As part of a series of engagements with South-East Asian governments and civil society over the last few weeks, IDPC staff were in Kuala Lumpur on 1st and 2nd October to take forward our country work in Malaysia under the International HIV/AIDS Alliance “Community Action on Harm Reduction” programme. Gloria Lai (IDPC's Senior Policy Officer) and myself had a packed itinerary of meetings, organised with our main partners in Kuala Lumpur, the Malaysian AIDS Council (MAC). We were ably supported by Nuno Capaz, the head of the Lisbon “dissuasion commission” in Lisbon, Portugal, who came to describe the Portuguese decriminalisation model. Our main focus was a symposium on diverting drug offenders from mandatory imprisonment, into health and social services, but we also had meetings with the de facto Minister of Law, Police Chiefs, civil society representatives, and legal advisors to the Attorney General.

The positive part of this blog post is that the recent gains in harm reduction policy support and programming, and the transfer of clients from compulsory treatment into voluntary and effective treatment services (primarily the “Cure and Care” clinics) are alive and well – and are showing signs of being an uncontroversial and accepted part of the Malaysian approach to drug use. Malaysian authorities – that is, the Ministry of Health and the National Anti-Drugs Agency (NADA) – have, in association with MAC, made great progress over recent years in scaling up the provision of NSP, OST, and community-based treatment across Malaysia. This is particularly welcome, as these services have the support of political and religious leaders in the country, despite some neighbouring governments (notably Thailand) still favouring repressive and punitive approaches to people who use drugs.

The less positive aspect of our visit was the lack of progress on changing laws that still criminalise drug use and the processes by which Malaysian police and prosecutors deal with arrested people who use drugs. The dominant view of people who use drugs amongst senior officials and (reportedly) the general public, is that they are primarily responsible for allegedly widespread street crime such as bag-snatching by motorbike riders, therefore deserve tough punishment. The current process faced by people who use drugs after arrest is a mandatory 14-day remand in custody while a bizarre assessment process (involving urine testing and an obscure medical assessment) is carried out to determine whether the individual will be considered an “abuser” or “drug addict”. Court appearances are often severely delayed, during which period the arrested individual stays in prison. Sentences include up to two years in a rehabilitation treatment centre or under a supervision order in the community (for more information see the IDPC briefing paper on drug policy issues in Malaysia).

When we visited Malaysia last year, we met with officials who were open to discussing an agenda for reform that would allow more diversion of minor drug-related cases from criminal justice processes, but during our visit this year little progress has been made to advance such reforms. There are progressive managers in NADA and the Narcotics Police, but our sense from this trip was that neither agency was willing or able to push forward a reform agenda. But there were two potential opportunities: a committee of legal experts reviewing the efficiency of the 14-day remand process, which may recommend the adoption of more humane and efficient processes for people caught with the possession of drugs, and; a positive meeting with the de facto Minister of Law, who was clearly well informed on the issue of diversion and decriminalisation (even seemed to have read the IDPC Drug Policy Guide), and promised to seriously consider and act on the recommendations of the committee of legal experts. However, overall, whether or not Malaysia represents progress in evidence-based policy making on drug issues is difficult to say.

Finally, we were able to secure a slot for Nuno Capaz to present the Portuguese model to the second Regional Consultation on Compulsory Centres for Drug Users organised by the UNODC, UNAIDS and ESCAP, and co-hosted by NADA, taking place in Kuala Lumpur at the same time as our visit. His presentation gave a useful insight into a successful model for decriminalisation and voluntary drug treatment, in the context of a meeting where the dominant tone was reportedly supportive of the phasing out of these centres – once again, of course, with the exception of Thailand.

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Malaysian progress from compulsory to voluntary treatment

When the head of Indonesia’s narcotics control agency (BNN), Mr. Gories Mere, said that his country’s drug policies were better than those of Portugal because they required all people who use drugs to be rehabilitated, he set the tone for his agency’s contribution to a national symposium on drug policies on diversion and treatment. IDPC, which was represented by Mike Trace (Chair), Ann Fordham (Executive Director) and Gloria Lai (Senior Policy Officer), were co-organising the symposium together with the United Nations Office on Drugs and Crime, BNN, and Indonesia’s Ministry of Health, held in Jakarta in early October.

In the context of ongoing difficulties with implementing new laws and regulations introduced since 2009, including mandating the registration of people who use drugs and their diversion into treatment centres, a Portuguese representative (Nuno Capaz, Dissuasion Commission, Lisbon) was invited to speak on his country’s system of decriminalisation and diversion of people who use drugs to treatment and services (only where the individual has such a need). Just three weeks prior to the Jakarta symposium, over 20 government officials (including Mr Mere), parliamentarians, civil society and international agency (UNODC, AusAID) representatives had taken part in a study visit to Portugal to see for themselves the Portuguese model of decriminalisation and drug treatment. However at the symposium, there did not appear to be a prevailing mood for change amongst government agencies. While the Ministry of Social Affairs insisted on the need to ensure that individuals were fully rehabilitated and did not relapse, though without explaining their plan to achieve that need, the Ministry of Health spoke frankly about the challenges faced in implementing laws on compulsory registration—including difficulties with coordinating all the agencies involved in the registration and treatment system—and improving the capacity of health centre staff to respond appropriately to people who use drugs.

In what seemed like a parallel universe, BNN representatives, proudly talked about having the ‘most beautiful’ rehabilitation centres in Southeast Asia, the effectiveness of relying on religious leaders to ‘rehabilitate’ people who use drugs where law enforcement agencies have failed in their efforts, and offering ‘sabbatical’ trips to islands for people who have stopped using drugs to help them with social reintegration.

However the symposium was refreshing in allowing a wide range of voices to be heard. A member of the House of Representatives committee responsible for health issues questioned the necessity and effectiveness of requiring the compulsory registration of people who use drugs, and urged the serious consideration of adopting instead drug courts (as with some states in Australia) or dissuasion commissions like those in Portugal. Edo Agustian of the national drug user network (PKNI) spoke about the fear that people who use drugs have about police abuse, and the need for them to feel assured about being safe from abuse and harassment if they were ever to willingly register themselves with the authorities. He also spoke about the increasing use of amphetamine-type substances (ATS) and the need for ATS-specific treatment on the one hand, but on the other, the need to recognise that many people use ATS occasionally and do not need treatment.

That there was an opportunity for a range of voices from government, community, and civil society to speak frankly about the specific issue of compulsory registration and the treatment system in Indonesia might have been an achievement in itself. That it could help to stimulate further steps towards lasting change in laws and institutional practises now depends on the ongoing efforts of all those involved. This was one of the aims of several Indonesian civil society actors, who gathered the day after the symposium for an IDPC civil society advocacy workshop.

At the workshop, IDPC shared an update on international and regional drug policy developments. At the international level, Mike shared some good news about movements toward drug policy reform in the United States and some Latin America countries. Meanwhile, news from the region showed that drug policy debates were not as dynamic as at the international level. Many Asian countries still impose compulsory treatment for people who use drugs, such as in Thailand.

Many participants exchanged views on the Indonesian government’s perception of diversion issues. Some participants also pointed out that there are still many civil society workers that lack understanding about Indonesia’s overall drug policy. To gain a better understanding about national-level policies, participants did an exercise to map the actors involved on drug policy issues in different areas, for example, providing harm reduction services, gathering data related to drugs, and policy advocacy. Participants also engaged in other exercises to help identify the key problems in Indonesia’s current drug policies, as a basis for developing an advocacy plan. Among the problems identified were the need to amend the Narcotic Law and address the lack of coordination among all government agencies involved in drug policy.

At the close of the workshop, one participant from Papua shared her concern about Papua’s unique conditions where, unlike in the big cities, access to treatment, data, and information are very limited. Overall it was a fruitful two-day discussion. Even though there might have been an issue with language barriers, everyone had their opportunity to share their opinion on the challenges and opportunities in reforming Indonesian drug policy.

Are Indonesia’s government and civil society actors debating drug policy in parallel universes?

Despite the wealth of evidence supporting key harm reduction interventions such as needle and syringe programmes (NSPs) and opioid substitution therapy (OST), they remain woefully underfunded around the world. We know this by looking at the global coverage: just 8% of people who inject drugs have access to NSPs, and 8% have access to OST. The cost-effectiveness of these interventions has been verified by multiple studies: the economic return from OST (through averted infections, reduced crime, etc) is estimated to be around four times the treatment cost, and studies have shown that every $1 invested in NSPs returned more than $4 in health care savings alone.

In a recent “Investment Framework” proposed by UNAIDS and partners, it is projected that US$ 2.3 billion will be needed in 2015 to reach the optimal coverage of harm reduction interventions (falling to US$ 1.5 billion in 2020 through savings in averted infections etc) – but this compares to just US$ 0.5 billion said to be available in 2011. In a global economic crisis, and with on-going uncertainty concerning the Global Fund to Fight AIDS, Tuberculosis and Malaria (the leading international donor for harm reduction as things stand), only the most devoted optimist can foresee the US$ 2.3 billion need being met in three years’ time.

Crucially, however, even if this funding need was met, we would struggle to know it. Most donors are reluctant or unable to divulge how much they have spent on harm reduction approaches, with global data limited to “guesstimations”. In 2010, Harm Reduction International released “Three Cents a Day is Not Enough” – the first attempt to provide a comprehensive overview of harm reduction funding around the world. The result was shocking: just $160 million was invested in HIV-related harm reduction in low and middle income countries in 2007 – US$ 0.03 per person who injects drugs, per day. In fact, the largest funders for harm reduction were people who inject drugs themselves, with ‘out-of-pocket’ expenses accounting for a significant amount of the global resources – “an unfair burden… that would be unacceptable in any other medical or public health field”. The report also highlighted the difficulties in calculating harm reduction budgets at this level. The UNAIDS National AIDS Spending Assessments (NASA) proved of limited use, and many donors did not report or disaggregate their expenditure on this population.

Since 2007, there is reason to anticipate that the amount of funding has risen – but the gap between reality and need remains significant. Prompted by the recommendations of the “3 Cents” report, the Global Fund has now released the results of a year-long portfolio analysis. Between Round 1 of funding (2002) and Round 9 (2009), they approved up to US$ 430 million for services targeting people who inject drugs. In Round 10 (2010), they launched a dedicated funding reserve for most-at-risk populations, and approved a further US$ 152 million for this population – taking the total to US$ 582 million over the ten funding rounds. However, the positive trend in recent years was undone when the Global Fund decided to cancel Round 11 in 2011. A further sixteen HIV proposals have been accepted through the Transitional Funding Mechanism that was created to alleviate the impact of cancelling Round 11 – nine of which include harm reduction (the budgets for these new grants will only be available for analysis in 2013).

But the need clearly remains for donors to better track their spending for people who inject drugs (as well as on other key populations, such as sex workers and men who have sex with men). Harm Reduction International plan to repeat and update the “3 Cents” research in early 2013, in time for the harm reduction conference in Vilnius. But this work should not be the sole responsibility of a small NGO – it should be a core part of the UNAIDS remit, and particularly the role of the United Nations Office on Drugs and Crime (UNODC), as the leading UNAIDS co-sponsor for injecting drug use. Hopefully the 2013 research will come up with a figure larger than US$ 0.03 – but the previous conclusion that “More money is needed for harm reduction, and it is needed now” is likely to still be true.

The on-going under-funding of harm reduction

On Monday 17th September, 2012, IDPC together with the Transnational Institute (TNI) held a high-level seminar in Bangkok co-hosted with the Thai Ministry of Justice Rights and Liberties Protection Department to discuss and review effective legal frameworks for managing drug-related problems. It was a crucial moment for such a discussion as the Thai government recently announced plans for the mass rehabilitation of up to 400,000 drug users in what essentially amounts to compulsory detention centres run predominantly by the Thai military in their ongoing push to make the country drug-free.

Thailand has become the unfortunate poster child for punitive drug control policies that have failed to reduce or eliminate drug use, and instead resulted in negative and damaging consequences. Since ex-Prime Minister Thaksin Shinawatra declared a war on drugs in 2003 that resulted in nearly 3000 extra-judicial killings, Thailand has repeatedly come under fire from the international community for an overly punitive approach to drug control that de-prioritizes health and human rights outcomes in favour of zero-tolerance ideology on drug use. The current administration, with Mr Shinawatra’s sister at the helm, Prime Minister Yingluck, declared a new war on drugs last year although there were assurances that the human rights abuses committed in 2003 would not be repeated.

The willingness of the Thai Ministry of Justice to co-host the high-level seminar with IDPC and TNI shows that there are parties in Thailand concerned with the existing policies and keen to bring international experiences into the national debate. The political space for this kind of discussion is extremely limited and the issue of drugs continues to be a very sensitive matter for policy makers but this event brought together several key actors in Thailand, including representatives from the Office of the Narcotics Control Board (ONCB), Thanyarak Institute (the government body responsible for drug treatment in Thailand), Thai law enforcement agencies, 12D network (representing 12 Thai civil society organisations advocating on harm reduction), Asian Harm Reduction Network, Asian Network of People who Use Drugs, academics (Thammasat University and Chiang Mai University), and United Nations agencies based in Bangkok (UNAIDS, UNDP and UNODC).

International participants included Michel Kazatchkine, representing the Global Commission on Drug Policy and former Senator for Bangkok Jon Ungphakorn of the Global Commission on HIV and the Law. These two Commissions are the most recent voices of concern to highlight Thailand’s alarmingly high rates of HIV among people who inject drugs, and the fact that the epidemic is fuelled by the country’s draconian drug control policies. TNI and IDPC representatives also spoke at the event, highlighting global trends in the drug policy debate, including reforms taking place in Latin America that signal a move away from strongly punitive legal frameworks towards more pragmatic and evidence-based approaches.

Dr Kazatchkine was very frank in his intervention, saying that Thailand’s war on drugs had failed by ‘every metric you can think of’. He condemned the failure to adequately address the spread of HIV among people who inject drugs and also to ensure adequate access to anti-retroviral medicines for those who had become infected with the virus. This was a major disappointment especially after Thailand’s laudable response to HIV related to sexual transmission almost 20 years ago with the 100 percent condom campaign. Jon Ungphakorn also expressed his dismay at the continuing obstacles to the effective provision of HIV prevention for people who inject drugs, in particular bad laws and policies. He noted the ineffectiveness of compulsory detention and called for drug treatment to be voluntary and evidence-based. Although Thailand has a harm reduction strategy that includes needle and syringe programmes (NSP), implementation is limited. Thailand’s Council of State, the government’s legal advisory body, found last year that NSP provision would be illegal as it ‘promoted drug use’. Ms. Lawan Sarowat, representing the 12D network, spoke firmly about the rights of people who use drugs to be able to access appropriate health services, and the need to stop the rhetoric and start the implementation of harm reduction programmes in Thailand. Thai government officials were mixed in their responses to these interventions although there was general acknowledgement that drug users should not be categorised as ‘criminals’ but instead, as ‘patients’— although both terms are stigmatising and problematic given that most people who use drugs fall into neither category.

There were a few clear issues that emerged from a day of in-depth and unusually open discussion on such a sensitive topic for Thailand. The first was around the issue of harm reduction. NSP is available in Thailand provided by the Global Fund CHAMPION IDU project led by PSI but coverage is limited as a result of the legal ambiguity introduced by the Council of State, which must be urgently addressed given the high rates of HIV and Hep C prevalence. The second issue was the need to review the methods adopted for ‘drug treatment’ in Thailand. An important part of this discussion focused on the need to clarify whether someone who uses drugs is actually in need of treatment given the majority of people who use drugs do so without becoming dependent. Global evidence suggests that only 10% of people who use drugs become addicted, so if there are 1.2 million ATS users in Thailand, in theory only 120,000 would need treatment—however there is a national target to treat 400,000 users. The related but equally important point is to ensure that any treatment provided is voluntary and evidence-based. Detention in military camps has yet to be proven as an effective drug treatment intervention.

Finally, in discussing ‘effective legal frameworks’ the issue of decriminalising drug use was a pertinent one. With respect to the issue of the mass incarceration of people charged with drug offences this is a critical factor. Dr Apinun Aramrattana from Chiang Mai University reported that Thailand has roughly 246,000 people in prison (more than double the official prison capacity) with around 64% of these incarcerated for drug offences. While disaggregated data for those imprisoned for personal use offences is not yet available to us, we can expect that the number of people imprisoned for personal use is high given a recent study of 468 people who inject drugs in Bangkok found that 78% had been imprisoned, with some 48% reporting that they had experienced police planting drugs on them.

Many of those now incarcerated in Thailand’s prisons are likely to be low-level traders and drug users, as they are more easy targets for police, rather than large scale traffickers and organised criminals. Subsequently the need to review both the criminalisation of drug use and proportionality in sentencing for drug offences is particularly relevant for Thailand.

Furthermore, of those incarcerated for drug offences, an overwhelming proportion are for offences related to ATS (95.4%, compared with 2.7% for opium and heroin-related offences, and the remainder for cannabis, kratom and other drugs). The use and supply of ATS is a growing issue of concern for the region. The current harm reduction and policy responses are woefully inadequate, marking a need to invest more in developing effective and evidence-based measures for HIV prevention and drug treatment in relation to ATS use.

It was clear during the seminar that decriminalisation of drug use is still a very challenging topic to raise for discussion in the Thai context. Many of the policy makers present deferred to public opinion, saying that Thai society cannot accept a pragmatic response towards drug use as they see it as a wrongdoing that requires harsh punishment. The question that we were asked by reform-minded individuals was how to influence the public when they held such an entrenched mindset towards drugs. But perhaps the more relevant question is how to dissuade the Thai government from using drugs as part of its populist approach to electioneering which further reinforces any misguided public perceptions.

Thailand is not alone in facing these challenging issues and the Ministry of Justice should be commended for seeking to encourage a dialogue on drug control policies and approaches. However, there are some indications that other South East Asian nations are moving a little on some of the most difficult policy issues. Malaysia has scaled up harm reduction programmes for people who inject drugs and has also been moving towards the greater provision of voluntary drug treatment. Vietnam is also slowly waking up to the need to shift away from compulsory detention for drug users (no doubt actual implementation will be slow but there are encouraging signs), which follows a call by UN agencies earlier this year to governments in the region to close compulsory detention centres for people who use drugs. As a result, it is possible that Thailand could become more isolated in its futile pursuit of a drug-free nation without regard for the negative social, economic or public health impacts on its people. Continuing to be part of an international dialogue that shares experiences and lessons learnt will be a key factor in encouraging Thailand to develop more effective and humane drug policies.

Amidst deep concern for Thailand's drug policies, some space for open debate

Robin Pollard, Operations Coordinator at Youth RISE

Last month saw the release of the book: “The protection of children from illicit drugs – A minimum human rights standard” presented by the World Forum Against Drugs (WFAD). As is to be expected, the book’s central premise is that a drug-free society is achievable and should be the central objective of every drug policy. But there is no mention of the collateral consequences of this utopian ideal, especially those for young people. No one would dispute the need for drug polices to focus on protecting children and young people – who remain one of the most vulnerable sections of the population in terms of drug related harms. However, this publication shows just how detached from reality the position of the WFAD is.

The majority of the publication’s content is spent criticising a number of UN agencies and civil society organisations. It lambasts WHO, UNICEF, UNODC, UNAIDS and “the unholy trinity of Harm Reduction International / International Harm Reduction Association, Open Society Institute and Human Rights Watch” for attempting to safeguard the human rights of people who use drugs. There is good reason why these UN agencies and civil society organisations, as well as the Committee on the Conventions of the Rights of the Child itself, have come out supporting harm reduction for young people (and in some cases supporting the removal of criminal sanctions against people who use drugs). It is because harm reduction interventions are empirically proven to be the most effective methods to mitigate the harms associated with drug use and thus protect young people from drug use. Ignoring the fact that young people use drugs will not protect them.

WFAD argues that every country that has ratified the Convention on the Rights of the Child must be obliged to protect and sustain children’s human rights to ensure a drug-free childhood. However, we believe this also requires countries to protect children from the harms associated with drug use, including allowing full access to the appropriate harm reduction services: a measure supported the Committee of the Convention on the Rights of the Child in its concluding observations for Ukraine in 2011, in which it claimed that these measures are in fact the best way to “protect children from the illicit use of narcotic drugs and psychotropic drugs”.

However, having a child-centred drug policy also requires the protection of children from policies that criminalise their drug use. From what we have seen over the last few years, the majority of young people who use substances (many for only brief periods in their lives) experience a far broader range of harms than WFAD acknowledges – including human rights violations and harassment which can lead to higher-risk behaviours. This, in turn, makes these young people more vulnerable to health problems such as overdose, HIV and hepatitis. Furthermore, the impact of drug convictions, cautions and criminal records on young people is totally ignored by WFAD. In countries around the world, drug charges for the possession of small amounts of substances can result in young people being expelled from school, denied financial aid for higher education or facing barriers to long-term employment.

As part of the on-going “Support. Don’t Punish” campaign, Youth RISE will be launching the “Our Stories” project. The project will publish testimonies from young people around the world, describing their own personal experiences of criminalisation, how it has impacted on their lives, and the realities they face as a consequence of punitive drug policies.

We hope that, by raising and empowering the voices of young people, we can raise awareness about the real (though often hidden) impact of criminalising young people who use drugs. We aim to drive forward a change in how drug issues are viewed, especially among the younger generations who will be integral to future policy formulation. Young people remain a population at risk, and they need to be given the opportunity to fulfil their potential. Policies restricted to the ideal of obtaining a drug-free society are not only unattainable; their unintended consequences will have serious long-lasting impacts upon the health, human rights and socio-economic status of young people. Humanism, pragmatism and the protection of the health and development of our youth must guide drug policy formulation – not moral crusades. This requires support, and- not punishment.

If you would like to share how your life has been impacted by drug policies, please contact robin@youthrise.org to find out more information.

The World Forum against Drugs: Stop ignoring the right to health of young people who use drugs

To coincide with the International Day against Drug Abuse and Illicit Trafficking on 26 June 2012, the United Nations (UN) General Assembly (GA) held an ‘informal’ debate in New York on the issue of drugs and crime as a threat to development. 

 suggests the real threat, however, remains the same old tired and failed thinking that is entrenching, rather than reducing, harms from the international illegal drug trade.

The call for this debate reflects UN discussions about transnational organised crime and its link to the illicit drug trade. In September of last year, UN Secretary General Mr Ban Ki Moon set up a UN taskforce, to be led jointly by the UN Department for Political Affairs and the UN Office on Drugs and Crime (UNODC), to mobilise the UN in a co-ordinated and coherent response.

The challenge to the UN of developing a system-wide response on the issue of drugs and organised crime should not be taken lightly. For many years, civil society actors have been calling for UN agencies to ‘speak as one’ on an evidence and rights- based response to reducing drug-related harm among people who use drugs.

HIV prevention in particular has been at the top of this agenda. There has been some progress on this issue, with broad acceptance across UN bodies (after many years of sustained civil society advocacy) of life-saving harm reduction interventions such as needle and syringe programmes and opioid substitution therapy as key interventions for the HIV response.

However, in recent months, we have witnessed a concerning roll-back by the UNODC on harm reduction and a misrepresentation of the agreed best strategy for HIV prevention among people who use drugs. This was well illustrated by my colleagues from the International Network of People who Use Drugs and Harm Reduction International in their guest editorial in the May 2012 edition of this publication. There, they discussed the censorship of civil society voices at this year’s 55th Session of the Commission on Narcotic Drugs and moves by UNODC to reframe abstinence-based drug dependence treatment as effective HIV prevention.

The UNODC’s misguided leadership on this issue is particularly worrying given it is the lead UN agency for responding to HIV prevention among people who use drugs under its mandate as a co-sponsor of UNAIDS. These recent developments highlight the ever-pernicious tendency to promote zero-tolerance approaches to drug use in an unfortunate recycling of the powerful ‘drugs as a threat’ narrative, despite the overwhelming evidence for both the failure and negative consequences of this approach.

It is this ‘drugs as a threat’ narrative that was used to frame the GA debate on 26 June. While there is absolutely no doubt that the power and reach of transnational organised crime and the activities in which such groups are engaged seriously undermine global development objectives enshrined in the Millennium Development Goals, presenting the issue in these terms reinforces the idea that people who use drugs, farmers engaged in producing drug-linked crops and the ‘little fish’ in drug distribution networks are also the ‘threat’.

This conveniently ignores the fact these groups are often the most marginalised in society and their involvement in the drug trade is based on a complex combination of factors such as socio-economic status, marginalisation, vulnerability and geography. The ‘drugs as a threat’ discourse has justified punitive measures towards consumers of drugs, crop eradication schemes and resistance to pragmatic harm reduction measures on both the demand and supply sides of the drug market.

The actual GA debate was chaired by Mr Yuri Fedotov, the Executive Director of the UNODC. As predicted, it was fairly uninspiring, which is typical of these large diplomatic gatherings. There were the many routine and hollow statements from most member states echoing those we hear each year at the CND. There were, however, a few progressive interventions that reflect the recognition by an increasing number of governments that the drug control system is in need of modernisation and reform.

The US, for so long the main proponent for prohibition, reiterated its statement that we need to prioritise treatment over punishment. Guatemala robustly defended its call for a review of current drug policies and Luxembourg highlighted the need to take under serious consideration the recommendations of the Global Commission on Drug Policy.

These cracks in the consensus are heartening. Yet, to really shift the debate towards reform, there needs to be clear acceptance of a number of inconvenient truths – the greatest of which is that the huge political and financial commitments to eradicating the illicit drug market have failed. The global drug trade has not been contained and is estimated to be worth some US$300 billion, most of which is in the hands of organised crime.

The second inconvenient truth is that many of the security and law enforcement-focused strategies employed to this end have only served to exacerbate the problems: the illegality of the market fuels the profits of organised crime and drug market violence; the criminalisation of people who inject drugs drives the HIV epidemic and leads to the overburdening criminal justice and prison systems; and harsh supply reduction strategies lead to the destruction of the livelihoods of some of the most marginalised communities for whom the only existing viable economic option is the drug trade.

In understanding the multi-faceted nexus between drugs and development and how to respond effectively and appropriately, there must be a coherent strategy in which drug control objectives do not adversely affect the same communities that development policies are designed to support but that instead are integrated, sophisticated and pragmatic.

The real threat to development would be to complacently recycle wasteful, failed and counterproductive strategies.

This article was initially published in Matters of Substance, August 2012.

Drugs and development: The real threat

The success of the global HIV response depends on effective HIV prevention for the 16 million people who inject drugs worldwide. Needle and syringe programmes have repeatedly been proven to prevent HIV by reducing the need to re-use or share potentially contaminated injecting equipment. However, it has been estimated that just 8% of people who inject drugs have access to these programmes – with just two needles and syringes distributed per injector per month. As a result of poor coverage, inadequate resources and paraphernalia laws in some countries that prevent people from carrying syringes, many people who inject drugs continue to use unsterile needles and syringes.

An emerging body of evidence suggests that changing the types of needles and syringes that are used could massively reduce HIV transmission. The evidence is still limited to laboratory studies and mathematical models – but has shown enough promise to warrant inclusion in recent hepatitis guidance from the World Health Organization.

The basic premise is this: all needles and syringes retain some fluid (i.e. blood and/or drug solution) once the plunger is fully depressed – this is known as “dead-space”. In some “high dead-space” designs, fluid is retained in the tip of the syringe, the hub of the needle and the needle shaft itself. In other “low dead-space” designs, fluid is only retained in the needle itself (see image). The difference can be 40-times less fluid in the low dead-space syringes.

In laboratory experiments simulating common injection practices, low dead-space syringes retained up to 1,000 times less blood. Therefore, a person who shares a low dead-space syringe is less likely to be exposed to HIV. Modelling exercises suggest that switching people who inject drugs from high dead-space to low dead-space syringes could prevent or reverse injection-related HIV epidemics.

But this effect now needs to be proven in reality. Crucially, low dead-space needles and syringes tend to only be available in smaller sizes – which are no good if people need larger ones (due to the types of drugs, or where on the body they are injecting). Changing from one type of syringe to another must only be done in full consultation with people who inject drugs, and with alternative syringes still available for those who need them. At the same time, work is on-going to try and convince syringe manufacturers to make further low dead-space products and options available in the right sizes and at the right prices.

But this is one area of research to watch closely – a potential game changer for harm reduction efforts in many countries. The developments to date have been excellently summarised in a newly published article by Dr William Zule and colleagues – available here (subscriptions may be needed) – and further work is planned to determine exactly what impact this relatively simple intervention has on the ground.

Saving lives with dead-space?

Evolving out of the Global Drug Survey, drugs meter is a tool that allows people to get non-judgemental feedback on their drug use. Adam Winstock explains.

For the last decade or so, with the help of some great colleagues, I have managed to get lots of people to answer questions about their drug use by collaborating with media organisations like 

. However, while I got to write papers and participants got to read the results, I felt that the Global Drug Survey (GDS) could provide an even more beneficial service. This led me to develop the drugs meter, an anonymous way for anyone to gauge their drug use, which, I hope will encourage people to make positive health choices in a non-judgemental way.

For most people, for most of the time, use of substances is primarily a source of pleasure and does not incur serious harm to themselves or others. Many people are able to self-regulate their use – they dabble for a while and stop – and others who run into problems are able to change the way they use. But some people don't recognise when their drug use is causing themselves or others harm.

Some people who take lots of drugs look at their friends and think everyone does the same.

I spend my working day as a consultant addiction psychiatrist in London with people who use heroin and crack, alongside other drugs and alcohol. People who are dependent on drugs and/or are in treatment represent the minority of people who use, or have used, drugs or alcohol, and almost all started using drugs in a way that did not cause them serious harm. The journey to problematic drug use may have taken several years, but no one is interested in people who use drugs before they develop serious problems or are causing a nuisance to society. There is no guidance for people who use most drugs about what constitutes safer levels of drug use. This is because most governments take the stance that all drug use is bad and the only way to avoid drug-related harm is to not use drugs at all. Although many governments embrace the concept of harm reduction, most is aimed at the minority of people who use heroin or inject. The hidden masses of drug users, those 2-3 million people who wont ever see a drug service kind of get left behind.

Getting people to change their behaviours is hard. The last three decades have seen a growth in individual psychological approaches to encourage behaviour change, with motivational interviewing and brief interventions being the most widely evidenced. While these have been applied to the full range of unhealthy behaviours, they typically require face-to-face contact with health professionals and disclosure by the individual. More recently, the theories of behavioural economics and social normative feedback have been explored to help craft simple large-scale approaches to motivating behavioural change – such approaches aim to ‘nudge’ people’s behaviours towards healthier and happier choices. The principal is simple.

So are people interested in how their use of drugs and alcohol compare to others? As part of the 2011 Global Drug Survey (GDS), we asked participants if they were interested in knowing how their use of drugs or alcohol compared to other people. About 70 per cent said they were, while another 20 per cent said maybe.

We asked over 12,000 people how they thought their use of drugs and alcohol compared to other people who had used that drug recently, and the findings were amazing.

However, we need to explain that for comparison we used other people who had filled in the Global Drug Survey. That might not be a fair comparison group but, given it was people from across the world, mostly in their 20s or 30s and with enough of an interest to fill in a survey about drug use, we don’t think it’s a bad comparison group.

Here are some examples of what we found from the UK data. Just under 20 per cent of people who were judged as alcohol dependent using the AUDIT screening tool thought their drinking was average or less than average compared to other drinkers. Just over 15 per cent of people who were smoking cannabis 20 or more days per month thought their use was average or less than average compared to other cannabis smokers, when in fact they were in the top 30 per cent of all cannabis smokers in our sample. Over 50 per cent of people using 4g or more of cocaine per month thought they were average or below average users when in fact they were in the top 20 per cent of all cocaine users in the sample. This tells us something about how people want to see themselves, as well as those they choose to compare themselves with. Like most of us, our participants probably compared themselves with their mates. So if you do lots of drugs and all your mates do lots of drugs it probably seems like everyone is doing lots of drugs. If all your mates drink a lot, then heavy drinking might seem like average drinking.

Drugs meter is designed to allow people to compare themselves to others like them – well, at the moment it compares you to everyone else but once we hit 50,000 (we are at about 20,000 to date) people we’ll allow you to choose your peer groups based on gender, country, age, sexuality and musical taste. Drugs meter is different to general mass harm reduction approaches by making information personal. In order to make informed choices people need personally relevant, objective information about their use of drugs. Drugs meter allows people to get rapid and objective feedback on their drug use and to compare themselves to others, ‘nudging’ them to be safer. It also offers simple tools to reduce risks associated with drug use and intoxicated related sexual behaviour and flags up when use might be causing problems. Drugs meter does tell not people what to do. It simply provides an anonymous, safe place where people can think about their use and check out the risks they face – or help a friend they think may be in trouble.

Drugs meter is not funded by any government and does not tell a person that their use of drugs is safe. If they are in the bottom 10 per cent of cocaine users it reminds them that only a tiny percentage of their population has used cocaine in the last year.

So what’s the feedback so far? Since its online launch at the end of July, more than 5,000 people have completed the drugs meter, adding to the 15,000 people who contributed their baseline data through the GDS 2011/12 survey. Seventy-five per cent would recommend it to friends, 80 per cent said it got them to think them to think about their use of drugs and alcohol in a way that was helpful, 75 per cent said it was accurate or very accurate in the way it assessed their use and 25 per cent said they would use less, or use is an way that caused them less harm as a result.

All ten drugs meter apps are now available for your smart phone and we are developing overdose and high-risk sex and injecting meters at present. We are working with local DATs to promote drugs meter, gather good quality data on drug use trends and ensure that drugs meter gets used as widely as possible. It’s free!

Interested? Please feel free to share drugs meter with your friends and colleagues. You can find it at 

Drugs Meter: This time it’s personal

Rubem Cesar, executive director of Viva Rio

On Monday, July 9th, the Brazilian Commission on Drugs and Democracy (CBDD) and Viva Rio launched a national campaign to change the law on drugs in Brazil.

Public support for the campaign, Drug Law: It’s Time to Change, has exceeded expectations. While the organizers hoped to collect 50,000 signatures in the first 30 days of the campaign, that number was reached in just three days.

The campaign hopes to reform law 11.343/2006 by collecting one million signatures calling for Brazil’s National Congress to support more effective and equitable drug legislation in the country.

While the existing law technically allows for a partial decriminalization of possession for personal use, the law does not make a clear distinction between people who use drugs and people with intent to distribute. This gap is resulting in the arrest of thousands of drug users that are trialed as drug traffickers.

Since its implementation in 2006, the number of people imprisoned for carrying drugs has doubled, rising from around 60,000 to 120,000. Many of these prisoners have never committed any other major crimes, have no ties to organized crime and were only carrying small quantities of drugs when arrested.

With campaign signatures now skyrocketing with over 80,000 Brazilian and international supporters, CBDD and Viva Rio have decided to present the bill to the to the president of Brazil’s National Congress this August.

Simultaneous to its official presentation, the bill will also be uploaded on the online public debate forum, e-democracy. Through this mean, citizens around the country will be able to engage in the transparent process of discussing the proposed bill and sharing their suggestions for change.

Some of the proposals that will be presented in the new bill include moving the issue of drugs from the realm of public security to that of health and social assistance; decriminalizing drug use and establishing clear differences between people who use drugs and dealers. The bill should also ensure quality treatment for people who use drugs, as well as support for networks and families.

We believe that all of these measures will bring justice to the thousands of drug users who have been subject to draconian punishments and have been deprived of support systems in which they can find help without having to fear years behind bars.

To sign a petition today, go online at http://www.eprecisomudar.com.br/.

Make your voice heard! It’s time to change!

Brazil’s “Drug Law: It’s Time to Change” Campaign Turns Viral

As a participant at last week’s 19th International HIV/AIDS Conference, I was reminded of President Fernando Henrique Cardoso’s and UNDP Administrator Helen Clark’s call to armsearlier in July that there is a new prescription for the AIDS response: ‘courage is needed’.

The event was a pivotal moment – it was the first time that an international AIDS conference has been held on US soil, and this was made possible because President Obama overturned the travel ban for people living with HIV to enter the US. However, the conference also starkly highlighted one of the fundamental barriers to a scaled up, sustainable and rights-based response to the epidemic – many sex workers and people who use drugs were unable to enter the US and attend the conference because they are deemed as criminals under US law. In an attempt to remedy this great failure of this year's conference, two hubs, one focusing on drug use and the other on sex work, were organised prior to and during the conference to ensure that the voices of these vulnerable groups be heard.

The criminalisation of sex work and drug use fuels the HIV epidemic, undermining the many hugely positive and exciting scientific breakthroughs that the HIV response can take credit for. These include increased access to antiretroviral treatment and the critical importance of HIV treatment as prevention. Both HIV prevention and treatment are of equal importance in a rights-based approach. However, in a resource-constrained environment it is arguably more cost-effective to prevent HIV transmission in the first place. For people who inject drugs, this means primary HIV prevention measures such as the provision of sterile injecting equipment and opioid substitution treatment.

Our efforts to reach zero new infections will always be fighting the tide if policy and legislative barriers continue to inhibit an effective HIV response. This issue has been pertinently highlighted recently both by the Global Commission on Drug Policy and the Global Commission on HIV and the Law. Both Commissions call for the decriminalisation of drug use and the removal of legal impediments to harm reduction interventions for people who inject drugs as part of a comprehensive HIV response.

Although many people from the global drugs movement could not be in Washington (and the conference was all the poorer because of their absence) there were several impressive sessions at the conference on HIV and drug use. The Harm Reduction and Drug Policy networking zone in the Global Village, organised by Harm Reduction Coalition was definitely a highlight and enabled the holding of many important sessions that did not get into the main programme. These included the launch of the Global State of Harm Reduction report by Harm Reduction International and an overview of the Community Action on Harm Reduction project, among others.

Within the main programme, one of the most compelling speeches was made by Debbie McMillan in the Thursday plenary entitled ‘Making Waves: The Changing Tide of HIV and Drug Use’. Debbie highlighted the multi-faceted and complex relationship between criminalisation and vulnerability to HIV – sex work, drug use, and discrimination on the basis of race, sexual identity, gender, incarceration and ultimately HIV status. Her speech encapsulates the point by President Cardoso, Helen Clark and other leaders last week, such as Michel Kazatchkine and Michel Sidibe – we must put human rights front and centre of the HIV response.

We know what to do, we know how to do it – now we just need the political courage to turn the tide.

AIDS 2012 – Time for courage if we are going to turn the tide

The Tenth Biennial International conference on Alcohol, Drugs and Society in Africa organised by the Centre for Research and Information on Substance Abuse (CRISA) is one of the few events that provide opportunities to discuss issues related to drugs and substance use in Africa. The conference, focusing on ‘Social Determinant of Substance Abuse in Africa: From Knowledge to Action’, is timely and necessary since substance use is increasing across the continent, while adequate interventions are scarce in terms of policy reform and the provision of evidence-based services.

The scientific papers presented at the conference provided insights into many social factors that influence drug use among Nigerians and other African countries. This has contributed to reducing the wide gap in sparse data on drug use in Nigeria and Africa as a whole. However, much more research is still needed to get a clear picture of the drug consumption situation in the region and understand how best to tackle the phenomenon.

One major reoccurring theme at the conference was that of drug use among young people. As a member of Youth RISE, a youth-led international network established to reduce the risks and harms associated with substance use and drug policy amongst young people, this was of particular interest for me. Young people are often most affected by drug use, but also by badly designed drug policies and programmes. They are also particularly subject to stigma and discrimination, which tends to drive them away from life-saving harm reduction and evidence-based drug treatment services services, when those actually exist.

Another element which strikes me from the conference is the need for much more collaboration between academics/researchers, policy makers and civil society organisations from the region. This is crucial if we want to move from knowledge to action – while research in the region is necessary to learn more about the drug use situation and related harms, civil society organisations can engage with the government and provide services that will seek to reduce these harms. Unfortunately, such a dialogue space is currently absent in Nigeria. Although this conference was an interesting, and important, step in the good direction, much more is needed if we want drug policies to truly respond to drug use and its related harms among young people and the whole of society.

Drug policy in Africa: Perspectives from the CRISA Conference

Today, there is overwhelming evidence that harm reduction and evidence-based drug dependence treatment are highly effective interventions in reducing drug-related harms. Despite the evidence, certain governments continue to promote punishment as the main response to drug use. This is the case in many Asian countries where compulsory centres for drug users continue to be used as the primary response to drug use. These centres are often run by law enforcement officials instead of health and social workers, and “treatment” generally consists of beatings, humiliations, starvation and forced labour.

Many NGOs and UN officials from around the world advocate strongly for the closure of these centres. This is the case, for example, in a recent join statement from UN agencies on the issue.

Nepal is one of the countries where compulsory centres for drug users are common practice. In Kathmandu, the capital of the country, there are more than fifty such centres. Whereas some of these centres offer friendly treatment services for people who use drugs, most of them use ill treatment and torture practices in the name of drug treatment.

The first rehabilitation centre to have adopted such an arrest & punishment approach to drug dependence is called Narconon Nepal, and is run by former police officers. Other rehabilitation centres are run by “recovering dependent users”. It is common practice in Nepal for people who use drugs (including those going to harm reduction services) to be forcibly picked up by rehab outreach workers. Most of the time, these workers do so in collaboration with the local police. Once in the centres, the main rationale is that of “no pain, no gain” when users undergo “treatment” – this involves beatings and other ill treatment, while high fees are being charged to users and their family upon entry in the centres. These agencies work in close collaboration with the police and the Ministry of Home Affairs to make society “drug free”.

The reach that these centres have on the media is equally worrying, as their main message consists of demonising users and harm reduction interventions. This can have a very negative effect on the Nepalese population in terms of knowledge on drug use and reducing drug-related harms, and further stigmatises people who use drugs in the country.

It is high time that Nepal changes its policy on drug dependence treatment to ensure that services are based on global evidence and human rights.

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