via blood or body fluids, sharing injecting equipment poses the greatest risk of HCV transmission among PWID. Also, whereas there is no increased risk of HCV transmission in a long-term heterosexual relationship, the risk of transmission increases with multiple sexual partners and among women who are infected with HIV or other sexually transmitted diseases. Similarly, engaging in sex work, younger age, cocaine injecting, depression, requiring help injecting, having unsafe sex with a regular partner, and having an HIV-positive sexual partner are associated with HIV infection among PWID.

Risk factors for HCV among PWID include sharing needles and other injecting equipment, longer duration of injecting career, increased frequency of injection, requiring help injecting, being female, and history of imprisonment.

Despite the heavy burden of injecting drug use and its associated risks, and burden of HIV and HCV among PWID, effective harm reduction interventions that can help prevent their spread are severely lacking in many countries including Uganda. In Sub-Saharan Africa, only eight countries operate the needle and syringe program (NSP); seven offer some form of opioid substitution therapy (OST), and ten have explicit support for harm reduction contained in national policy documents. The current policies and guidelines for prevention and treatment of HIV and AIDS in Uganda do not support OST and NSP.

While Uganda is one of the 179 countries where injecting drug use is present, data on PWID is limited. No studies have enquired about risk injecting and sexual practices for HIV and HCV among PWID. We therefore conducted this study to assess the risk practices among PWID in Uganda. We compared PWID sampled from Kampala, the only capital and central business city of Uganda, and Mbale Municipality, an urban center in Eastern Uganda.

HIV- and hepatitis C-related risk behaviours among people who inject drugs in Uganda: implications for policy and programming

Globally, support for drug policy reform has grown over the past 10 years. Even as the drug prohibition consensus-keepers in Vienna have voted for yet another 10-year extension to their still unsuccessful 20- year strategy for global drug control at the March 2019 Commission on Narcotic Drugs High Level Review meeting, a reform movement among global member states has been gaining credibility and strength.

The United Nations General Assembly Special Session on Drugs (UNGASS) meeting of member states in New York in 2016 was a soft watershed moment in the history of global drug policy. It was significant in its revelation that the global consensus on drug prohibition that had existed for 55 years now appears to be an openly fractured and vulnerable accord, one that was – and continues to be – in a state of flux.

The purpose of this report is to reflect on the changing drug policy environment in Africa, particularly in the period leading up to and after the seminal UNGASS 2016 meeting of member states. It also examines the politics of continental drug policy prohibition and reform in the context of the growing global movement to embrace drug policy alternatives to the once universal approach of strict prohibition. Observations and recommendations are made regarding incorporating drug policy reform in the context of achieving developmental success with respect to the continental Agenda 2030 and Agenda 2063 goals.

The evolution of illicit drug markets and drug policy in Africa 

By Susan E. Collins, Heather S. Lonczak, Seema L. Clifasef

Drug users and dealers frequently cycle through the criminal justice system in what is sometimes referred to as a “revolving door.” Arrest, incarceration and prosecution have not deterred this recidivism. Seattle’s Law Enforcement Assisted Diversion (LEAD) program was established to divert these individuals to case management and supportive services instead of jail and prosecution. A nonrandomized controlled evaluation was conducted to examine LEAD effects on criminal recidivism (i.e., arrests, criminal charges). The sample included 318 people suspected of low-level drug and prostitution activity in downtown Seattle: 203 received LEAD, and 115 experienced the system-as-usual control condition. Analyses were conducted using logistic generalized estimating equation models over both the shorter term (i.e., six months prior and subsequent to evaluation entry) and longer term (i.e., two years prior to the LEAD start date through July 2014). Compared to controls, LEAD participants had 60% lower odds of arrest during the six months subsequent to evaluation entry; and both a 58% lower odds of arrest and 39% lower odds of being charged with a felony over the longer term. These statistically significant differences in arrests and felony charges for LEAD versus control participants indicated positive effects of the LEAD program on recidivism.

Seattle’s Law Enforcement Assisted Diversion (LEAD): Program effects on recidivism outcomes

By Jenna Mae L.Atun, Ronald U.Mendoza, Clarissa C.David, Radxeanel Peviluar N.Cossid, Cheryll Ruth R.Soriano.

As soon as President Rodrigo Duterte assumed office in 2016, the Philippine government launched a nationwide antidrug campaign based on enforcement-led anti-illegal drugs policies primarily implemented by the national police. This was followed by a spate of killings resulting from both acknowledged police operations and by unidentified assailants. This study assembles a victim-level dataset of drug-related killings covered by the media during the Philippine government’s antidrug campaign, and presents a spatial and temporal analysis of the killings.

The dataset covers information on 5021 people killed from May 10, 2016 to September 29, 2017. Data collected systematically through online search procedures and existing listings of media organizations detailing information about incidences of drug-related police operations and drug-related killings in 'vigilante-style' manner reveal patterns for who were being killed, where, and how.

Over half of the killings were due to acknowledged police operations, and the rest were targeted in so-called 'vigilante-style' killings. The first three months after Mr. Duterte was sworn in were the deadliest months. Those who were killed were mostly low-level drug suspects.

The analysis of temporal pattern reveals the scale of killings in the country, with rapid escalation starting in July 2016 and lasting throughout the rest of that year. Observable declines occurred during periods when the 'drug war' was suspended and operations were moved to a non-police enforcement unit and rose again when police were brought back into operations. The spatial analysis indicates a large concentration of deaths in the National Capital Region (40%) compared to the rest of the country with wide variations across cities and regions.

Overall, the Philippine 'drug war' exhibits similarities with violent wars on drugs waged in other countries such as Thailand, with heavily police-led interventions leading to fatalities in the thousands over a span of under two years. Findings of this study point to important policy adjustments that need to be made, including the role that local governments play in drug policy implementation, the disproportionate negative impacts of enforcement-led policies against drugs on urban and poor areas, the targeting of low-level suspected drug dealers and users, and the importance of proper data monitoring and transparency by the government to inform policy adjustments in the face of high costs to human life. We also discuss the importance of independent monitoring systems when the government reports conflicting information.

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

The Philippines’ antidrug campaign: Spatial and temporal patterns of killings linked to drugs

Several drug policy researchers have noted that the concept of harm reduction could be applied to the field of drug policing in order to assess the negative consequences and potential benefits of policing in this area. However, the application of harm reduction principles to drug policing has only been realized to a limited extent in the current responses to drug use and markets. Accordingly, studies that empirically investigate already existing policing practices, which might be described as operating within such a harm reduction framework, are relatively scarce. In order to address this gap, this article provides an investigation of how policing of an open drug scene has been organized in Denmark since drug possession has been partly decriminalized, following the introduction of drug consumption rooms in Copenhagen. The policing of this open drug scene was investigated through document analysis, interviews, and observations with a patrolling police officer. The article argues that decriminalization has resulted in a shift in the “logics” of policing by enabling the production of an alternative “governable identity” for the drug-using subject, where people who use drugs could more readily be perceived as citizens with rights rather than just as offenders. Accordingly, in this new logic, the violence and victimization experienced by marginalized people who use drugs could more readily be identified as proper objects for police action. The study contributes to our knowledge of how the police can become potential allies rather than adversaries in harm reduction initiatives and broader public health concerns.

Harm reduction policing: From drug law enforcement to protection

The Dundee Drugs Commission has been an intensive and rapid review of the recent history of the impact of drug use across Dundee, and the help available for people who use drugs in the city. Local Commission members have been supported by experts from across Scotland and the wider UK. To be clear, the Commission was set up in part to assess the effectiveness of the strategic planning and delivery of services co-ordinated by the Dundee Alcohol and Drug Partnership and more broadly across community planning partners (Objective #4). During the course of our work, we have learned about inadequacies in our local systems and services. We have frequently heard from individuals and families who feel that the system has failed them. All our recommendations are born out of the experiences of people in Dundee.

As a Commission, over the course of the last year, we have received evidence from over a thousand different people – those with lived experience of problems with drugs (current and past); family members; members of the public; clinicians and GPs; staff who work in drug treatment and support services; staff who work in wider health and social care services; senior officials within NHS Tayside, Dundee City Council and Dundee’s third sector; politicians and elected members; and academics.

Some individuals and families have spoken in great detail to us about positive experiences of the help and support they’ve received and the strategies they have used themselves to move towards recovery from drug use. Many individuals and families shared their grief and loss over the devastation that has been caused by drug use. We have heard numerous stories of immense challenges and barriers put in front of those who require help and support, compounded by the pervasive stigma that is still attached to being a person who experiences drug problems. Staff working in services have shared both positive and enthusiastic accounts of their efforts to help those who present to services, as well as details of immense frustration and anger when things do not work as they should.

Our review of a substantial amount of evidence has taken time to distil and balance. We have been aware that when an independent Commission is set-up then you tend to have all the stories coming to the fore of how things are not working. However, we have also taken the time to seek out and listen to those who have a positive story to tell – whether one of how they’ve successfully made changes to their drug use by themselves (or with help from family and others) – or whether a story of how they have received the help required from local services. By so doing, we believe that we have achieved a balanced understanding of the reality of issues faced.

Our review has led us to identifying a number of key messages – all of which we have used to form the challenging set of recommendations. The key messages in our report are structured underneath the key themes of our work:

Responding to drug use with kindness, compassion and hope - Report by the Dundee drugs commission

Welcome to our latest Progress Report which chronicles another remarkable year for IDPC. The most critical highlight is our civil society shadow report, Taking Stock: A Decade of Drug Policy, which we produced together with many IDPC members and partners from around the world. We undertook this ambitious report to address the lack of a formal review by governments, or the UN, of progress towards the goals and targets set out in the 2009 Political Declaration and Plan of Action on drugs to significantly reduce or eliminate the global drug market by 2019.

The report attracted widespread global media attention and helped to secure the comprehensive ‘stock-taking’ language in the 2019 Ministerial Declaration by not allowing governments to shy away from the inconvenient truth of a growing global drug market despite the billions invested to eliminate it. The first report of its kind in UN drug control fora, it represented a watershed moment of civil society creating crucial accountability in the UN debate on drugs and consolidated the IDPC network’s role as watchdog in this space.

The drug policy reform movement continues to strengthen and diversify with many new players joining the calls for a serious re-think of repression and punishment as instruments of drug control. Repressive drug control measures are increasingly being understood as a form of state violence that serves to deepen and entrench structural inequalities which has garnered stronger interest in challenging current drug policies from other social movements such as those working on racial inequality, women’s rights, indigenous rights, LGTIQ+ rights to prison abolition and beyond. Building cross-movement solidarity on key human rights and social justice issues is more important than ever in the current troubling geo-political context and will be a core focus of the IDPC Secretariat in the coming years.

This year, I am pleased to share this foreword with Alison Holcomb, Chair of IDPC’s Board of Directors and Bikas Gurung, Asia representative on IDPC’s Members Advisory Council, who give their reflections on the past year for the network. We hope you enjoy reading this Progress Report!

Publications