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This submission provides valuable inputs ahead of the OHCHR analytical study on key challenges in ensuring access to medicines, vaccines and other health products, pursuant to resolution 53/13. Addressing the barriers faced by persons or groups in situations of vulnerability or marginalization in accessing medicines, vaccines and other health products, this submission will focus on access to harm reduction as an essential element of the right to the highest attainable standard of health; and on the main challenges experienced by people who use drugs in accessing essential harm-reduction medicines and other health services.
Barriers to accessing controlled medicines for pain relief
Universal and equitable access to harm reduction is an essential component of the right to the highest attainable standard of health for people who use drugs both in the community and in detention settings; from which States’ obligations derive, specifically ensuring availability, accessibility, acceptability and quality of harm reduction services. In March 2023, the need to ensure access to harm reduction services was recognised by the Human Rights Council in resolution 52/24, and the recent High Commissioner report on human right challenges in addressing the world drug problem includes harm reduction as a key strategy for a human right approach to drugs use and policies. The World Health Organization (WHO) also recognises harm reduction as an effective life-saving strategy, recognising morphine, methadone and buprenorphine -drugs commonly used to treat opioid dependence – in the list of Essential Medicine Programme.
These and other drugs on the list, such as antiretroviral drugs, are also essential for the treatment of HIV, HCV, and TB, and for pain management and relief. As stated by the OHCHR’s recent report on human right challenges in addressing the world drug problem, affordable access to and adequate availability of internationally controlled essential medicines for palliative care, cancer treatment and drug dependency, and other treatments, also constitute core minimum obligations of the right to health. However, as some are classified as “controlled substances” under the international drug conventions, their availability for medical purposes is often excessively limited or restricted despite there being no basis for this in international law. More than 80 per cent of the world’s population, living mainly in low- and lower-middle-income countries, have no access to internationally controlled essential medicines to address serious health related suffering associated with severe pain, palliative care needs, treatment of substance use disorder, and other conditions. Lack of training of the health workforce, unduly restrictive regulations, and “fear of addiction” are the main impediments to opioid availability.
Criminalisation as a barrier for harm reduction
People who use drugs continue to face criminalisation, stigma and discrimination that prevents access to services. Although over 36 countries have removed criminal sanctions for drug possession for personal use, punitive responses to drugs remain a key contributing factor to prison overcrowding, with drug offences accounting for 22% of the global prison population. Contrary to global trends towards abolition of the death penalty, as of 2022, 35 countries still retain the death penalty for drug offences, with 285 people executed which represents and 118% increase from 2021 and an 850% increase from 2020. Additionally, 303 people sentenced to death and more than 3000 currently in death row for drug offences worldwide.
Criminalisation of drug paraphernalia
In 2018, UNAIDS reported that in ten countries, the mere “possession of a needle or syringe without a prescription could be used as evidence of drug use or cause for arrest.” One example is that of the United Kingdom, where it is a criminal offence to supply or offer an object for providing or preparing controlled drugs, including “crack pipes”, “grinders”, and “spoons”, among others. Despite safer smoke kits being essential harm reduction equipment, both for engaging people who use stimulants with harm reduction services and reducing transmission risks for HIV, hepatitis C and tuberculosis, its distribution is illegal in the country. The only exemption is aluminium foil, which is the only harm reduction equipment that is distributed for smoking. Russian national policy explicitly mentions the introduction of measures to ban substitution therapy programmes, prevent “legalisation of drugs”, and “unjustified expansion of the use of narcotic analgesics” for pain relief. As such, the provision of OAT is prohibited, to the detriment of the health of people who use drugs. As a part of the implementation of the new drug policy strategy-2030, the distribution of “drug propaganda” (including online) is illegal in the country. The very concept of “drug propaganda” is very vague and can be used to prosecute not only organisations providing harm reduction services, but also independent media, as well as writers and musicians, making it hard to inform on safe drug use. Notably, according to HIV Justice Worldwide, Eastern Europe and Central Asia has the second highest number of laws criminalising HIV exposure, non-disclosure and transmission, with Belarus, Russia and Uzbekistan having particularly high numbers of criminal cases related to these laws. Similarly, according to UNAIDS, as of 2022, at least 21 countries’ policies exclude people who use drugs from receiving anti-retroviral treatment (ART), despite the lack of any health justification for it.
Strict and exclusionary regulations
Another structural challenge to access to harm reduction services are strict and exclusionary accessibility rules rooted in overly medicalised approaches to harm reduction. In some Eurasian countries, for example, enrolment in a programme is only allowed with a psychiatrist’s or other supporting documentation and a government-issued identity document, which in some cases, such as in North Macedonia, involves registering a residential address. This is an often-insurmountable barrier for people who use drugs belonging to already marginalised groups (such as homeless and Roma individuals) and in contexts where widespread discrimination and stigma in healthcare settings discourage people from disclosing their drug use. Similarly, in countries such as Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Moldova, Tajikistan, and Ukraine, to enrol on OAT or other drug dependence treatment, people need to register in a “drug user register”. However, such registration can limit access to jobs and studies and may have repercussions on the custody of children. In Belarus, for example, children are deemed to be in a ‘socially dangerous situation’ if they are parented by a woman who either uses drugs or is on OAT. In this case a mark is put in the parent’s passport and medical records, increasing stigma, discrimination and further perpetuates sexist drug policy; and the woman risks losing custody of the child.
Furthermore, certain populations experience these barriers particularly acutely, most notably, women, LGBTQI+ people, people who are migrants or refugees, young people, and Black, Brown, and Indigenous people, who experience compounding forms of discrimination and lack tailored services to meet their needs. The latest systematic review on injecting drug use and harm, and exposure to behavioural and environmental risks among people who inject drugs reported that 25% of people who inject drugs globally had experienced recent homelessness or unstable housing, close to 60% had a history of incarceration, and 14,9% had recently engaged in sex work. Additionally, direct and structural racism leads to Black, Brown and Indigenous people having less access to harm reduction services. This is mainly due to Black, Brown, and indigenous communities being targeted by drug law enforcement agencies and disproportionately detained or imprisoned.
In line with international human rights obligations that bind States to provide harm reduction services and essential medicines for all population, and following the information provided through this submission we encourage the OHCHR to recommend Member States to:
Guarantee equitable access to harm reduction and essential medicines for all population;
Eliminate all legal and policy barriers and stigmatising and discriminatory practices that limit the access to harm reduction and essential medicines for people who use drugs, including through the decriminalisation of drug use, drug possession and drug paraphernalia;
Maintain disaggregated data about distribution of harm reduction and essential medicines;