Decolonizing drug policy

Considering the official figure on drug-related deaths in Austria, the problem of substance abuse has dramatically worsened over the last years. There is a distinct lack of comprehensive information concerning drug-related deaths in Austria, although deaths of drug users may be potentially important indicators of the extent of drug-related problems in the population. The results of examinations performed on 372 deceased substance abusers at the Institute of Forensic Medicine in Vienna between 1985 and 1992 are presented. Drug-related deaths are defined according to the official definition issued by the Austrian Federal Ministry of Internal Affairs. A distinction was made between injecting drug users and non-injecting drug users with respect to infectious diseases transmitted by sharing of paraphernalia. Between 1985 and 1992 there was a distinct increase in drug-related deaths. In approximately 30% an accidental single substance intoxication, mainly due to morphine, was found. A connection with a better quality of street drugs is assumed but not proven. In 207 corpses more than one drug, including alcohol, was detected. During the investigation there was an evident trend towards multi-substance abuse patterns. Furthermore, blood alcohol concentration, an additional risk factor for narcotic overdose, was strongly associated with higher age. The small number of examined drug injectors found positive for the human immunodeficiency virus type-1 (HIV-1) makes it difficult to draw any kind of conclusion regarding the HIV-I seroprevalence among injecting drug users in Vienna.

The USA ranks last in life expectancy among high-income countries. Since 2000, excess US mortality has been particularly concentrated in the working ages, which are also the ages hardest hit by the increase in drug deaths. This study measures the effect of drug-related mortality on the gap in life expectancy between the USA and other countries. Data from the Human Mortality Database and the World Health Organization were combined to construct age-standardized mortality rates for 2000-14 in 12 high-income countries and the USA for seven broad causes of death, including drug use. The contribution of each cause to the difference in life expectancy between the USA and the other 12 countries was estimated. In 2014, the increase in drug-related deaths accounted for 10-15% of the US disadvantage in mortality, but with marked differences by age group. For working-age men, the increase in drug-related deaths accounted for up to 38% of the difference. Overall, American mortality is higher than the comparison countries across a wide range of causes. The severity of the drug epidemic appears to be specific to the USA, but it only partly contributes to the American shortfall in mortality.

The opioid epidemic unfolded in three distinct waves, with the latest comprising of deaths attributed to illegally manufactured synthetic opioids. We discuss evidence for a 'silent epidemic' alongside the opioid epidemic comprising co-ingestion of stimulants including methamphetamine and cocaine. Data regarding opioid- and stimulant-use trends (specifically methamphetamine and cocaine) were collected from the National Institute on Drug Abuse (NIDA) (1999–2021) in the United States for unintentional and intentional deaths. For Canada, opioid- (2016–2022) and stimulant-use (2018–2022) trends for unintentional and intentional deaths were collected from the Public Health Agency of Canada and the Alberta Substance Use Surveillance System. Joinpoint regression analysis was used to investigate trends for opioid and stimulant use in the United States and Canada. As a proxy for public interest in opioid- and stimulant-related trends, Google Trends Relative Search Interest (RSI) was used to measure the interest over time (2004-present) for opioid- and stimulant-related search terms. Spearman's non-parametric correlation was used to measure the relationship between the RSI and drug-related deaths. Although public attention is mostly directed at the opioid epidemic, stimulant-use is increasing year over year. Moreover, the use of stimulants and opioids together is associated with a higher rate of increase in drug-related deaths each year compared to stimulants or opioids alone. Despite the importance of the potential stimulant contribution to opioid-involved deaths, Google Trends RSI revealed public interest in stimulants has dropped from a peak value in 2004–2005, whereas relative interest in opioids is relatively much higher on Google in comparison to the interest in stimulants. Given the contribution of stimulants to the ongoing drug poisoning crisis there is an urgent need to develop and implement strategies that reduce the health risks associated with stimulant use. To achieve this, we must raise awareness among clinicians, policymakers and the general public regarding the potential impacts of stimulant use, including deliberate and unaware co-use of stimulants and opioids, on drug poisoning deaths, population health and the healthcare system.

BackgroundPrison settings have been neglected in the growing literature on drug-related deaths. This paper explores policy and practice issues regarding the governance of drug-related deaths in prisons in England and Wales from 2015-2021. MethodsThematic documentary analysis was conducted on national level policy documents published between 2015-2021 (e.g. drug strategies, prison policy documents, Her Majesty's Inspectorate of Prisons and Prison and Probation Ombudsman (PPO) annual reports and guidance for staff). At the local (prison) level, all of the PPO fatal investigation reports and their associated action plans relating to 171 drug-related deaths from 2015-2021 were analysed thematically. Various modes of governance were identified using Head's ‘wicked problems’ conceptual framework including avoidance and denial, coercive controls, compartmentalised micro-management, incremental and pragmatic adjustment and technocratic problem-solving. ResultsThere was strong evidence of the dominance of denial of the problem of drug-related deaths, coercive controls, micro-management and reliance on technological solutions in the early years (2015-2018). In some prisons, there developed a move towards the adoption of more pragmatic and incremental policies and push towards comprehensive policies over time. In others, remnants of denial and coercion remained. In our analysis, the focus on new psychoactive substances came to dominate attention, to the relative neglect of other substances and of the contribution of mental and physical illness to these deaths. Staff are not equipped, supported or resourced adequately to deal with the two ‘wicked problems’ of increasing rates of drug use and mental illness which collide in the prison setting. ConclusionThe PPO investigations repeatedly recommend reducing supply and improving monitoring and surveillance and the emergency response. There is less focus on prevention and reducing demand or improving the wider environmental context and culture in which the deaths occur. Policy needs to pay more attention to the fundamental issues driving the current deterioration in conditions in prisons.

Studies have demonstrated that autopsy is the gold standard for determining cause and manner of death. Indeed, the current National Association of Medical Examiners standard B3.7 states that a forensic pathologist (FP) shall perform a forensic autopsy when the death is by apparent intoxication by alcohol, drugs, or poison. Unfortunately, the recent increase in drug-related deaths has led to some question about the feasibility of maintaining compliance with standard B3.7. We constructed a voluntary survey to address consensus on standard B3.7 and the use of supervised accredited pathologists' assistants (PAs) in performing select medicolegal autopsies. Additional questions were included to help characterize variables related to FP's workload and experience. Each of these variables was predicted to influence FP's attitudes toward B3.7 and the use of PAs. Our respondent pool (n = 107) consisted primarily of actively practicing FPs with administrative responsibilities (42%) and actively practicing FPs without administrative responsibilities (41%). Sixty-five percent agreed that standard B3.7 is appropriate. Opinion on the use of PAs was split between those who agreed (45%) and those who did not (44%). Tendency to agree with either B3.7 or the use of PAs was not a function of FP's individual or office workload; however, respondents were more likely to agree with B3.7 if they previously experienced a case where internal autopsy findings radically altered diagnosis in an otherwise suggestive overdose case (P < 0.001). In certain offices and under certain conditions, the use of PAs may be one solution to ensuring all potential overdose deaths receive an autopsy.

BACKGROUND: People who use heroin and crack cocaine today are older than in the past. The main causes of illness and death are shifting from infections and drug poisoning (the main health issues in this population in the 1980s and 1990s) to respiratory, cardiovascular, and other non-communicable diseases. Qualitative research has identified barriers to treatment of these conditions. However, research remains focused on preventing crime, drug overdoses, and transmission of blood-borne viruses. This thesis aims to understand the physical health needs of this population, with a focus on people using heroin and crack cocaine in England, and provide recommendations for more accessible healthcare. METHODS: The thesis includes: (a) literature reviews relating to frequency of healthcare utilisation, access to healthcare for physical health problems, and interventions that aim to improve physical healthcare; (b) a qualitative study of clinicians working in community drug and alcohol services to understand how they perceive their role in physical healthcare; (c) a study of causes of death among people who use illicit opioids; (d) a case study of the burden and treatment of chronic obstructive pulmonary disease (COPD) among people who use illicit opioids. RESULTS: The literature reviews found limited research into access to physical healthcare for people who use illicit drugs, or the effectiveness of interventions that aim to improve healthcare for this population. Existing studies focused on cancer screening participation in the United States, finding that illicit drug use was associated with lower uptake. The qualitative study found that clinicians working in community drug and alcohol services in the UK often take a ‘health advocate’ approach to help their clients get appointments with GPs and other health services. However, participants reported limited success, and many referrals end in non-attendance. Although participants said they were often the first point of contact for a wide range of health problems, they did not have the resources to respond to these needs and felt isolated from other health services. The study of mortality found that illicit opioid use was associated with greater risk of all causes of death, including respiratory diseases, cancers, cardiovascular diseases, infections, liver disease, and accidents. While the highest relative mortality risks were associated with drug poisoning and viral hepatitis, more excess deaths were caused by physical non-communicable diseases. At a population level, the increasing average age of people using drugs explains an increase in deaths due to non-communicable diseases, but not the recent increase in drug-related deaths. The case study of COPD found that a history of illicit opioids was associated with more severe disease at diagnosis, approximately double the risk of adverse outcomes such as acute exacerbations, but similar probability of treatments such as COPD-specific medications, immunisation against respiratory infections, and smoking cessation support. CONCLUSION: The health needs of people who use heroin and crack cocaine are shifting toward physical non-communicable diseases. Services that support people who use heroin and crack cocaine are not equipped for this. The case study of COPD suggests that COPD-related inequalities are likely to be driven by exposures before diagnosis and later diagnosis, rather than access to care after diagnosis. This shows the need for more accessible primary care for this population and investment in primary prevention such as smoking cessation. FUNDING: National Institute for Health Research

The paper outlines the nature and extent of illegal drug use in Scotland. The paper provides a detailed discussion of the impact of HIV among injecting drug users in Scotland. It is shown that although HIV remains a major public health concern within parts of Scotland, most notably in Edinburgh and Dundee, HIV infection remains low elsewhere within Scotland. Although concern in relation to HIV has receded in light of the continuing low prevalence, there has been growing concern over the marked increase in drug-related deaths among drug users within parts of Scotland. Within the policy sphere greater attention is now being given to topic of drug prevention and the impact of drug use on community well being.

Shaping drug policy in Poland

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.

This article explores the impact of the current drug policy on women in the US and ways to move drug policy forward in a gender-responsive way. It examines the two competing, incompatible perspectives on addiction: “health” or “moral weakness”. Due to a historical policy alignment with the “moral weakness” perspective, the current drug policies adversely affect a woman’s ability to receive evidence-based care and parent their children.

The basic aim of a drug policy is to ensure that effective and safe drugs of good quality are available to cover the health needs of a country. A national drug policy should be considered an integral part of any comprehensive health-care policy. The formulation of national drug policies varies even between similar countries because of conflicting interests and different political, economic, and social pressures. It is influenced by such factors as:the health situation of the country;the medical care system;the education and training of health personnel;the social security and health-insurance schemes;drug research and development possibilities;the domestic production of drugs;the determination of the demand for drugs;the system of drug distribution;the possibilities for evaluation and control of drugs; andinternational policies on medicinal products.

Harm reduction has since the late 80s gradually been part of Norwegian drug policy, challenging original working strategies for police in open drug scenes; places with extensive public trade and use of illegal drugs. This study addresses the research questions: What characterizes police work in open drug scenes in Oslo? How do the police solve the practical challenges of working within a ‘dual-track policy’ combining harm-reducing and punitive approaches? This historical analysis of police approaches to open drug scenes concerns the years 1993–2015. The open drug scene has moved continuously within a limited area around the Central train Station. The study uses data from newspaper articles, semi-structured interviews of responsible police in the area and public action plans by the Municipality of Oslo. Police strategies in Oslo’s drug scenes have changed from strictly punitive to a mixture of harm-reducing and punitive efforts. The police change back and forth between these strategies, and within the same time period they sometimes engage in both. Within the current drug policy, the dilemmas of practical police work persist, as inhabitants of the drug scene perform numerous criminal acts and simultaneously are in need of care.

Drug strategies in Great Britain emphasize the notion of recovery, with the concept being central in England, Wales and Scotland. There are however tensions, with recovery being defined differently across jurisdictions. In this study we address this dilemma by critically interrogating how the term recovery is represented, how these presentations are shaped and what effects are subsequently had. We applied an adapted version of Bacchi's What's the Problem Represented to Be? (WPR) policy analysis approach to the 2017 UK Drug Strategy, the 2008–2018 Welsh Drug Strategy and the 2008 Scottish Drug Strategy notions of service user responsibility; (b) recovery as ‘a problem of product quality’, shaped by the implicit notion of service provider responsibility and the disease model of addiction; (c) recovery as ‘a problem of service collaboration and teamwork’, underpinned by the bio-psycho-social model of addiction. We conclude that the problematisations found in GB’s current drug policies have the ability to shape the drug policy-making process which may limit mainstream knowledge of recovery, and thereby unintentionally contribute to a narrow understanding of how to effectively support the service user community in their recovery from problematic drug use.

Police attitudes towards pre-booking diversion in Baltimore, Maryland

This volume is part of the response to the 2016 UN General Assembly Special Session (UNGASS) on international drug policy and the emergence of analysis of international drug policy in academic literature. Editors David Bewley-Taylor and Khalid Tinasti, both respected authors in their own right, have collated a rich collection of essays and chapters from a welcomely international list of academic and specialist authors, with significant representation from non-Anglophone and non-Western countries. They have selected authors to provide an analytical critique of international drug policy, evidencing their stance of challenging "official" literature on the topic. The editors describe current policy as being "a predominantly supply oriented approach based on prohibition and a reliance on law enforcement, and in some cases military, interventions". Organised in four parts - "History of international drug control", "The geospatial dimensions of drug policy" (chapters cover the Americas, Africa, Muslim nations, Asia, Oceania and Europe), "Emerging tensions within the UN drug control system and beyond", and "Future challenges" - the variety of authorial backgrounds provides a correspondingly rich collection of themes, regions, countries and political processes, extending the debate on international drug policy and the workings and failings of the UN Conventions. Themes include the origins of international drug policy, access to essential medicines, human rights, the growth of alternative policy and practice and the implicit disregard of the orthodoxy this represents, the emergence of novel psychoactive substances and responses to them, crypto-markets, metrics and the use of international drug policy by some nations as a disguise or justification for internal repression. The editors posit that contradictions and disagreements amongst the international community and international agencies are pulling the "consensus" in different directions, reform versus prohibition, revealing the lack of reality (and success) in the Conventions' terminology of a drug-free world and societies free of drug abuse and the damaging and destructive impact of the policies and practices which operate under their umbrella. The chapters are the results of research, many portraying geographies and themes that are themselves the result of research and field-work, which will not be welcomed by some regimes. The book is not, though, a handbook of research methodologies: the closest it comes to being so is Measham's chapter on novel psychoactive substances (NPS), describing research practices which have been developed to determine the prevalence of NPS and the chemicals involved in them. This does not detract from the overall breadth and richness of the contents. Nor is it the "first comprehensive overview ... of the drug policy landscape", as the editors suggest, having been preceded byKlein and Stothard's 2018 collection, to which both editors contributed chapters.