BACKGROUND:Since 2015, the risks of dying due to drug-related causes are higher in prison than in the general population, with opiates and psychoactive substances being the most common substances recorded on death certificates in prison. Many individuals use drugs before entering the prison environment, it is not clear which individuals continue to use drugs while in prison. This study is a first step towards identifying characteristics of those who use drugs in prison, while exploring substances commonly used. METHODS:This retrospective cross-sectional analysis was performed on 299 men (mean age 38 years [SD 11]) in a long-stay UK prison in South Wales who participated in a research study exploring cardiometabolic risk in prison, in which substance misuse was included as a risk variable. All men aged 25 years or older with no previous diagnosis of cardiometabolic illness were eligible to participate. Data were collected between Oct 7 and Oct 23, 2019. Participants were asked details about their substance use before and since entering the prison. Mental wellbeing was assessed using the short Warwick Edinburgh Mental Wellbeing Score and low mental wellbeing calculated as 1 SD below the population mean score. To examine associations between characteristics (age groups, mental wellbeing, exposure to prison environment) and drug use, we used binary logistic regression (adjusted for characteristics such as age group, mental wellbeing, and exposure to prison environment ). FINDINGS:Overall, 195 (65%) of 299 participants reported a history of drug use before entering prison. Since entering prison 49 (16%) participants reported using drugs including methadone, and 24 (8%) reported using drugs excluding methadone. The next leading substances used in prison were spice (11 [4%] participants) and cannabis (six [2%] participants). All those who used drugs in prison had a history of drug use. Individuals more likely to continue using drugs in prison were aged 39 years and younger (adjusted odds ratio [aOR] 4·72, 95% CI 1·88-11·89; p=0·0009), with reported low mental wellbeing (3·38, 1·54-7·41; p=0·002), and had spent collectively more than 2·5 years in the prison environment (4·77, 2·09-10·91; p=0·0002). INTERPRETATION:This study, from a limited sample, describes the characteristics of those who use drugs in prison. Harm reduction interventions targeted to these individuals could reduce the risk of prison drug-related deaths. These findings should be interpreted with some caution, as this is a single site and may not reflect the wider UK prison environment. FUNDING:Public Health Wales.

Harm reduction has become increasingly influential in drug policy and practice, but has developed primarily around adult drug use. Theoretical, practical, ethical and legal issues pertaining to children and adolescents under the age of majority - both relating to their own use and the effects of drug use among parents or within the family - are less clear. This commentary proposes a sub-field of drug policy at the intersection of harm reduction and childhood which we refer to as 'child-centred harm reduction'. We provide a definition and conceptual model, as well as illustrative questions that emerge through a child-centred harm reduction lens. Many people in different countries are already working on these kinds of issues, whose work needs greater recognition, analysis and support. In beginning to name and define this sub-field we hope to improve this situation, and inspire further international debate, collaboration, and innovation.

This is the first detailed examination of compulsory detention for ‘drug treatment’ through the lens of a rapidly evolving international legal framework. It is estimated that as many as half a million people worldwide are detained for the purpose of ‘drug treatment’, many held for months or years at a time without being charged criminally or being able to challenge the legality of their detention. This is therefore a key issue sitting at the intersection of human rights, drug policy and medical ethics. The article explores arbitrary detention and involuntary committal on medical grounds within international human rights law, as well as the historical-legal evolution of drug ‘treatment’ as the term is understood within international drug control law. It assesses whether drug use or drug dependency constitute a reasonable limitation of the right to liberty, and concludes that this type of detention represents a violation of international law.

This chapter examines the engagement and progress on human rights by the United Nations drug control regime from 2008 to 2018 through a comparative qualitative assessment of the official work of four principle political and normative institutions: the Commission on Narcotic Drugs, the International Narcotics Control Board, the Human Rights Council and the UN human rights treaty bodies. Breaking this ten year period into three distinct stages, and using the 2016 UNGASS as a benchmark, this chapter demonstrates how human rights and drug policy has achieved significant attention within these institutions, and provides a summary interpretation of these official records that can enable scholars, policymakers, and other students to better understand how this issue has evolved across each fora.

Background This study examines the use of new psychoactive substances (NPS) and the harm reduction response in six Eurasian countries: Belarus, Moldova, Serbia, Kazakhstan, Kyrgyzstan, and Georgia. The aim is to identify current patterns of NPS use and related harms in each country through recording the perspectives and lived experience of people who use drugs and people who provide harm reduction services in order to inform the harm reduction response. Methodology The study involved desk-based research and semi-structured interviews/focus groups with 124 people who use drugs and 55 health and harm reduction service providers across the six countries. Results People who use drugs in all countries were aware of NPS, primarily synthetic cathinones and synthetic cannabinoids. NPS users generally reflected two groups: those with no prior history of illicit drug use (typically younger people) and those who used NPS on an occasional or regular basis due to the lack of availability of their preferred drug (primarily opiates). In many cases, these respondents reported they would not use NPS if traditional opiates were available. Common factors for choosing NPS included cost and accessibility. Respondents in most countries described NPS markets that use the DarkNet and social media for communication, secretive methods of payment and hidden collection points. A recurring theme was the role of punitive drug policies in driving NPS use and related harms. Respondents in all countries agreed that current harm reduction services were important but needed to be enhanced and expanded in the context of NPS. Conclusions The study identified patterns and drivers of NPS use, risk behaviours and drug-related harms. It identified gaps in the current harm reduction response, particularly the needs of non-injectors and overdose response, as well as the harmful effects of punitive drug policies. These findings may inform and improve current harm reduction services to meet the needs of people who use NPS.

This chapter discusses protections of the health-related rights of prisoners that are encoded in widely ratified human rights instruments and in guidelines for which there is broad international consensus. People who use drugs while detained or incarcerated, however, rarely enjoy the standard of care to which they are entitled, which includes HIV prevention activities and other services that are available in the community. In some countries, people accused of minor drug infractions may be detained for long periods in centers that purport to provide treatment for drug dependence but are effectively labor camps that do not provide health care and where “patients” face physical abuse and denial of due process. There is an urgent need to establish and scale up health services for people who use drugs in custodial environments, with independent monitoring of the existence and quality of care and measures to ensure that health professionals working with people who use drugs in prison and pre-trial detention can work without interference. More important, however, drug dependence and minor drug infractions that often accompany it should be managed through health and social services rather than criminal sanctions. Reducing the use of prison and pretrial detention as a response to drug use and minor possession may be the most important measure for respecting, protecting and fulfilling the health-related rights of people who use drugs. Compulsory “treatment” centers should be closed in favor of humane care provided in the community.

Treaty interpretation has long been a subject of interest for international legal scholars. However, it is only recently that advocates for drug policy reform have taken up these questions. This article examines the proposition put forward by several authors that a legally regulated market in cannabis may be permissible under the international drug control treaties if considered as a policy ‘experiment’. These authors contend that such measures conform to the general obligation of the Single Convention on Narcotic Drugs to limit uses of cannabis ‘strictly to medical and scientific purposes’. Reviewing this position using the formal methods set out in Articles 31 and 32 of the Vienna Convention on the Law of Treaties, we conclude the interpretation proposed is untenable. While we share with these authors the objective of wider drug policy reform, we find the arguments supporting this position weak, and based on absent, flawed or incomplete interpretive methodology.

The intersection between drug control and the death penalty represents a key nexus for human rights and drug reform advocacy and constitutes one of the most visible examples of the link between abusive law enforcement and drug control in the current period. The issue has emerged as a flashpoint of international debates on drugs and is one that raises important questions and challenges for both 'abolitionist' countries that oppose the death penalty and 'retentionist' States that continue to execute people. The death penalty for drug offences cannot be dismissed as simply an internal matter for States. Not only do executions for drug offences violate significant international human rights legal protections, domestic capital punishment laws in many cases cannot be separated from the influence of the international drug control treaty regime. This chapter will explore the question of the death penalty for drug offences and the challenges it presents for the international drug control regime more broadly.(1)

Multilateral treaties on drug control predate the foundation of international human rights law by several decades. Over the last half-century, these two legal systems have exerted significant influence on state practice. Today, the impact of human rights norms can be seen in policy areas as disparate as warfare, terrorism, trade, intellectual property, the environment, and global health, while the three UN drug conventions influence domestic drug control policy and law in almost every country of the world. However, the two systems are in a position of tension. The human rights impacts of drug control are vast, spanning all regions of the world, engaging the full spectrum of civil, political, economic, social, and cultural rights, and affecting the health and welfare of people and communities, whether they have any involvement in the drug trade or not. International drug control law, meanwhile, has evolved largely absent any normative guidance that may be offered by human rights law. This commentary sets out a case for 'international guidelines on human rights and drug control', a project being spearheaded by the International Centre on Human Rights and Drug Policy and the UN Development Program in collaboration with the Canadian HIV/AIDS Legal Network and other NGO partners.

HIV, hepatitis C virus (HCV), and TB in prisons and other places of detention are serious public health concerns, with prevalence and incidence considerably higher than in the general community because of the overrepresentation of risky behavior, substandard conditions, overcrowding, people who inject drugs, and the wholly inadequate prevention, care, and treatment of these conditions, including the denial of harm reduction services. This is not only a severe public health crisis but also a serious human rights concern. This article works to clarify the standards established by human rights law with regards to HIV, HCV, TB, and harm reduction in prisons by examining international and regional case law, minimum standards on the treatment of prisoners and public health, as well as the work of UN treaty bodies, Special Rapporteurs, and prison monitoring bodies. It is imperative that urgent steps are taken to close the gap between human rights and public health standards on the one hand, and effective implementation in prison settings on the other.

Worldwide, a disproportionate burden of HIV, tuberculosis, and hepatitis is present among current and former prisoners. This problem results from laws, policies, and policing practices that unjustly and discriminatorily detain individuals and fail to ensure continuity of prevention, care, and treatment upon detention, throughout imprisonment, and upon release. These government actions, and the failure to ensure humane prison conditions, constitute violations of human rights to be free of discrimination and cruel and inhuman treatment, to due process of law, and to health. Although interventions to prevent and treat HIV, tuberculosis, hepatitis, and drug dependence have proven successful in prisons and are required by international law, they commonly are not available. Prison health services are often not governed by ministries responsible for national public health programmes, and prison officials are often unwilling to implement effective prevention measures such as needle exchange, condom distribution, and opioid substitution therapy in custodial settings, often based on mistaken ideas about their incompatibility with prison security. In nearly all countries, prisoners face stigma and social marginalisation upon release and frequently are unable to access health and social support services. Reforms in criminal law, policing practices, and justice systems to reduce imprisonment, reforms in the organisation and management of prisons and their health services, and greater investment of resources are needed.

As Member States gather at the UN General Assembly Special Session (UNGASS) in April 2016, they will discuss strategies for the next 10 years of global drug policy which may inform the high-level meeting on HIV/AIDS in June around declarations for ending the AIDS epidemic by 2030 [1]. At this time, we reflect on how much harm reduction has achieved despite punitive drug policy and legal environments prioritized by most of the world's governments. A recent Lancet Commission on public health and international drug policy implores the world to move away from a war on drugs and to put health at the centre of revolutionizing drug policy [2]. Over the past decade, harm reduction has been proven time and again, across varying countries, regions, social and cultural settings, to be a highly effective HIV prevention measure, a cost-effective set of interventions, and an approach promoting the human rights and dignity of a marginalized and criminalized community. Its adoption in policy and practice has slowly but steadily increased. Today, the majority of the 158 countries with documented injecting drug use have adopted harm reduction measures to some degree in domestic policy and practice: 91 countries allow for harm reduction in national policy documents, 90 have at least one needle-syringe programme (NSP) and 80 countries provide opioid substitution therapy (OST)—an increase of 17 since this monitoring began [3]. Where harm reduction programmes have had adequate financing and the legal and policy space to flourish, the impact has been dramatic. This has been observed among early harm reduction pioneers, as well as in countries to more recently adopt harm reduction. Across Western Europe, there have been low rates of new HIV infections among people who inject drugs (PWID) due to the wide implementation and success of harm reduction policies and services. There and across numerous other settings, regardless of country income status, there is clear evidence that harm reduction implementation is cost-effective [4,5]. As this evidence has mounted, so too has the endorsement of harm reduction from multilateral agencies such as the World Health Organization, UNAIDS and UNODC [6]. By contrast, there have been recent increases in HIV incidence in settings where there have been low and/or reduced access to harm reduction services, such as in Greece, Romania, Pakistan, India, Thailand and the Philippines [7–10]. The clear public health and economic case for harm reduction is further strengthened by steadfast backing from UN human rights mechanisms. Multiple UN human rights bodies now call on governments to implement harm reduction programmes as part of fulfilling the right to the highest attainable standard of physical and mental health, the right to benefit from scientific progress and its applications, and, in places of detention, to freedom from cruel or degrading treatment or punishment. This includes calls for ending compulsory drug detention [11–13]. With this UNGASS comes unequivocal recognition that the global drug policy regime has not achieved the aims previously set [14]. Drug use has not been reduced. Instead, hundreds of billions of US dollars [15] have been misspent on useless and, in many cases, harmful approaches without an evidence or human rights base. Conversely, the potential of harm reduction in many countries has been limited by a lack of strong state support and funding. In many places, services remain small-scale and NGO-driven, not supported to the degree necessary to meet need. While available estimates of global harm reduction investment are outdated, they illustrate a dire situation which will only worsen as donor funds shift away from middle-income countries. At last count, only 7% of the estimated US$2.3 billion required for harm reduction in 2015 was available from international donors [16]. It is clear that funding for these programmes is in crisis. The world has missed the UN target of halving HIV among PWID by 2015 by a staggering 80%, and continuing the status quo will result in a failure to meet the ambitious goal of ending AIDS by 2030. In October 2015, at the International Harm Reduction Conference, the harm reduction sector released the Kuala Lumpur Declaration [17], calling for alternative responses to drug use that are rooted in evidence, public health, human rights and dignity. The Declaration urges governments and international organizations to adopt harm reduction as a key principle of drug policy throughout the next decade, and to end punitive drug laws, human rights abuses and the mass incarceration of people who use drugs. It also proposes a global target: to redirect 10% of funding from ineffective punitive drug control activities into health and human-rights based programmes, including harm reduction (the “10 by 20” campaign). As the 2016 UNGASS on the World Drug Problem approaches, the many organizations and individuals who have signed this declaration are sending the message that the provision of harm reduction services is no longer a discretional policy option but must be understood as a core obligation of States to meet their international legal obligations under the right to health. To demonstrate potential impact, we used the Optima model [18] to contrast the minimal impact that continuing the status quo will achieve with the potential of adequately financing harm reduction if policy environments would allow for good access to services. Optima was calibrated to HIV epidemics among PWID in each world region (Asia, Eastern Europe and Central Asia, Western Europe, North America and Oceania, Latin America and the Caribbean, Middle East and North Africa, sub-Saharan Africa) and was then used with region-specific harm reduction cost estimates [4] to produce a global model of HIV among PWID. Future projections were then conducted, revealing that if even a relatively small amount of additional funding were directed into harm reduction, with removal of barriers to service access, the course currently plotted could completely change. A redirection of just 2.5% of the US$100 billion spent each year on drug control [15] could secure a 78% reduction in new HIV infections among PWID by 2030 (Figure 1a). Taking investment to 7.5% of drug control spend has even greater potential, reducing new HIV infections among PWID by a staggering 94% and reducing HIV-related deaths by similar proportions. Thus, the end of AIDS among PWID is thoroughly achievable, contingent on improved policy environments to allow the services to be utilized without harassment or criminalization. What's more, it is achievable through use of a small proportion of the resources currently being used for the target population. This shift towards harm reduction ought to be a no-brainer for governments. The lack of scaled harm reduction is largely due to poor political will that manifests as none or very limited state support. More politically palatable programs are prioritized in many countries despite lower cost-effectiveness ratios. The potential of harm reduction in these settings has not been observed because they have remained small-scale and NGO-driven, not supported to the degree necessary, and are operating despite government and police hostility. Modelled projections of the global HIV epidemic among PWID comparing the status quo with scenarios where (a) 2.5% of global resources for punitive responses to drugs was used for harm reduction and (b) 7.5% of global resources for punitive responses to drugs was used for harm reduction. Harm reduction programmes save lives, save money and help respect, protect and fulfil the human rights of people who use drugs. Now is the time to consolidate and secure the success of harm reduction and commit to making the next 10 years The Harm Reduction Decade. Catherine Cook and Rick Lines work for Harm Reduction International, a non-governmental organization working to promote and expand support for harm reduction. CC and RL wrote the first draft; DW conducted the modelling, edited the manuscript and oversaw its development.