The INCB Annual Report, prepared in accordance with the international drug control treaties, examines the global drug control situation, and makes recommendations to Governments and regional and international organizations. The thematic chapter of the INCB Annual Report for 2017 focuses on treatment, rehabilitation and social reintegration for drug use disorders as essential components of drug demand reduction. The Report also focuses on the linkages between human rights and drug control policy, particularly as 2018 marks the occasion of the seventieth anniversary of the United Nations Universal Declaration on Human Rights. The Report's review of the functioning of the international drug control system also contains a number of key policy positions of the Board, for example on the non-medical use of cannabis and "drug consumption rooms".

INCB Annual Report 2017

Since 2009, we provide harm reduction services to people who use drugs in Moscow. The political and financial climate as well as the epidemiologic situation are not very supportive for our work - Russia still has one of the fastest growing HIV epidemics in the world with more than 1 million cases being registered and more then 50 000 HIV positive people living in Moscow. Officially registered number of people who use drugs living in Moscow is over 30 000 people. Unsafe injection of drugs is still the major cause of HIV transmission in Russia (more than 60% of all new cases), HIV epidemic is escalating in the country and its capital, but the government still denies the effectiveness of harm reduction measures and provides zero support to NGOs working on HIV prevention among key affected populations. Russian drug policy is still known as one of the most conservative and repressive among those around the world - it continues to declare a zero tolerance towards drug use inflaming the stigma and discrimination towards people who use drugs because of their drug dependence and primarily they are considered not as patients who need proper treatment and support but as criminals. It restricts the access for drug users to vitally important for them information on health issues and to the health services needed such as needle exchange programs and opioid substitution treatment.

Andrey Rylkov Foundation: Provision of harm reduction services in Moscow in 2017

In April 2016 the UN General Assembly convened a special session on the world drug problem in order to review and evaluate existing drug control policies and strategies. More specifically, the special session (UNGASS) set out to “review the progress made in the implementation of the Political Declaration and Plan of Action, including an assessment of the achievements and challenges in countering the world drug problem, within the framework of the three international drug control conventions and other relevant United Nations instruments.” The UNGASS 2016 outcome document represents the most recent global consensus on drug policy and signals a shift toward placing public health, development, and human rights at its center.

In the months preceding UNGASS, several civil society organizations and some member states were vocal about the importance of using the special session to reconsider how the success of drug policy is measured. An important part of the reasoning behind this call was that current drug policy too often has a negative impact on communities and runs counter to efforts to ameliorate poverty through sustainable development.

Although the UNGASS 2016 outcome document does not heed this call directly, the preamble does “promote research by States…to better understand factors contributing to illicit crop cultivation…, including through the use of relevant human development indicators, criteria related to environmental sustainability and other measurements in line with the Sustainable Development Goals.” This paper looks to further this debate, arguing that aligning the way we measure and evaluate drug policies with the 2030 Agenda for Sustainable Development will have two clear benefits:
1. It will help overcome many of the limitations of effective drug policies resulting from suboptimal metrics for measuring their impact; and
2. It will help make sure that drug policies enhance, rather than hinder, efforts to achieve the SDGs.

Drug policies therefore need to be designed in coordination with other relevant policy agendas to guarantee that achievements in one agenda do not hinder those in another. In fact, achieving the SDGs will address many of the factors driving vulnerable populations to engage in the illicit drug trade.

Aligning agendas: drugs, sustainable development, and the drive for policy coherence

There is growing recognition of the importance of environmental factors in health behaviour. Environmental prevention complements the more established approaches of providing information/warnings and skill/competence development.
Traditional substance use prevention approaches in Europe have predominantly focused on warning and informing people of the risks and consequences of drug use and/or informing them of safer ways to use substances. More recently, developmental approaches aimed at helping young people to develop the necessary social skills and competences to avoid substance use have been used alongside informational approaches.
These types of interventions focus on the individual as the main driver of behavioural change. The role of executive functions and how they develop during childhood and are influenced by upbringing is often neglected. It has been claimed that an over-reliance on approaches that fail to consider executive functions contributes to the persistence of health inequalities. Many behaviours we perform every day are automatic and are generally reactions to common and familiar stimuli, demonstrating the importance of environmental and social cues, and of automatic processes in influencing behaviour. This may explain the limited success of prevention approaches that focus solely on individual responsibility for decision-making and self-control.
The purpose of environmental prevention policies and interventions is to limit exposure to unhealthy or risky behaviour opportunities (or to promote the availability of healthy opportunities). This approach differs from traditional behavioural prevention approaches as it targets the automatic system of behaviour (one that does not require deliberate cognition). Thus, it requires lower individual ‘agency’; individual personal resources, such as conscious decision-making, motivation and intent, are less important in these types of intervention.
Nevertheless, there are barriers to the implementation of environmental prevention measures, including the lack of knowledge of their theoretical underpinnings; criticism of them as expert defined; and the perception that they are complex and difficult to implement.
Environmental prevention covers a wide range of measures and it is therefore useful to classify these interventions, both to understand the underlying logic of the different types of interventions and to guide mapping of intervention availability. The operational definition proposed in this publication categorises environmental prevention measures into three categories: regulatory, physical and economic.
A survey of prevention experts in Europe was undertaken to provide an overview of the availability of environmental prevention interventions in the region and the extent of implementation of measures (enforcement of regulatory and economic measures or existence/provision of physical measures).
To gather this information, an electronic questionnaire was distributed to the emailing lists of five European organisations whose members have expertise in one or more of the domains related to substance use. Participants opted in to the survey and suggested other potential participants. The questionnaire link was also circulated through social media.

Environmental substance use prevention interventions in Europe

Substance use can cause harms to individuals and societies, but opinions differ regarding how these harms are best reduced. Such opinions will also reflect how we view trade-offs, as policies need to balance the harms of use against negative consequences of restrictive policies and the pleasures and benefits that the majority of users may claim to experience. Over time, and across regions, policies – even for the same substance – have ranged from strict prohibitions criminalising production and consumption to relatively unregulated commercial markets. In recent years, policy changes in US states, Uruguay and Canada have fuelled a growing debate on whether cannabis supply and consumption should be legalised and, if so, how strictly it should be regulated (Caulkins & Kilmer, 2016; Hawken, Caulkins, Kilmer, & Kleiman, 2013; Room, 2014; Uchtenhagen, 2014). The appropriate balance between “free market” and “government control” also remains an issue for alcohol, with a current example being the debate over minimum unit pricing (Holmes et al., 2014; Stockwell, Auld, Zhao, & Martin, 2012). Public health arguments are frequently emphasised in these discussions (Hall & Degenhardt, 2009; Hall & Lynskey, 2016; Room, Babor, & Rehm, 2005) with a particular focus on adolescent use (Hasin et al., 2015; Simons-Morton, Pickett, Boyce, ter Bogt, & Vollebergh, 2010), while other concerns include social consequences (Klingemann & Gmel, 2001; Laslett et al., 2011) and crime and criminalisation (Csete et al., 2016a; MacCoun & Reuter, 2001).

A new approach to formulating and appraising drug policy: A multi-criterion decision analysis applied to alcohol and cannabis regulation

Worldwide there is now a greater shift towards more sensible approaches to substance use rather than the combative policies of the past. Growing acknowledgement of the overdose crisis in the USA saw it declared a public health emergency. Norway moved to decriminalise drugs for personal use, inspired by the success of the Portuguese model. In the Philippines, the failed drug war approach and its disregard for human rights reached a new nadir as extra judicial killings took thousands of lives. In Australia, the National Drug Strategy continues a theoretical balance between the pillars of supply, demand and harm reduction. However, harm reduction receives less than 3 per cent of the funding, a missed opportunity to address the needs of people affected by continued drug use. In Victoria over many years, local community members and experts have been calling for the trial of a medically supervised injecting centre (MSIC) in Richmond, Melbourne’s heroin overdose epicentre. In late 2017, the Victorian Government announced a trial would commence in Richmond. The MSIC trial is an opportunity for health professionals to better engage with people who use drugs at their most vulnerable. It should save lives. Sydney’s MSIC has been evaluated many times since opening in 2001, with the most recent report (May 2015) stating they have supervised 965,000 injections and managed more than 6000 overdoses with no fatalities. Penington Institute continues to push for a more enlightened approach to substance use. We had many highlights and we invite you to read about these in this Review. We continued to increase recognition of the growing tragedy of drug overdose – in Australia and around the world. More than 100,000 people die of a drug-related accidental overdose each year around the world – this is a conservative estimate. Our leadership on this issue, though International Overdose Awareness Day (IOAD) and other activities included:

– The 2017 IOAD – a campaign with close to 500 registered (many more not registered) events around the world, significant growth in engagement online and local outcomes for event organisers including increased access to naloxone – the opioid overdose reversal medication. – Releasing Penington Institute’s seminal publication Australia’s Annual Overdose Report 2017. The extent of overdose resulting from pharmaceutical medication misuse and the impact of the opioid fentanyl received considerable coverage in Australia. – Publishing the Not Just Naloxone report which examined innovative local and international approaches to reducing the harm associated with drug use, highlighting that there are many effective and yet unrealised opportunities in Australia. – Providing extensive workforce development to frontline professionals, linking the latest research with practical support. Late in 2017 we welcomed the YEAH organisation as a new program of Penington Institute. YEAH – originally Youth Empowerment Against HIV/AIDS – focuses on youth led sexual health through face-to-face peer education and a major online community. YEAH is a great opportunity to expand the work of Penington Institute, to learn from and empower young people on alcohol and other drugs, as well as sexual health. To conclude, we would like to thank our Patrons, Board, funders, supporters, volunteers and staff for their involvement in 2017. We would particularly like to recognise the work of our volunteers. As a not-for-profit organisation with only 12 full-time equivalent staff, Penington Institute relies heavily on the contribution of volunteers. From our hundreds of volunteer International Overdose Awareness Day organisers around the world to our interns and advisory group members, thank you.

Ms Kathryn Greiner AO Chair and Mr John Ryan Chief Executive Officer

Annual Review 2017 Penington Institute

Psychedelic drugs are making waves as modern trials support their therapeutic potential and various media continue to pique public interest. In this opinion piece, we draw attention to a long-recognised component of the psychedelic treatment model, namely ‘set’ and ‘setting’ – subsumed here under the umbrella term ‘context’. We highlight: (a) the pharmacological mechanisms of classic psychedelics (5-HT2A receptor agonism and associated plasticity) that we believe render their effects exceptionally sensitive to context, (b) a study design for testing assumptions regarding positive interactions between psychedelics and context, and (c) new findings from our group regarding contextual determinants of the quality of a psychedelic experience and how acute experience predicts subsequent long-term mental health outcomes. We hope that this article can: (a) inform on good practice in psychedelic research, (b) provide a roadmap for optimising treatment models, and (c) help tackle unhelpful stigma still surrounding these compounds, while developing an evidence base for long-held assumptions about the critical importance of context in relation to psychedelic use that can help minimise harms and maximise potential benefits.

Psychedelics and the essential importance of context

Few commodities are as global as drugs. Cannabis, opium, heroin, amphetamines, Lysergic acid diethylamide (LSD), khat, psychedelic cacti and mushrooms as well as an interminable list of other natural or synthesised substances travel and are consumed around the globe for all possible reasons. Human migration, trade, cultural trends, medical practice, political repression: together they constitute the drug phenomenon today – and indeed in much of human history. In this, drugs are spirit-like commodities, their value resting upon a fundamental ambiguity made up of individual, psychological, social, cultural, economic and medical circumstances. Defining a drug is an attempt at defining a spirit on the edge, which metamorphoses in time and space. At the same time, drugs remain a fundamentally political object. They are substances controlled by states, through mechanisms of policing, legitimated by judicial and medical evaluation, condemned often on moral grounds. Situated between a fluid social existence and a static legal dimension, drugs can become inspiring hermeneutic objects of study.

Yet academe has systematically left scholarship dealing with drugs to a corner of the whole, especially in the social sciences. Drug scholarship is met with curiosity and anecdotal interest. These feelings are a reflexive spasm at the heart of which stands a formalistic understanding of social sciences and humanities, one that narrows the scope of social and political phenomena to univocal manifestations. The ambiguous nature of drugs in the modern world and their transversal effect are seen as dispensable oddities in a world made up of institutional records, leadership personalities, econometric stats and epidemiological surveys. Can social scientists and humanities scholars dispense drugs as a side note of bigger questions around the social and the political?

In October 2016, 12 scholars coming from different disciplinary backgrounds gathered in Oxford at St Antony’s College to test the potentials and perils of interdisciplinarity in drug research. The event, sponsored by the Wellcome Trust Small Grant for Society & Ethics, took the form of a symposium titled ‘Drugs, Politics and Society in the Global South’, which later gave the name to this special issue. The primary objective was not that of simply producing new analytical and descriptive knowledge to be added to the annals of drug studies. The goal, instead, was to build through an interdisciplinary platform fresh insight into the study of the modern and contemporary world. Historians, political scientists, urban and cultural anthropologists, geographers, criminologists and medical anthropologists enlivened the discussion for two days. Rather than gathering a list of the usual suspects working on drugs, the symposium enabled a venue for the encounter of a unique blend of multiple disciplines. The blending of these different approaches resulted in a polyvocal and multi-faceted engagement around and within the phenomenon of drugs. Drugs became a frame, a lens, through which one could interpret and relocate broader historical and epistemological questions.

Click here to read the journal (restricted access).

Third World Quarterly special issue: Drugs, politics and society in the Global South

Drug use is criminalized in all countries of the MENA region, and a large number of PWUD are incarcerated, mostly for drug use, but sometimes even for the mere possession of syringes (UNAIDS, 2016; MENAHRA program data). Moreover, PWUD face high levels of stigma and discrimination in the region (MENA Regional Networks, 2016), which are further reinforced by their criminalization (UNAIDS, 2017a). Both the criminalization of drug use, and high stigma and discrimination faced by PWUD, negatively affect access to health services for this population. A number of studies have reported that this criminalization, manifested by punitive laws, incarceration, and prohibitions on harm reduction services, negatively affects harm reduction efforts. These negative effects include decreases in access to Needle/Syringe Programs, increased risky behaviors of sharing used injecting materials, and an increased HIV burden among PWID (UNAIDS, 2017a). Injecting drug use has been document within prisons in a number of countries in MENA, with unsafe injecting drug use being the primary mode of HIV and HCV transmission among prisoners (HRI, 2017). Furthermore within these settings, OST and ART are often unavailable, discontinued, or severely delayed - further exacerbating negative health consequences.

Police/law enforcement can also be a source of stigma and discrimination. In an Operational Research on PLHIV who inject drugs in 6 countries of the region, 7.7% of participants reported to have faced stigma and discrimination from police (MENAHRA, 2017a).

Of further concern are women who inject drugs, who remain more vulnerable and at higher risk than their male counterparts due to social stigma and gender related factors, whether within prisons or not. These vulnerabilities further hinder access to health services among women (MENAHRA, 2015). Women who inject drugs also have high risks being subjected to sexual violence from police and law enforcement agencies, as has been reported by a study conducted in 2015 (UNAIDS, 2017a).

Policy brief for law enforcement officials on the provision of harm reduction services

Life expectancy in the United States has declined for two years in a row, largely driven by the opioid epidemic. Overdoses claimed more than 64,000 lives in 2016 and all indications are that the impact of the crisis in 2017 will be even greater. Fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine, is the primary cause of the rapid increase in overdose deaths. Fentanyl and its associated analogues (including carfentanyl, furanyl fentanyl, and acetyl fentanyl) have been found mixed with heroin, cocaine and pressed into counterfeit prescription drugs. In 2015, the Drug Enforcement Agency issued a nationwide alert calling fentanyl a “threat to health and public safety.” Recently, the Centers for Disease Control and Prevention reported that fentanyl and associated analogues were associated with over half of the opioid overdoses in ten states during the second half of 2016.

The potential of death from even small amounts of fentanyl has changed the landscape of opioid use in the United States. Evidence to date suggests that people who use drugs often do not know whether fentanyl is present in what they are about to consume. A recent study among 242 heroin users across 17 sites in British Columbia, Canada, found that 29% tested positive for fentanyl, 73% of whom did not report knowingly using fentanyl.

To explore the viability of a public health response to the fentanyl crisis, the Bloomberg American Health Initiative awarded funding to support the Fentanyl Overdose Reduction Checking Analysis Study (FORECAST). This study aimed to examine the accuracy of three technologies in identifying the presence of fentanyl in samples of illicit drugs. It also aimed to gauge whether people who use drugs and other stakeholders would be interested in using such technology as part of harm reduction programs.

Fentanyl overdose reduction checking analysis study

The last remaining DEA agents left Bolivia in January 2009, bringing to a close more than three decades of DEA-presence within the country. President Evo Morales had ordered the expulsion of the US agency in response to the harms caused by the ‘war on drugs’ and perceived US-meddling in the internal affairs of Bolivia. As part of the dispute, Morales had also expelled US Ambassador Philip S. Goldberg in September 2008, accusing the US of fomenting civil discord. ‘Without fear of the US empire, I stand before the Bolivian people today and declare United States Ambassador Mr. Goldberg persona non-grata,’ Morales announced, ‘We don't want people here who conspire against our unity. We don't want people who threaten our democracy.’ The period thus marked a nadir in US-Bolivian relations, and a turning-point for the course of counterdrug policy in Bolivia. For better or worse, the Bolivian government would now seek to cut its own path: moving away from the drug war approach of the US. But how did US-Bolivia relations arrive at this point? What were the historical antecedents of this point of fracture? Drawing on 27 oral history accounts with US and Bolivian political actors, the paper considers Bolivia’s post-transition period as a key moment in this history of fractious US-Bolivian relations and the ‘war on drugs’ in the Andes.

Many of the same themes of grievance raised by Morales were apparent during this period. Bolivia transitioned to democracy in 1982 against a background of economic crisis. The imposition of harsh-neoliberal structural reforms would bring stability to the national economy, but at a severe social cost. For large swathes of the population, the coca-cocaine economy provided a vital social-safety net during this period of crisis. Furthermore, narcodollars played a crucial role in helping to stabilise the economy: boosting national reserves and inward investment. Given these socio-economic realities and the relative absence of drug-related violence in Bolivia, there was a level of ambivalence towards the drug trade. Instead, the escalation of the US ‘war on drugs’ was, at-times, viewed to pose the greater risk to Bolivia’s social, political and economic stability. This US drug war approach included the militarisation of counterdrug operations and coca eradication. For many Bolivians, the exercise of US power in advancing its counterdrug goals invoked ‘Yankee Imperialism’ and recent memories of US-Cold War interference in Bolivia. US agencies, for example, operated in Bolivia with little local oversight, while Bolivian politicians from this period believed accusations of drug corruption were used to silence opponents of US policy. Perceptions that US counterdrug policy ran contrary to local interests, and that the US exploited the ‘war on drugs’ to exercise control in Bolivia, created an atmosphere of mistrust between the US Embassy and the Bolivian government. As evidenced by the expulsion of the DEA in 2008 and the breakdown of US-Bolivian relations, such mistrust continues to manifest itself to this day. Speaking in June 2017, Morales stated, ‘I do not regret the decision to expel the DEA. The United States used the “war on drugs” in order to control the country's politics and loot our natural resources’.

The	 coca-cocaine economy, the US	 ‘War on Drugs’ and Bolivia’s democratic	transition (1982-1993)

By David Powell, Rosalie Liccardo Paccula and Mireille Jacobson

Recent work finds that medical marijuana laws reduce the daily doses filled for opioid analgesics among Medicare Part-D and Medicaid enrollees, as well as population-wide opioid overdose deaths. We replicate the result for opioid overdose deaths and explore the potential mechanism. The key feature of a medical marijuana law that facilitates a reduction in overdose death rates is a relatively liberal allowance for dispensaries. As states have become more stringent in their regulation of dispensaries, the protective value generally has fallen. These findings suggest that broader access to medical marijuana facilitates substitution of marijuana for powerful and addictive opioids.

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

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