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

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

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

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

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

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

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

By Maciej Czachorowski, Juliana Coelho and others

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Report on drug use in the Americas

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

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

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

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

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

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

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

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

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

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

Rethinking the “drug dealer”

Coinciding with the United Nations international day to eliminate violence against women, and the subsequent 16 Days of Activism against Gender-Based Violence Campaign (25 November to 10 December), women who use drugs and their allies around the world unleashed a diverse and dynamic series of actions under the uniting themes:

The war on drugs enables violence against women

Drug use is NOT an excuse for violence and abuse.

also utilising orange (reflecting international ‘orange the world’ theme colour for eliminating violence against women. Women who use drugs are exposed to higher rates of violence than other women).

This violence includes, (but is not limited to) rape, sexual harassment, extortion, loss of child custody, imprisonment for mere personal possession, extra judicial killing, capital punishment and penalisation for drug use in pregnancy. Prohibition either directly causes or greatly exacerbates conditions for all of these violations. Gender-based violence cannot be eliminated if those most affected are not directly and meaningfully involved at all levels in relevant policy and programming.

Women who use drugs are boldly stepping out to take their place in the women’s movement and efforts to stop Gender-based violence. Collectively we and our allies call for governments to end the gendered, failed and murderous policy of drug prohibition.

The following summary features actions performed in Indonesia, Burundi, Australia, Ukraine, Nigeria, Greece, Mexico, Spain, USA, Mauritius, Nepal, Lithuania and Seychelles.

Elimination of violence against women who use drugs - Global campaign summary

In 1998, the OAS member states agreed to and designed a multilateral evaluation mechanism that would make periodic recommendations to OAS member states on improving their capacity to control drug trafficking and abuse, and enhance multilateral cooperation. The Heads of State and of Government of the Americas turned the concept of multilateral evaluation into a mandate, declaring in the Plan of Action that their countries would undertake the following specific actions:

"Continue to develop their national and multilateral efforts in order to achieve full application of the Anti-Drug Strategy in the Hemisphere, and will strengthen this alliance based on the principles of respect for the sovereignty and territorial jurisdiction of the States, reciprocity, shared responsibility and an integrated, balanced approach in conformity with their domestic laws;

With the intention of strengthening mutual confidence, dialogue and hemispheric cooperation and on the basis of the aforementioned principles, develop, within the framework of the Inter-American Drug Abuse Control Commission (CICAD-OAS), a singular and objective process of multilateral governmental evaluation in order to monitor the progress of their individual and collective efforts in the Hemisphere and of all the countries participating in the Summit, in dealing with the diverse manifestations of the problem."

Based on these mandates and in order to execute them, the twenty-third regular session of CICAD (May 1998) formed an Inter-Governmental Working Group on the Multilateral Evaluation Mechanism (IWG-MEM). Headed by Canada and Chile to design the mechanism, the MEM was set to begin in 1999.

As the only multilateral evaluation of its kind in the world, the MEM highlights the strengths and weaknesses of OAS member states in its country reports, and encourages national dialogue among policymakers. The MEM also publishes a hemispheric report, which reflects the reality of member states in the Hemisphere as a whole regarding the drug problem, outlining clearly the challenges encountered, the strengths and the collective progress in implementing drug policies. Based on the CICAD Hemispheric Drug Strategy and the Plan of Action, the reports focus on the following thematic areas: institutional strengthening, demand reduction, supply reduction, control measures, and international cooperation.

During the sixty-second regular session (December 13-15, 2017), the CICAD Commissioners approved the Evaluation Questionnaire, Evaluator's Manual, Procedural Manual, and Calendar of Activities, for the seventh evaluation round. This round began in January 2018 with the submission of the MEM Evaluation Questionnaire to each OAS member states’ National Coordinating Entity (NCE), followed by the publication of the national evaluation reports on drug policies in July 2019.

Evaluation on drug policies in the Americas - Seventh evaluation round

By the Cooperation Programme between Latin America, the Caribbean and the European Union on Drug Policies (COPOLAD)

The production, distribution and consumption of drugs have a significant impact on the health, social development, economy, security and governance of societies and citizens throughout the world. The challenges posed by this phenomenon can only be addressed through effective and collaborative international efforts to counteract the numerous problems related to drugs. These problems have an adverse impact on the daily lives of citizens and the societies in which they are present, especially with regard to the most vulnerable social groups.

The Cooperation Programme between Latin America, the Caribbean and the European Union on Drugs Policies is a bi-regional cooperation programme aimed at supporting the implementation of effective pubic policies to reduce the risks associated with drug use and supply within the Community of Latin American and Caribbean States (CELAC). To achieve this objective, COPOLAD shares and fully advocates the European Union's position of supporting public policies on drugs based on a global and balanced approach linked to human development objectives such as full respect for human rights, including gender sensitivity and women's empowerment, a public health-oriented approach, good governance and the rule of law.

Study on institutional capacities for the implementation of alternative development

The right to personal cultivation and consumption of all parts of the cannabis plant by adults in the privacy of their own home

The establishment, control and regulation of the Maltese cannabis market by the Government of Malta by not later than 31 December 2020

The removal of all punitive and criminal laws for cannabis consumers in Malta and the right to consume cannabis in designated public spaces

The possibility for Maltese citizens to partake in a legal and regulated cannabis market, including also Hemp

Introduce preferential access schemes to ensure local farmers have access and reap benefits from the emerging cannabis market

Include amnesty and expungement of criminal records for non-violent cannabis convictions, and through a social equity program ensure their participation in the legalised and regulated cannabis market

Promote holistic harm reduction tools and encourage a more open dialogue with cannabis consumers

The creation of a national cannabis seed bank, protection of newly created local hybrids and promotion of a sustainable and environmentally conscious cannabis market

A legalised and regulated market should place the well-being of cannabis users at the helm of every decision. It is imperative that cannabis consumers are consulted and included at all levels of the discussion. A functional cannabis market needs to ensure it promotes public health without introducing an invasive and over-regulated scenario incapable of competing with and effectively eradicating the illegal market. Therefore, the type of cannabis strains available, pricing and accessibility need to reflect local and regional trends, whilst the highest standard of privacy and protection of personal rights need to match those of already established markets in Europe and around the world.

ReLeaf Malta: A Maltese legalised and regulated cannabis market 2020

Since 1999, UNODC has been monitoring illicit crop cultivation areas and socio‐economic conditions in rural villages in different supply countries. In most countries, the results indicate that illicit crop cultivation and poverty are closely interlinked and coupled with other development issues, such as security and governance.

This report aims to contribute to this process by providing evidence to assist in improving the resilience of rural communities to opium poppy cultivation. It also aims to identify socio‐economic differences between villages that may be driving opium‐poppy cultivation and to evaluate the status of poppy and non‐poppy villages (villages that cultivate opium poppy are hereafter referred to as “poppy villages” and villages that do not as “non‐poppy villages”) in relation to the SDGs and their challenges for achieving the SDGs. This report does not include estimates of opium poppy cultivation area, opium production (as reported in the cultivation and production report) or socio‐economic analyses outside Shan State.

In 2018, UNODC conducted a survey in a random sample of 599 villages in the opium poppy cultivation risk area in Shan State and gathered socio‐economic and other relevant data to compare poppy villages and non‐poppy villages. Since 2011, Myanmar has been undergoing a period of political transition and Myanmar’s economy has been increasingly opened. In a few years, almost every aspect of life has been affected by fundamental economic and political reforms aimed at improving the living conditions of the population.

By disaggregating a range of socio‐economic village‐level data by opium poppy cultivation status and region (and gender, where appropriate), this report highlights some major differences in living conditions among farmers in Shan State.

In launching the 2030 Agenda for Sustainable Development, Member States pledged to “leave no one behind”. They recognized that the dignity of the individual is fundamental and that the goals and targets should be met for all nations, peoples, and all segments of society. Furthermore, they declared their endeavour to first reach those who are furthest behind. To support the implementation of the Sustainable Development Agenda, a better understanding of the links between poverty, illicit drug cultivation, production and trafficking is required.

Opium poppy cultivation and sustainable development in Shan State, Myanmar

According to the estimated needs to sustain HIV and TB responses in Albania, approximately US$3 million is required per year to address the two epidemics effectively. The implementation of the current Global Fund HIV and TB grant of approximately US$5.8 million is ending in December 2019. The last transition grant is expected to start in January 2020, but its level of investment will only be in the region of one-third of the value of the current grant.

This case study looks at the challenges faced in sustaining HIV prevention programmes among KAPs, implemented primarily by civil society organisations (CSO’s), as a result of the withdrawal of the Global Fund through the transition period of 2020 to 2022 and the lack of government capacity and resources to maintain the already limited services that will likely result in the re-emergence of HIV epidemics among people who inject drugs (PWID), sex workers (SW) and men who have sex with men (MSM).

Based on the issues raised in this case study, it is evident that the Global Fund, bilateral donors and private foundations need to establish a ‘safety net‘ through which sustainable bridging funds can be made available that are able to address the challenges faced in those countries, such as Albania, which can no longer rely on Global Fund grants in the future. If such a mechanism is not forthcoming, there will be a serious risk that Albania will become re-eligible for Global Fund support due to re-emerging epidemics among vulnerable groups, as has been the case in Montenegro, Serbia and certain other countries of South Eastern Europe.

The challenges of Global Fund transition in Albania: Harm reduction services on the brink of collapse

By Man et al., National Illicit Drug Indicators Project

Each year, the Australian Bureau of Statistics (ABS) makes available to Drug Trends in-depth data on drug-induced deaths in Australia. This year, we have produced a suite of products to summarise trends in drug-induced deaths in Australia from 1997 to 2018.

Preliminary estimates indicate that there were 1,740 drug-induced deaths among Australians in 2018 (1,549 drug-induced deaths among those aged 15-64 years). This estimate does not include deaths where conditions related to alcohol or tobacco were the underlying cause of death.

This number equates to nearly five drug-induced deaths per day in 2018, a similar figure to that observed in 2017 (1,795 deaths). It is also similar to the number recorded during the peak in deaths in 1999 (1,740 deaths).

The rate of deaths in 2018 was 7.0 deaths per 100,00 people (9.5 deaths per 100,000 people aged 15-64). The rate of drug-induced deaths has been increasing since 2006 yet remains lower than the peak rate observed in 1999.

Higher rates of drug-induced deaths were observed among males, but there has been a shift from younger (25-34) to older (35-54) age groups over the period of monitoring across both males and females. The gap in rate of deaths between males and females lessened with older age in 2018.

In 2018, the majority of drug-induced deaths among Australians were deemed accidental (70%), although nearly one-in-five deaths (23%) were considered intentional.

Excluding Northern Territory, the rates of drug-induced deaths in all other jurisdictions ranged between 6.3 and 9.9 per 100,000 people in 2018. There are important jurisdictional differences in drug-induced deaths in major city versus regional areas, with a higher rate of drug-induced deaths in major cities in Western Australia and South Australia and in regional areas in New South Wales and Victoria (noting fluctuations in these trends over time).

Opioids were the main drug cited in drug-induced deaths (1,129 deaths in 2018). Indeed, they were noted as the underlying cause of 1,088 deaths (including 876 deaths deemed accidental).

Natural and semi-synthetic opioids (e.g., morphine, oxycodone) have historically been the most commonly cited opioids in opioid-induced deaths. This has changed over the past two years, with the rate of opioid-induced deaths involving heroin converging with the rate of opioid-induced deaths involving natural and semi-synthetic opioids.

When studying accidental deaths only, heroin is now the leading opioid underlying opioid-induced deaths. There have also been increases in deaths involving synthetic opioids (e.g., fentanyl, tramadol) over the past decade, although preliminary estimates do not support a further increase in 2017 and 2018.

An increasing rate of deaths involving psychotropic medicines (e.g., benzodiazepines, antipsychotics) and non-opioid medicines used for treatment of certain pain conditions (e.g., pregabalin) is of concern. It is important to note that these medicines are often identified alongside other drugs (e.g., cases where opioids are the underlying cause of death and benzodiazepines are an associated cause of death).

The rate of deaths attributed to amphetamines (e.g., methamphetamine, MDMA) increased substantially from 2011 to 2016; preliminary estimates do not support a further increase in 2017 and 2018. The number of cocaine-induced deaths remained relatively small (i.e., less than 20 deaths).

Trends in drug-induced deaths in Australia, 1997-2018

The first market size estimates for cannabis, cocaine, MDMA, amphetamines and heroin were published in the EMCDDA‐Europol 2016 European Drug Markets Report, covering 2013. The challenges in obtaining such estimates were recognised at that time, though the need to assist policymakers in prioritising interventions by providing information on the scale, relative importance and changes in the markets for different drugs outweighed these concerns. The project was seen as a process, where the estimates would be improved in subsequent rounds by addressing data issues and developing the methodology. Since 2016 additional and different data sources have become available and where appropriate the methodology has been changed, though the basic underlying method remains as it was.

Developments for the estimates published in this report include:

data on the amounts of drugs used by various types of user have been extended and updated, using information from the European Web Survey on Drugs (EWSD);

routinely monitored data from the Member States have been updated, improving estimates of the number of users and drug prices. For example, 24 of the EU countries have reported a more recent general population survey than that available when the initial estimates were made;

crack use by high‐risk opioid users has been included in the cocaine market size estimates;

data on patterns of use for cannabis herb and resin, separately obtained from the EWSD, have been used to estimate the contribution of these different forms of cannabis to the overall cannabis market. In the previous estimates, numbers of seizures were used in the absence of suitable information about use of these products.

The hidden nature of the topic, the limitations inherent in some of the available data and the need for simplifying assumptions contribute to uncertainty around the estimates. Alternative methods of estimation were considered and are mentioned in the report, though each has its own data issues and weaknesses. The demand‐side approach remains the favoured method, though it is recognised that the estimates are the outcome of the approach adopted, and alternative approaches will generate different values.

Some key principles underpinning the approach taken are:

wherever possible, the data used came from routine data collections held by the EMCDDA to facilitate the planned process of improving and updating over time;

European estimates were obtained by summing individual country estimates;

where imputation of missing data was necessary, as far as possible, this was based on other related data;

every effort has been made to note all imputations and assumptions made within the estimation process, so that the limitations are clear.

As with the initial estimates, the 2017 figures are likely to underestimate the market; given the available data from which they were constructed, and despite their substantial size, these estimates should be considered as minimum values. Country estimates have not been produced, given issues of comparability in the data, the focus remaining on obtaining EU estimates of the quantity and value of the market for cannabis, cocaine, MDMA, amphetamines and opioids. A consequence of this process is that the 2013 and 2017 estimates are not directly comparable and should not be interpreted as a trend.

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