International Society for the Study of Drug Policy (ISSDP) 2024

“Accessing and Maintaining Prescribed Safer Supply During Dual Public Health Emergencies.”

Bernie Pauly; Talk

Background/Objectives
In 2020, amidst declared dual public health emergencies (COVID 19 and toxic drug deaths), BC introduced Risk Mitigation Guidance (RMG), the first provincial safer supply initiative allowing prescribing of some categories of opioids and stimulants. We identified factors influencing access and continuity of prescriptions from the perspectives of those accessing RMG medications.

Methods:
We undertook a mixed methods study within a broader framework of community based participatory research involving people who use drugs, and informed by the Consolidated Framework for Implementation Research. Baseline and longitudinal surveys (n = 353) were conducted over the phone or in person. A subset of survey participants (n=54) completed a qualitative interview. Convergent analysis was conducted of survey and interview data to identify factors influencing access and continuity.

Results:
Within an ongoing context of criminalization of drug use, 22% of participants, who had an encounter with police, reported confiscation of prescriptions. The organizational delivery of RMG varied widely across the province creating uneven implementation and a range of diverse experiences within different settings. Experiences with pharmacies were identified as a key factor influencing the implementation process and continuity. The intervention was effective for managing withdrawal in less than half of participants, highlighting issues with medication dosages, types, and routes of administration.

Implications
These findings highlight wide variation in RMG implementation and the impacts of prohibition on implementation. Program level factors such as organizational culture in clinics and pharmacies as well as individual tailoring of the intervention are important to maintenance of a prescription.

“Adverse outcomes of cannabis use in Canada, before and after legalization of non-medical cannabis”

Anastasia Marquette; Talk

Background: Many countries are adopting permissive cannabis laws, including Canada, which legalized recreational cannabis in October 2018. To date, little evidence exists regarding the extent that cannabis legalization affects the prevalence of population-level adverse events.

Objectives: The current study examined trends in the prevalence of adverse events among people who consume cannabis before and after Canada’s legalization of recreational cannabis.

Methods: Data comes from International Cannabis Policy Study survey waves, which were conducted online prior to recreational cannabis legalization in Canada (2018), and in the three following years. Analysis included 18,285 Canadian respondents who reported cannabis use in the past 12-months. Outcomes included types of adverse events experienced from cannabis use, medical help-seeking, and types of products used. Weighted logistic regression models examined differences in help-seeking, emergency room usage, and cannabinoid hyperemesis syndrome across survey years.

Results: Approximately one-third of consumers reported at least one adverse event within the past 12-months, including 5% who sought medical help. Prevalence of seeking help and types of adverse events were similar before and after legalization; however, the proportion seeking help from emergency rooms increased post-legalization (F=2.77, p=.041). Adverse events were associated with various product types. Help-seeking associated with edibles significantly decreased post-legalization (p=.001).

Implications: A substantial proportion of consumers report adverse events, suggesting widespread ‘dosing’ difficulties. This is avoidable and may burden healthcare services. The reduced likelihood of adverse events from edibles may suggest federal product standards’ effectiveness.

“Agent-based modeling of community and jail-based take-home naloxone distribution”

Harold Pollack; Talk

Importance: Opioid overdose (OOD) accounts for more than 80,000 deaths per year in the U.S. People who use drugs leaving jails face particularly high OOD risk, and may correspondingly benefit from opt-out naloxone distribution.

Objective. To explore the population impact of opt-out naloxone distribution upon jail release to reverse OOD among people living with opioid use disorders.

Design. We use the agent-based Justice-Community Circulation Model (JCCM) to model a synthetic population of individuals with and without histories of opioid use. We examine 27 experimental scenarios to capture diverse strategies of naloxone distribution and use. We then employ sensitivity analysis to identify critical mediating and moderating variables that affect population impact and a proxy metric for cost-effectiveness—the direct costs of naloxone kits distributed per death averted..

Setting. We used epidemiological data from greater Chicago, Illinois to identify parameters pertinent to our synthetic population.

Findings. Opt-out naloxone distribution upon jail release is estimated to reduce post-release OOD mortality by more than 20%. Sensitivity analyses indicate that presence of willing and capable bystanders at OOD reversal are prominent moderators of population impact of such interventions. The costs of distributed naloxone kits are estimated to be below $30,000 per averted death in all scenarios.

Conclusions. Naloxone distribution at jail exit can reduce opioid overdose mortality. Training and preparation of proficient and willing bystanders are central factors in reaching the full potential of such interventions.

“A Looming “Replication Crisis” in Drug Policy Research: Towards Robust Standards of Legal Measurement”

Scott Burris; Talk

Background: Drug policy research is at an important methods crossroads. There has been concern but no explicit consensus about methods for properly measuring exposure to policy – typically the independent variable in any causal inference study of policy effects. Increasing availability of open-source legal data produced using transparent “policy surveillance” methods (such as PDAPS and Rand’s OPTIC data) has been positive, but studies continue to be published that do not use robust methods of legal measurement, or do not provide sufficient detail for assessing and replicated legal measurements.
Objectives: To explicitly set out basic standards for measurement of policy exposure in drug policy research.
Methods: The presentation draws on existing methods literature and the authors’ expertise.
Results: “Policy” for evaluation purposes consists of an observable law or law-like text. Research should objectively measure attributes of the text relevant to the hypothesis being tested, normally including effective date (or other theoretically relevant date such as enactment, signing or implementation), start and end dates of observation, regulated activities/specified standards, persons subject to the law, and penalties. Any categorization (such as “ “stringency”) should be conducted as a secondary operation based on the previously measured features of the text. Data should be public and be accompanied by a code book and detailed protocol describing research and quality control procedures for collecting policy texts and measuring their features.
Implications: Attention to feasible methodological standards can ensure that published drug policy research exhibits transparent, replicable and credible measurement of policy exposure.

“An Economic Framework for Analyzing Possible Effects of Prescribed Safer Supply”

Jonathan Caulkins; Talk

Background: Illegal opioids are associated with the greatest rates of death and social harm worldwide, and synthetic opioids – notably fentanyl – have contributed to very high overdose death rates in Canada and the United States over the last decade. During the COVID-19 pandemic, the Canadian province of British Columbia, which as long been a world leader in conventional harm reduction approaches, responded to this crisis by starting to provide prescribed safe supply (PSS). PSS provides the same or equivalent opioids via legal and quality-controlled channels as were being purchased illegally. For example, participants may be eligible to receive up to 14 8-mg hydromorphone pills daily, via a low-barrier approach.
Objectives: This paper lays out an economic framework for thinking through the possible intended and unintended consequences of PSS on participants, their associates, potential new initiative, and the broader market, considering potential effects on overdose, addiction, income-generating crime, diversion, and illegal supply, including cross-effects on other substances.
Methods: The unit of analysis is the market, thereby complementing the existing literature which more often takes an individual level frame. The methods are standard market models and methods, informed by review of the literatures on PSS, illegal opioid supply, market prices, and price response. One emphasis is on giving a sense of scale of the various potential effects, favorable and unintended.
Results and Implications: The work is ongoing with an expected completion date of early March 2024, so it is too soon to report results at this time, but they will be available by the time of the conference.

“An innovative harm-reduction approach to youth prevention in connection with the planned cannabis legalization in Germany”

Anke Stallwitz; Talk

In 2023, Germany decided to legalize cannabis for recreational consumption. Originally, the government intended to first legalize non-commercial cannabis cultivation in the form of home cultivation and cannabis clubs, and later commercial cannabis distribution through special dispensaries.
However, due to Germany’s obligation to comply with various international treaties, the government decided on restricted non-profit cultivation and a pilot trial of commercial supply in selected model regions from 2024.
Besides reducing the cannabis black market, German politicians cite the protection of young people from contaminated and overly potent products as the main argument for the national legalization. At the same time, the current draft law excludes under-18-year-olds. Cannabis-using 16- and 17-year-olds, who make up a significant proportion of the cannabis-using population in Germany, must thus continue to resort to the black market, with all the potential risks of illegal drug acquisition.
Appraising the international research findings on the physical and psychological risks of cannabis use for young people, a pragmatic harm reduction approach is proposed, modelled on the German alcohol policy: A strictly regulated cannabis supply system should allow 16- and 17-year-olds to acquire limited amounts of quality-tested, THC-reduced cannabis products. Before purchase, a qualified, youth-credible person must inform youths on possible consumption risks and the principles of risk-competent substance use. As part of a global paradigm shift in cannabis policy, this youth-prevention approach should be considered internationally and in relation to alcohol consumption.

“A roadmap to end Canada's overdose epidemic”

Dan Werb, Mohammad Karamouzian; Talk

Overdose mortality has become a generation-defining public health crisis in Canada but there is a lack of meaningful action to address it. We therefore need to create an evidence-based roadmap to end the overdose epidemic in Canada.

This roadmap has three key components. First, we will generate estimates of the key populations at risk of overdose (youth, tradespeople, rural populations, Indigenous communities, and people living with socioeconomic marginalization in urban centres), as well as effect sizes for interventions and policies (expressed as population preventable fractions and population attributable risks). Second, we will employ these estimates to develop simulation models describing how different policy, programmatic, and clinical intervention scale-up scenarios will decelerate, reverse, or accelerate the overdose mortality epidemic across key populations. Third, we will develop and deliver a roadmap to end Canada’s overdose epidemic to policymakers, multisectoral stakeholders, affected communities, people who use drugs, and the general public. This will link different scenarios to specific policy levers and their likely outcomes, along with measures of uncertainty, thereby providing clarity regarding what is possible, what is most likely, and how long it will take.

Canada is a leader in policy and programmatic innovation on substance use. Without a coherent national strategy to end the overdose epidemic, however, this innovation will fail to yield real gains in terms of lives saved.

“Baseline results for the experiment with a closed supply chain for recreational cannabis in the Netherlands”

Stijn Hoorens; Talk

Background. Despite tolerated sales in coffeeshops since 1970s, production of recreational cannabis has remained unregulated in the Netherlands, forcing coffeeshops to supply from illegal growers. In 2024, Netherlands will kick-off an experiment to examine whether and how quality-controlled recreational cannabis can be supplied from licensed growers to 75 participating coffeeshops in a closed supply chain in 10 cities.
Objectives: The study evaluates the experiment and monitor developments in the participating municipalities on cannabis consumption, public health, public disorder, and the illegal market.
Methods: Quasi-experimental design compares 10 municipalities (intervention group) to a control group of 10 municipalities. Mixed methods approach includes: coffeeshop visitor counts (n=1252); surveys among coffeeshop visitors (n=922) and neighbourhood residents (n=437); online survey among illegal market buyers (n=788); interviews (n=130). Baseline data about purchasing behavior, substance use, health, nuisance and illegal transactions were collected Sept’21-Aug’22.
Results: Results show relatively satisfied customers who frequent coffeeshops primarily for the atmosphere, location and high-cannabis quality. Most customers (73%) are (almost) daily cannabis users. The main reason for buying outside coffeeshops is price. Hasj and weed are cheaper on the illegal market.
Implications: These findings set the stage for subsequent assessments and inform policymakers and researchers about evaluating cannabis policies. Results suggest recreative cannabis regulation must compete with the illegal market on quality, variety and price.

“Becoming a Cannabis Professional”

Alexander Kinney; Talk

In recent years, U.S. states have relaxed their laws to permit the operation of a commercial cannabis market despite enduring federal criminalization. While media outlets tend to consider money to be the primary motivation for working in the newly regulated cannabis industry, this article advances an alternative view that becoming a cannabis professional is linked to a broader process of drug-related identity formation. By drawing on interviews with cannabis professionals in three U.S. states (N=56), this study reveals that careers in regulated the regulated cannabis industry are facilitated through diverse moral meanings associated with this plant regardless of economic success. These meanings are filtered through imagined futures of the cannabis trade that draw people to cannabis occupations, anchor their commitment to the trade, and formalize their professional identity. Collectively, these touchstones link the process of becoming a cannabis professional the development of an authentic self-concept turning their occupational role into an extension of personal actualization. In the spirit of reflecting on cannabis policy at the twilight of drug prohibition, this article sketches out new directions for studying commercial cannabis and advocates for greater attention to the projective element of capitalism in the operation of legally contested markets.

“Between Main Street and Black Markets: Self-Reported Prices and Source Premiums in US Cannabis Markets”

Rasmus Munksgaard, Freja Ilsing Magnussen; Talk

Background: Criminalization levies a “risk tax” on illicit drugs through drug enforcement. Cannabis legalization aims to undercut illegal prices to subvert black markets. However, drug prices vary not only by legality but also by source. We examine sourcing premiums to assess whether legal cannabis, in general, is competitive with illegal cannabis.

Methods: Self-reported cannabis prices in the US were collected through the Global Drug Survey between 2017 and 2022. We analyzed the price of 1 gram and the quantity-adjusted price-per-gram using OLS with state-level fixed effects, adjusting for quantity, age, gender, and survey wave to assess whether legal markets are competitive at the price of 1 gram (N=13,430, N=4,727), and remain competitive for larger purchases (N=4,727).

Results: At the level of 1-gram we find that cannabis from illegal sources is sold at a substantial discount compared to legal sources. Adjusting for quantity discounts, this gap is reduced. Adding an interaction between source and quantity discount the gap widens again, and results suggest a steeper quantity discount for legal cannabis.

Conclusion: Our results suggest that illegal cannabis in the US is priced significantly lower or at the same level as legal cannabis. However, steeper quantity discounts can make legal cannabis competitive on price in larger quantities.

“Bridging the Gap: Exploring Consumer Experiences and Motivations for Transitioning Between Illicit and Regulated Cannabis Markets”

Jennifer Donnan; Talk

Background: Canada pioneered the legalization of non-medical cannabis production and sales, witnessing substantial growth in the regulated market over the five years, post-legalization. However, persistent barriers hinder many consumers from transitioning to the legal market, necessitating a nuanced understanding of their behaviors for targeted policy interventions.
Objectives: To improve understanding of cannabis consumers’ unregulated purchase decisions, and to explore motivational factors for transitioning to the legal market.
Methods: We conducted semi-structured interviews with cannabis consumers in British Columbia, who were at least 19 years old and purchased some or all of their cannabis through unregulated sources. Interviews were transcribed and an inductive thematic analysis was conducted using NVivo. Through coding iterations, we developed broad themes.
Results: Participants (n=31) represented a broad range of demographic characteristics (i.e., gender, age, education, income). Five themes emerged: product characteristics, retailer characteristics, personal values, social influences, and consequences of cannabis legalization. Despite purchasing all or some of their cannabis from the unregulated market, most participants were supportive of legalization and felt that legal cannabis is safe, accessible, and of reasonable quality. However, several barriers prevent consumers from regularly accessing the regulated market, including: price, potency of edible products, limited product variety, and inadequate product interaction.
Implications: This study delineates barriers that obstruct consumers' transition to the regulated market. These findings, aligned with considerations for public health and safety, offer valuable insights to inform cannabis policy and promote a more effective and consumer-oriented regulatory framework.

“Cannabis legalization and exposure to cannabis promotions and advertisements: The effect of legalization and the strength of cannabis policies.”

Lauren Elizabeth Winfield-Ward, David Hammond, Maryam Iraniparast; Talk

Background: A growing number of US states have legalized adult “recreational” cannabis. Promotional restrictions are a key component of cannabis regulations in legal markets; however, there is little evidence on the impact of restrictions to date.
Objectives: To examine differences in exposure to cannabis marketing in US states where cannabis was illegal (‘illegal states’), legal for medical use (‘medical states’), and legal for recreational use (‘legal states’). This study also examined differences in exposure by the comprehensiveness of promotional restrictions among ‘legal’ states.
Methods: Data are from the US component of the International Cannabis Policy Study: repeat cross-sectional data from national surveys conducted with 148,975 respondents aged 16-65 over 5 annual waves (2018-2022). Regression models examined self-reported measures of ‘noticing’ cannabis promotions and associations with the state-level legal status of cannabis, the ‘strength’ of marketing restrictions in ‘legal’ states, and sociodemographic factors.
Results: Exposure to cannabis promotions was highest among individuals in ‘legal’ states, followed by ‘medical’, and ‘illegal’ states (all contrasts p<.05). Younger respondents reported higher levels of exposure, and exposure was highest from retail stores and digital media channels. Trends in exposure were similar between ‘legal’, ‘medical’, and ‘illegal’ states, although differences narrowed over time. Finally, the strength of state-level promotional restrictions in legal jurisdictions was associated with lower exposure to cannabis promotions.
Implications: Cannabis legalization is associated with greater exposure to cannabis advertising and promotions, including among young people; however, stronger restrictions in legal jurisdictions demonstrate a protective effect.

“Cannabis legalization and public health: Insights from a systematic review”

Elle Wadsworth; Talk

Background
The cannabis policy landscape in the Americas is dramatically changing, and other jurisdictions are implementing or considering their own policy changes—from the Australian Capital Territory to multiple countries in Europe. Even in the past 5 years, there have been further changes to recreational cannabis policies in Americas, including changes to supply models or product availability. Understanding the consequences of these changes will be important to inform future policy developments in the Americas and beyond.
Review Methods
We developed a search protocol, run in five academic databases and three grey literature sources to cover the period between July 2018 to October 2023. Empirical quantitative studies were included if they had credible counterfactuals, were peer-reviewed, conducted in English or Spanish, and conducted in Uruguay, Canada and U.S. states that had legalized recreational cannabis. Further inclusion criteria included using 1) a quasi-experimental design; 2) representative samples; 3) pre- and post-legalization periods. We also discuss articles that examine within-jurisdiction changes post-legalization.
Results and implications
We identified 172 studies, covering nine outcomes: 1) Perceptions and attitudes; 2) Use-related outcomes; 3) Other substance use; 4) Traffic collisions; 5) Healthcare-related outcomes; 6) Market-related outcomes; 7) Crime and criminal justice; 8) Labour markets and financial indicators; and 9) Other. The presentation will largely focus on the health-related outcomes. From this review, there are lessons to be learned for other countries exploring changing their cannabis laws, particularly with changes to the European market.

“Cannabis-related Political Discourse on Twitter: A Mixed Methods Approach”

Nicholas Athey; Talk

Twitter is among the most widely used platforms for staying updated on current events and for following prominent figures such as celebrities, influencers, and political leaders. Politicians utilize Twitter to share their viewpoints and disseminate information about legislative changes, prompting inquiries into their role in influencing public opinion on social media. This study began by extracting a large sample of Tweets (n = 5,875,315) authored by current U.S. Governors, Senators, and Representatives (as of March 2022) which were then filtered to examine a set of cannabis-related tweets (n = 10,086) to understand the nature of political discourse on social media. The entire subsample of cannabis-related tweets is analyzed with descriptive and inferential statistics, while a subsample (n = 1,714) is subject to a qualitative thematic analysis. The majority of tweets are informative in nature and maintain a neutral tone, although some politicians—mostly authored by Democratic politicians—use non-neutral language to convey their message about the War on Drugs and ongoing cannabis prohibition. Cannabis tweets can be categorized into four categories: economy, government/governing process, public health, and justice. The results are discussed in the context of ongoing policy liberalization with an eye toward their implications for future research and our understanding of political discourse on social media.

“CANNABIS USE TO MANAGE OPIOID AND STIMULANT CRAVINGS AMONG PEOPLE WHO USE UNREGULATED DRUGS DURING IN THE FENTANYL ERA”

Hudson Reddon; Talk

Background: Accumulating evidence documents that cannabis is employed as a harm reduction strategy among some people who use unregulated drugs (PWUD) yet the impact of overdose risk has not been investigated. We sought to investigate the association between cannabis use to manage cravings for drugs and self-reported changes in substance use among structurally-marginalized PWUD. We also analyzed longitudinal associations between cannabis use and risk factors for overdose.

Methods: Interview and urinalysis data were systematically collected from PWUD in three prospective cohort studies of PWUD in Vancouver, Canada. We analyzed the association between cannabis use and overdose risk (non-fatal overdose and fentanyl exposure) using multivariable generalized estimating equations. The analysis of cannabis use to manage drug cravings was collected from a subsample of these cohorts who completed a supplementary cannabis questionnaire and binary logistic regression was used to analyze the association between cannabis use to manage drug cravings and self-reported changes in unregulated drug use.

Results: We enrolled 3,937 PWUD into the present study between December 2005 to November 2023. Daily cannabis use was associated with decreased odds on non-fatal overdose (Adjusted Odds Ratio [AOR]=0.90, 95% confidence interval [CI]: 0.82, 0.98) and recent exposure to fentanyl (AOR=0.48, 95% CI: 0.43, 0.54) as measured by urinalysis. Cannabis use to manage opioid and stimulant cravings was common (opioids: 44%, stimulants: 45%) and was significantly associated with decreased odds of opioid (AOR=0.44, 95% CI: 0.23, 0.86) and stimulant use (AOR=0.24, 95% CI: 0.10, 0.56), respectively.

Conclusions: These findings indicate that cannabis use to manage cravings for other unregulated drugs is a prevalent motivation among PWUD and is associated with self-assessed reductions in opioid and stimulant use. Frequent cannabis use was also longitudinally associated with decreased odds of non-fatal overdose and fentanyl exposure. These results suggest that supporting the intentional use of cannabis for harm reduction among people at highest risk of overdose could be a useful intervention to mitigate exposure to the toxic unregulated drug supply.

“Changes in opioid toxicity deaths after the implementation of COVID-19 emergency measures in Ontario, Canada: An interrupted time series”

Valeria, sanjana.mitra@unityhealth.to; Talk

BACKGROUND: In March 2020, in response to the COVID-19 emergency, Ontario, Canada implemented public health risk mitigation strategies, including the closures of schools and non-essential businesses, physical distancing, border closures, and modified health services. We examined their association with changes in opioid toxicity mortality and assessed variations across age, sex, health region, and drug type.
METHODS: Opioid toxicity death records (January 2018 to February 2021) from the Ontario Office of the Chief Coroner were analyzed using a generalized linear model for count time series. Our study estimates the changes in the weekly death count following the first (March 17th, 2020, to May 19th, 2020) and second (November 23rd, 2020, to February 10th, 2021) waves of province-wide lockdown measures, modelling interventions as a level shift in the number of opioid toxicity deaths between those dates.
RESULTS: Across the study period, of 5573 individuals who died, 73.7% were male, and the median age was 40 (interquartile range: 31 to 51). The weekly number of deaths ranged from 10 to 72. Following the province-wide state of emergency and first lockdown, there was a step increase in the number of deaths, with an estimated Rate Ratio of 1.20 (95%CI 1.00 to 1.79). There was no significant change following the second wave of lockdown measures (1.06 [95%CI 0.92 to 1.95]).
IMPLICATIONS: The period after initial COVID-19 measures was associated with increases in opioid toxicity mortality. Future responses to public health emergencies must proactively mitigate the potential unintended consequence of competing hazards of mortality among substance-using populations.

“Changes in prenatal cannabis-related diagnosed disorders after the Cannabis Act and the COVID-19 pandemic in Québec, Canada.”

Jose Ignacio Nazif Munoz; Talk

Public health concerns regarding pregnant women’s health after the enactment of the Cannabis Act in Canada (CAC), and the potential impact of the COVID-19 pandemic, calls for a contemporary assessment. Our study focuses on examining how the CAC and the pandemic are associated with the monthly prevalence rates of cannabis-, all drug-, and alcohol-related diagnoses disorders among pregnant women in Quebec.
We conducted a retrospective population-based study drawing on data from the Québec Chronic Disease Surveillance System. Using time-series regression analyses, we assessed changes associated with the CAC (October 2018) and the COVID-19 pandemic (April 2020) in the age-standardized monthly prevalence rate of cannabis-, all drug-, and alcohol-related disorders of pregnant women aged 15 years to 49 per 100,000 population between 2010 and 2022.
Before the CAC, the prevalence rate of cannabis-related diagnosed disorders significantly increased each month by 1% (95% confidence interval (CI) 1.00 – 3.00). After the CAC, there were significant increases of 25% (95% CI: 0.01-54.00) of cannabis-related diagnosed disorders. No significant changes were observed for all drug-and alcohol-related diagnosed disorders associated with the CAC. Increases in the prevalence of diagnosed prenatal cannabis-related disorders before and after the CAC, echo public health concerns associated with potential cannabis-related harms in this population including long-term impact on offspring children. In Quebec, a more comprehensive approach to better understand and prevent increases in this outcome should be applied.

“Comparing policy responses to safer drug consumption facilities and drug checking services in Scotland”

Hannah Carver, James Nicholls; Talk

Background: Safer drug consumption facilities (SDCF) and drug checking services (DCS) are interventions that are currently progressing towards implementation in Scotland in response to historically high rates of drug-related deaths (DRD). Recent research in Scotland has explored the potential for, and feasibility of, implementing both interventions in a number of cities. Despite both interventions having the aim of reducing DRD, policy responses and discourses have been markedly different.

Objectives: To critically analyse Scottish (and UK wide) policy discourses concerning these two harm reduction interventions to better understand: how problems are framed; how political barriers and opportunities are conceptualised; and the extent to which these dynamics can be explained by key policy theories.

Methods: We draw on our extensive experiences as academic researchers, advocates, service delivery leaders, public commentators. and political advisors on these topics over the preceding years. The analysis will be informed by Multilevel Governance Theory (Marks, 1993) and Multiple Streams Analysis (Kingdon, 1984).

Results: While SDCF and DCS are important interventions in response to DRD in Scotland, they have progressed through different policy routes. Policy responses to their introduction have been constrained by a combination: of political conflict at both national and regional levels; legislative restrictions; limitations on devolved powers; intense media scrutiny; and tensions between different ways of framing both the causes and potential solutions to the ongoing drug deaths crisis.

Implications: Understanding political drivers of, and barriers to, innovation in harm reduction is critical to developing effective strategies for change and building consensus for action.

““Decriminalization” as recriminalization? Police consultation, cooptation, and regulatory capture”

Liam Michaud, Tyson Singh Kelsall; Talk

Some jurisdictions in Canada have experimented or called for policy interventions under a banner of drug “decriminalization” in recent years. Despite decriminalization proponents calling for the removal of enforcement actors and reduction of criminal legal governance from the lives of people who use drugs, police have been remarkably involved in crafting such measures, in limiting their purview, and in carrying out their implementation. The development of decriminalization initiatives has culminated in measures characterized by uncertain legal protections, and have sustained or expanded police discretion and role in the governance of people who use drugs, particularly those racialized and/or poor.

This study examines this key contradiction through a critical realist review (Pawson, 2005; Stevens, 2019) of the decriminalization models proposed to the federal government and corresponding consultations with law enforcement, through an assessment of Freedom-of-Information and Access-to-Information requests.

The findings reveal the deference to – and privileging of – law enforcement positions throughout the policy process by health authorities. The findings provide clear demonstration of law enforcement mission creep in which police are positioned as playing a crucial role in “linkage” to healthcare and drug treatment. The presentation discusses the adaptive strategies of enforcement actors through their reliance on other legal tools to sustain their role in governing the lives of people who use drugs (Singh Kelsall & Michaud, 2023). The study further highlights the contributions of methodological approaches employing Freedom-of-Information requests to drug policy scholarship, by mapping the responses of criminal legal actors ambivalent or hostile to the aims of drug law reform.

“Decriminalization for whom? People who use drugs’ perceptions of and experiences with police following decriminalization in British Columbia”

Alissa Greer, Naomi Zakimi; Talk

Background. One of the main objectives of the recent drug decriminalization policy implemented in British Columbia, Canada is to reduce stigma and re-frame drug use as a public health issue. The current study examined the perceptions of and experiences with police for a diverse sample of people who use drugs (PWUD) in the first year of decriminalization in British Columbia.

Methods. We conducted semi-structured interviews with 77 people who use drugs in British Columbia. To ensure a diverse range of perspectives, we purposively sampled a range of socioeconomic positionings. Data were analyzed thematically and organized under topic domains.
Results. Findings uncovered three main topic domains: (1) Experiences of arrest and drug seizures (2) The role of social marginalization in police interactions (3) Hopes for long-term impacts of decriminalization. Findings overall demonstrate that decriminalization has produced a sense of safety around police for some people who use drugs, but this experience hinges on social inclusion or marginalization of the person. For people who use drugs who are socially marginalized, officers may use alternative mechanisms to continue policing this group.
Implications. Findings suggest that the social benefits of decriminalization may be more pronounced among people who use drugs depending on their social positioning, begging the question: decriminalization for whom? This study points to the need for intersectionality and diversity considerations as this and other policies are developed and implemented.

“Democratic politics and drug law reform”

Toby Seddon; Talk

Drawing on two chapters from my new book, Rethinking Drug Laws (2023, OUP), this paper examines the politics of the ‘drug question’. It explores how we can understand what exactly is at stake when drugs and drug control become matters of political contestation. Using concepts drawn from political science, it argues that rather than the politicisation of drugs being a barrier to drug law reform efforts, a serious engagement with politics and ideology is essential to finding better ways of regulating drugs. The drug question is ineluctably political. Surfacing the politics of drug control in this way highlights the need to understand law and policy not simply as technical solutions to social problems but also as about competing visions of the ‘good society’. The paper goes on to explore what a ‘better’ politics of drugs would look like and how we might achieve it. It examines different approaches to normative thinking (propositions about how the world should be) and reviews the debate on ‘public social science’. It then considers ways in which drug politics could be democratised, not only through creating more spaces for democratic deliberation but also by ‘thinking democratically’ in a broader sense. It argues for the necessity of developing a cosmopolitan vision of politics which moves beyond Western-centrism. In conclusion, the paper suggests the need to amplify the voices of those who most directly experience the punitive edge of prohibition, especially in the Global South.

“Does gang involvement in drug selling change retail drug markets?”

Chris Wilkins; Talk

Background – In New Zealand, it is often claimed that outlaw motorcycle gangs control the illegal markets for methamphetamine and cannabis, including purposively suppressing the local availability of cannabis to encourage sales of the more profitable methamphetamine.
Aims – (1) Explore predictors of higher levels of gang involvement in retail illegal drug markets. (2) Investigate whether higher levels of gang involvement and number of gangs are predictors of differences in the price, potency and accurate sale weight of different drugs types compared to lower levels of gang involvement.
Methods – An online convenience drug survey (NZ Drugs Trends Survey) was broadly promoted via Facebook™ from November 2018 to March 2019 (n=10,966). Respondents were asked to what extent gangs control the sale each drug type (1=none-5=only gangs), how many different gangs were selling in the area (1=many-4=one), and how price, potency and weight provided by gangs compared to non-gang sellers.
Results – Region was a significant predictor of extent of gang involvement in drug selling. Higher methamphetamine availability and conversely lower cannabis availability was associated with higher gang involvement. Higher relative price of cannabis was positively associated with extent of gang involvement and lower number of different gang sellers. Lower sale weight of cannabis was positively associated with greater gang involvement and lower number of different gang sellers. Weaker cannabis potency was associated with lower number of different gang sellers.
Implications - Economic theory of monopoly and marketing offers important insights into these findings.

“Does Regulating Drug Precursors Affect Illicit Drug Markets?”

Luca Giommoni; Talk

This paper seeks to answer a key question: Does controlling the availability of certain chemicals (precursors) affect drug markets? Essentially, it wants to find out if restricting access to substances used in making illegal drugs can reduce drug use, trafficking, and related issues like overdoses. To explore this, the paper will critically analyse existing research, which primarily focuses on American literature, particularly the works led by James K. Cunningham and his team. The research shows that the regulation of chemicals essential to produce drugs such as heroin, cocaine, and methamphetamine is associated with several positive outcomes. These include a decrease in drug purity, a reduction in seizures, lower demand for treatment and hospitalization, and an increase in drug prices. This decrease in harmful outcomes results from a combination of diminished overall consumption and a reduction in harm per dose. However, the paper also highlights significant gaps in the current literature that need addressing to fully understand the impact of precursor regulation. These include questions about the external validity of these studies, the extent of regulation implementation and enforcement, and potential economic side effects, given that some of these chemicals also have legitimate uses in the chemical and pharmaceutical industries. Despite certain limitations in the evidence base, regulating precursors emerges as a promising strategy to diminish drug availability and its associated issues. This approach could be a cost-effective way to tackle the growing problem of synthetic opioids like fentanyl, which are already widespread in North America and are becoming more prevalent in Europe. In 2021, the United States saw an average of 220 deaths per day from opioid overdoses. Regulating drugs precursors could help save some of these lives.

“Drug decriminalization, the introduction of fentanyl to drug markets, and fatal overdose in Oregon”

Michael Zoorob, Brandon del Pozo; Talk

Introduction- This research evaluates whether the January, 2021 decriminalization of drug possession in Oregon was associated with changes in fatal drug overdose rates after accounting for the timing and spread of fentanyl through Oregon’s unregulated drug market, a substance known to drive fatal overdose rates.

Methods- The association between fatal drug overdose and enactment of M110 in Oregon was analyzed using a matrix completion synthetic control method imputed from 48 US states and Washington DC. The rapid escalation of fentanyl in unregulated drug markets was determined using the state-level percentage of all samples reported to the National Forensic Laboratory Information System that were identified as fentanyl or its analogs. A changepoint analysis was used to determine when each state experienced a rapid escalation of fentanyl in its unregulated drug market. Mortality data were obtained from the Centers for Disease Control and Prevention from 2008-2022.

Results- Analysis indicated a rapid escalation of fentanyl in Oregon’s unregulated drug supply occurred in the first half of 2021, contemporaneous with the enactment of M110. The crude association between decriminalization and fatal overdose rate per 100,000 per half-year was significant (Tau = 1.83; SE = 0.39; p < 0.001); however, adjusting for the rapid escalation of fentanyl as a confounder, the effect of drug decriminalization on overdose mortality in Oregon was null (Tau = -0.51; SE = 0.36).

Conclusions- Future evaluations of drug policies should account for confounding changes in the composition and potency of unregulated drug markets.

“Drugs, Race, and Policing: Intergenerational Cultural Narratives about Drug Policing in Black British Communities”

Bisi Akintoye; Talk

Background: Drug legislation is a major driver of racial disproportionalities in policing. While much discourse surrounding policing focusing on using stop and search to tackle serious violence, the majority of these stops result in no outcomes. In practice, stop and search is frequently used for the policing of drug offences and remains disproportionately used against Black Britons.

Methods: Semi-structured qualitative interviews from 58 Black young people, parents and community workers, unstructured qualitative interviews, focus group with school aged 13–14-year-olds. Interviews focused on perceptions and experiences of policing, both direct and vicarious.

Results: Experiences of racialised drug policing has resulted in intergenerational cultural narratives, creating frameworks for understanding drug policing experiences that are often more powerful than actual experiences. Cultural narrative frameworks through direct discussion and the indirect transmission of information through cultural understandings are explored. Taking an intersectional approach to policing, the ways in which race, gender, age, class, and immigration histories enable analysis how structural and cultural positionality mediate experiences of drug policing.

Implications: While there is no homogenous Black experience of policing but that ongoing experiences of racialised drug policing have produced negative perspectives of the police throughout communities. Cultural narratives, drawn from decades of racialised drug policing, have deeply embedded negative perceptions of the police throughout Black communities. This has significant implications for the future relationship between the police and Black Britons. The eradication of racialised drug policing is central to improving this contentious dynamic and improving trust and confidence in the police.

“Effectiveness of Court-mandated Compulsory Treatment in Promoting Abstinence among People with Substance Use Disorders in Iran”

Mohammad Karamouzian; Talk

In Iran, people living with substance use disorders who engage in public drug use may be subjected to court-mandated compulsory treatment in compulsory drug detention and rehabilitation centers (CDDRC). This study aims to assess residential CDDRC’s effectiveness in promoting sustained abstinence among people who use drugs (PWUD) in Kerman, Iran.

Between October 1, 2021, and September 30, 2022, 1,083 adult PWUD with a diagnosis of substance use disorders and a history of engagement in public drug use were admitted to the CDDRC in Kerman. They were followed-up for 12 months after discharge. The relationship between baseline variables and abstinence, assessed using rapid urine tests, was examined using crude logistic regression models.

Most PWUD were 30 or older (n=876, 80.9%) and had a history of previous CDDRC admission (n=638, 58.9%). At the end of the 12-month follow-up, only 2.6% (95% CI: 1.7-3.7) were abstinent. Individuals with limited education (OR = 3.43; 1.50-7.95) and those with a prior history of admission to the CDDRC (OR = 3.73; 1.55-9.89) had increased odds of relapse.

The effectiveness of CDDRC in promoting abstinence among the participants was minimal. This highlights the necessity of reassessing support and investment in these interventions and considering more evidence-informed alternatives in Iran.

“Ending Stigma for Whom? A Critical Analysis of Race, Class, and Representation in Canadian Substance Use Anti-Stigma Campaigns”

Scott D. Neufeld; Talk

Background: The escalating crisis of toxic drug deaths in Canada has prompted a significant increase in substance use focused anti-stigma campaigns. This onslaught of novel, and mostly government-produced, anti-stigma campaigns has received little scrutiny. Objectives: This paper explores how Canadian substance use anti-stigma campaigns 1) construct the problem of “stigma” 2) represent the identities of PWUD. Methods: Study 1 used a systematic review to identify patterns in representations of PWUD and constructions of stigma across 134 examples of Canadian anti-stigma campaigns (2009-2020). Study 2 asked 8 focus groups with 41 marginalized PWUD to respond to two mainstream anti-stigma campaigns. Results: Study 1 found that campaigns frequently constructed stigma as an individual rather than structural problem, and rarely mentioned the intersections of racism, classism and substance use stigma. Nearly 75% of PWUD represented appeared to be White and Middle-Upper class. In Study 2, participants critiqued campaign framing of stigma as an individual problem affecting White Middle Class PWUD, decrying a double standard that ignored their intersectional stigma experiences as mostly racialized and low-income PWUD. Participants also expressed resistance to their exclusion from these campaigns. Implications: Both studies suggest that many anti-stigma campaigns in Canada have seemingly attempted to rescue only privileged PWUD from stigma, whilst potentially deepening the societal exclusion of marginalized PWUD.

“Enhancing Harm Reduction: A Qualitative Evaluation of Athens' Drug Consumption Room”

Ben Scher; Talk

Drug Consumption Rooms have become integral to public health systems in many European countries including in Greece, where in March 2022 the city of Athens opened the country’s first legally sanctioned site. To date, no qualitative research has explored the experiences of people accessing the site, or the community of people who use drugs in street-based settings locally.

Employing a participatory rapid-ethnographic approach, this study collected data through an initial 5 weeks of ethnographic observation, followed by 1 community consultation, 5 focus groups with DCR clients, 12 interviews with staff and 25 interviews with people who use drugs locally who do not access the DCR. Data was collected by two graduate students as well as a local peer researcher.

Seven main themes arose from the focus groups, including: 1) The DCR as a Sanctuary, 2) Privacy and Reduction in Street-Based Drug Use, 3) The Positive Impact of Staff, 4) Suggestion 1: Increased Communication of the Facility, 5) Suggestion 2: Extended Hours and Locations, 6) Suggestion 3: The Potential of Peer Involvement, 7) Stigma as a Potential Barrier. Four main themes arose from the street-based interviews: 1) Community Awareness of the DCR, 2) Urgency and Time Constraints, 3) Perceptions of Limits and Regulations, and 4) Supportive Environment and Human Connection. Four main themes arose from the staff interviews: 1) Human Connection and Reconnection Through the DCR, 2) Operational Challenges and Staff Well-Being, 3) Reflections on Harm Reduction and 4) Client Feedback.

The opinions, attitudes, and lived experiences of DCR clients, as well as potential clients should be used to inform the design of services as a means of overcoming barriers to their uptake and effectiveness. The results of this study have informed a number of recommendations specific to this local context. These include (but not limited too): 1) involving peers in the delivery of services to make it a more welcoming and relatable service, 2) establishing a peer advisory committee so that clients have ongoing input into the delivery of services, and 3) explore the need and demand for additional DCRs in Athens.

“Estimating the causal effect of arrest for drug possession or use on frequency of injecting drug use in Melbourne, Australia: An emulated target trial.”

Michael Curtis; Talk

Background: Among people who inject drugs, evidence suggests that contact with the criminal justice system is associated with an elevated risk of experiencing drug-related harms. Decriminalisation of drug possession and use is proposed as a response to reduce the burden of drug-related harms; however, some are concerned that removing criminal sanctions for drug possession and use will encourage increased injecting frequency and related harms.

Objective: To estimate the effect of arrest for drug possession or use (drug-related arrests; excludes cultivation and trafficking-related offences) on frequency of injecting drug use among people who inject drugs.

Methods: We will use inverse-probability weighting to estimate the average causal effect of drug-related arrests (‘intervention’) on the frequency of injecting drug use. Participants are individuals in the prospective SuperMIX cohort study who complete at least one follow up interview (N=997; observations= 4876; incident drug-related arrests=399; 2008-2023). Longitudinal causal analysis will account for pre-specified confounders (e.g. age, sex, ethnicity, income, housing, public vs private injecting location, previous IDU frequency, participation in acquisitive crime, opioid agonist treatment).

Implications: Findings will provide crucial evidence of the effect of law enforcement on deterring injecting drug use and inform debate around decriminalisation of drug possession and use. Further, findings would inform estimation of population-level changes in rates of injecting-related sequalae including overdose, injuries, and infections, and rates of emergency healthcare use if drug decriminalisation were implemented.

“Evaluation of Decriminalizing Small Amounts of Illicit Drugs in Victoria, BC: A Seasonally Adjusted Time-series Analysis of Police Data”

Alexander Kuzma-Hunt; Talk

Background: In response to the toxic illicit drug crisis, British Columbia (BC) decriminalized possessing ≥2.5g of illicit drugs in January 2023, with the goals of improving access to health services and reducing drug-related stigma and provincial overdose deaths (>13,536 since 2016). Fear of arrest and drug seizure are the most commonly reported barriers to accessing health supports among people who use drugs (PWUD). Drug seizures also affect drug acquisition behaviour, increasing individual overdose risk. Therefore, ongoing evaluation of decriminalization as a harm-reduction strategy requires analysis of changes in police data over-time (pre-decriminalization, decriminalization announced without enactment, and post-implementation). As part of BC’s Monitoring and Evaluation plan, this study will investigate impacts of decriminalization in Victoria. Objectives: Analyze trends in drug possession-related arrests, prosecutions, and convictions (with mean drug weights), across three periods: pre-decriminalization, decriminalization announcement without enactment, and post-implementation. Methods: A seasonally adjusted interrupted time-series analysis of changes in number of drug-related arrests, seizures (with weights), possession charges (simple and for purpose of trafficking), and convictions from Jan-2020 to Dec-2023. Results: Findings will permit testing of hypotheses about the reduction in drug-related arrests for below-threshold possession, by examining events prior to the announcement of decriminalization, between the announcement and implementation of decriminalization, and post-implementation of decriminalization (analyses underway). Implications: Quantifying sociolegal impacts of decriminalization at the street-level will guide policy makers in on-going implementation adjustments and health-systems decision-making.

“Exploring the influence of New Psychoactive Substances (NPS) Opioids trafficking and abuse on crime trends in Nigeria and the consequential implications for (TOC) in West Africa”

Abdulrahman Adebusola Adebowale; Talk

This ongoing study investigates the growing impact of New Psychoactive Substances (NPS) Opioids trafficking and abuse on crime trends in Nigeria, particularly its implications for Transnational Organized Crime (TOC) in West Africa.
Global increases in NPS Opioids trafficking, driven by higher costs of traditional drugs and geopolitical shifts, have reshaped the criminal landscape. Nigeria, experiencing a surge in NPS Opioids, serves as a crucial case study within West Africa.

The research aims to explore the intricate links between NPS Opioids trafficking, abuse, and various crimes like Kidnapping, Banditry, Oil bunkering, and Terrorism.
Utilizing a mixed-methods approach, the study combines quantitative crime data analysis with interviews of key stakeholders and employs network analysis to reveal connections between NPS Opioids-related crime and TOC networks in West Africa.

Preliminary findings, rooted in arrests and seizures, highlight a significant correlation between the increase in NPS Opioids trafficking and abuse and the rise of specific crime types in Nigeria. Identified hotspots and demographics underscore the interconnectedness of NPS Opioids-related crime with TOC networks in the region.

The study's implications extend to the development of targeted interventions, offering valuable insights for law enforcement, policymakers, and healthcare professionals. By addressing the intricate relationship between NPS Opioids, crime, and TOC, the research contributes to the formulation of comprehensive strategies to combat trafficking and abuse, not only in West Africa but with broader implications for regional and international initiatives.

“Exploring the khat chewing topography: a qualitative study of its constituents and contextual factors”

Amanti Baru Olani; Talk

Introduction: The WHO expert committee on drug dependence noted in its 2006 review of khat that excessive use of khat leads to adverse social and health consequences, and recommended drawing attention to such use patterns. Similarly, several of the studies reporting the association between khat and health problems emphasized the role of ‘heavy use patterns.’ Such findings and recommendations indicate the need to understand factors shaping khat-chewing topography, which is defined as the study of how one chews khat and the contextual factors shaping such behaviours.
Methods: The study relied on a qualitative method in which 102 khat-chewers were recruited from the general community in Jimma, Ethiopia using a snowball sampling from May 2021 to February 2022.
Results: Our findings reveal that khat-chewing topography constitutes the amount, the duration of a chewing session, the frequency, the rate, and the timing of chewing. The khat chewing topography is shaped through a complex interplay of multiple variables, which we categorized into six themes: perceived harms, the pre-chewing state, the khat variety, norms of khat chewing rate, the khat rhythm factor, and the context of chewing.
Conclusion: The typical khat-chewing topography identified in this study shows that khat-chewers regulate their chewing behaviour by considering multiple factors, including the social norms of khat consumption and the possible harm to their health, social life, and budgets. As a result, most of the chewers were able to build a consumption topography that can be described as ‘harm reduction from below.’

“Exploring the Signifiance of Drug User Participation in Safe Supply Models”

Jack Farrell; Talk

While much discussion surrounding safe supply (SS) focuses on outcomes of clinical models such as reduced overdose death or increased connections with healthcare supports, less consideration has been given to the need for drug user participation in such programs. This presentation explores desired models of safe supply centred around the concept of drug user participation.

This presentation uses data from Imagine Safe Supply, a community-driven study which explored perceptions of drug users and FLW about participation in safe supply. This study conducted 33 semi-structured interviews, collected remotely in early 2021, with drug users and FLW in British Columbia, Alberta, Ontario, and Quebec. Imagine Safe Supply featured the leadership of a committee of community members with lived expertise of drug use and frontline work who contributed to the design and completion of all research activities.

Results focus on descriptions of participation in existing clinical SS models, as well as the levels of participation associated with desired models of SS. Many participants perceived existing clinical models to be dehumanising and disempowering. In contrast, participants desired models with robust drug user participation, which they perceived as comfortable, trustworthy, non-judgmental and a source of community-building.

Results indicate a wider range of possible models of SS than usually acknowledged. The participation of drug users in SS models was seen as essential to overcoming barriers and optimising programs towards drug users’ goals. This presentation encourages drug user participation as a key input metric in future design and evaluation of SS programs.

“Fentanyl detection on stimulants and harm reduction in cities of Mexico. Outcomes of a pilot intervention from Aguascalientes”

Alejandra García de Loera; Talk

The objective was to explore the presence of fentanyl in illegalized stimulants from various regions of the country to complement the epidemiological panorama at the national level due to the existing research gap on this opioid and regarding the analysis of substances in Mexico. As well as, implement harm reduction strategies in regions that have not had similar community interventions, such as the city of Aguascalientes. There, personal use kits for stimulants were provided and 151 samples of crystal, cocaine and MDMA were tested out of a total of 485 collected in Mexico City, Tijuana and Mexicali. No fentanyl was detected in any of the samples collected in the four cities. Similar findings were reflected in Canada, based on empirical evidence that fentanyl is not a common adulterant in the supply of stimulants in these cities. This suggests that contamination of this market, at least in these regions, is an isolated case, but there is definitely a possibility that it could occur on a common basis. What requires the implementation of a permanent monitoring system by community organizations and research on barriers and facilitators of access for its development, such as stigma, the main barrier found in Aguascalientes where the detection of crystal in others is also pertinent. stimulants made illegal due to their predominance in the local market for these substances.

““Fentanyl Exceptionalism” and Drug Policy Responses to People Experiencing Homelessness who Co-use Fentanyl and Stimulants in San Francisco and New York”

Kelly Ray Knight; Talk

Background: People who use drugs and experience homelessness are targets of public discourse about urban decay and significantly vulnerable to overdose mortality.
Objectives: We explored responses to overdose and housing crises from the perspectives of diverse stakeholders, media reports, and policy documents.
Methods: POLY HOME employs longitudinal ethnographic and qualitative methods to examine the
contexts of fentanyl-stimulant polysubstance use among people experiencing homelessness (PEH) and patterns and overdose vulnerability among PEH in San Francisco and New York, US. We conducted qualitative interviews with representatives (n=50) from local and national stakeholder groups, including substance use and housing services and drug user-led organizations, and reviewed local media reports and policy documents. Data were coded and analyzed using a modified grounded theory approach.
Results: Stakeholders emphasized the need to document how the proliferation of fentanyl and new adulterants (e.g., xylazine) and rising fentanyl-stimulant polysubstance use shape overdose vulnerability as PEH navigate ongoing housing crises. While local media reports consistently framed fentanyl as “unprecedented” and “exceptionally dangerous”, stakeholders contested such framings by focusing attention on structural factors that exacerbate overdose vulnerability (e.g., poverty, housing vulnerability, access to evidence-based substance use treatment and harm reduction services). Stakeholders expressed concern that ‘fentanyl exceptionalism’ was driving policy responses unsupported by evidence, such as criminalization (e.g., street sweeps, arrests) and mandated substance use treatment.
Implications: ‘Fentanyl exceptionalism’ intersects with homelessness to potentially drive punitive approaches to substance use and urgent attention toward underlying structural dynamics driving overdose vulnerability is needed.

“For Successful Implementation of Depenalization Decriminalization in Quebec”

sandhia vadlamudy, Louis Letellier de St-Just, Julie-soleil Meeson; Talk

Canadian civil society organizations remain deeply outraged by the number of deaths linked to drug poisoning in the country, more than 30,000 to date. From organizations of people who use drugs, families affected by the consequences of substance use, those active in the defense of rights, the advancement of policies or those working on the first line of services, in December 2021 they supported the dissemination of the flagship strategic document “SUCCEEDING IN DECRIMINALIZATION: a path to human rights-based drug policy. »

This framework emphasizes:
— The decriminalization of all possession of drugs for personal use, sharing or selling of drugs for subsistence purposes
— The redistribution of resources allocated to law enforcement and policing towards non-coercive and voluntary policies, programs and services.

The discussions will tend to highlight the essential elements of successful diversion and policies free from racism, sexism and colonialism. Different initiatives will be discussed, including those of the International Drug Policy Consortium, as well as the decriminalization experience in British Columbia.

Multidisciplinary panel to promote the coherence of actions in health and social services, justice, public and community safety.

The panel will feature six speakers representing a diverse range of sectors intimately involved and affected, including Indigenous perspectives, experiential knowledge, security, justice, and others, as part of the mobilization led by l’Association des intervenants en dépendance du Québec.

“‘From little things big things grow’ - Policy and practice diffusion and development in wider availability of naloxone in Australia 1999-2023”

Simon Lenton; Talk

Background: Since the early 1990s there have been calls to make the opioid antagonist naloxone more widely available including through take-home naloxone (THN) programs where naloxone is made available to potential overdose witnesses such as people who consume opioids, their peers and family members. A THN program was established in the Australian Capital Territory in 2012 with similar programs established in other Australian jurisdictions shortly thereafter. They were established in the context of an increasing trend in overdose deaths, but unlike parts of North America, no opioid crisis had been declared.
Objective: This presentation will track the development of THN in Australia from a small-scale program in one jurisdiction, through to THN availability across the country at no charge.
Methods: Using a narrative approach theories of policy change will be used to explore the role of consumers, clinicians, researchers, health officials and policy advocates in shaping THN policy and practice In Australia.
Results: Utilising partnership, piloting, evaluation and policy diffusion, a coalition of across-sector stakeholders, committed to evidence-based expansion of THN in Australia, led to widespread support for policy changes in a variety of settings, services and target groups.
Conclusions: Although a public health opioid overdose emergency has not been declared in Australia, it has been possible to advocate for the establishment of THN and develop an evidence base and advocacy coalition that has led to a nationwide free naloxone program and empowering those most at risk of opioid overdose related harms.

“Gave Me a Number Ahead of Time and Made Me Ready for Jail: Policing Survival in Rhode Island”

Julianna Brown, Claire Macon; Talk

Background: The state of Rhode Island has a unique history within the U.S. as indoor prostitution was decriminalized from 1980 - 2009. While studies of this period through metrics like disease incidence or violent crime rates have been used to discuss various legal models, many Rhode Island-based sex workers still found themselves criminalized. An in-depth understanding of the relationship between sex work, drug use, racism, transphobia, xenophobia, and poverty is necessary in developing policy that will promote safety and health.

Objectives: This work explores the narrative experiences of criminalization of drug use and sex work in Rhode Island, USA.

Methods: This community-based research was carried out among in-person sex workers in Rhode Island in 2021. We collected 100 surveys and 35 semi-structured interviews and completed analysis using grounded theory qualitative analysis.

Results: Sex work and drug use exist as sites of criminalization. These are also practices that provide support in the face of oppression and economic precarity and are a means of survival for many. While indoor full service sex work was decriminalized in RI, marginalized sex workers continued to be prosecuted.

Implications: We have seen a number of developments in the past 5 years in both decriminalizing drugs as well as sex work. However, the experiences of many sex workers during Rhode Island’s period of decriminalization suggest that decriminalization must be understood as only effective within a larger effort to dismantle the US’s carceral state built upon settler colonialism and anti-blackness.

“Global Policy Challenges in Implementing Drug Checking to Monitor the Unregulated Drug Supply”

Ju Nyeong Park, Doris Payer; Talk

The unregulated drug supply is constantly evolving, and recent increases in illicitly manufactured fentanyl, counterfeit pills and xylazine are linked to severe and complex health consequences. Timely localized drug supply data are being scaled up across the Americas to inform public health efforts and intervene upon the harmful physical and psychological effects of addiction. Unlike traditional forensic and toxicology drug surveillance programs, drug checking services (DCS) allow voluntary submissions of drug samples by the community for “real-time” testing and communication of results. Our aim is to present emerging epidemiologic and economic research on drug checking services in the Americas and discuss the legal and policy challenges being faced by these programs.

To fully realize the potential benefits of DCS globally, we call upon governments and international agencies to consider developing and implementing new policies to support DCS staff and service users, in collaboration with DCS staff and service users:
1. Legal protections for DCS organizations and service users with regards to suspected drug sample and DCS equipment possession, distribution, transport and mailing.
2. Federal/regulatory warnings or bans on the selling and marketing of drug checking equipment that are falsely advertised, inaccurate, or perform suboptimally in DCS environments.
3. Funding and technical assistance for point-of-care instruments that are suitable for DCS.
4. Funding and technical assistance for harm reduction organizations that offer DCS.
5. Workforce development opportunities for people with lived and living experience to work in service delivery.

“Grassroots Activism, High Politics and Everything in Between: A Comparative Analysis of Cannabis Social Movements in Latin America”

Jonas von Hoffmann; Talk

Background: Collective, societal actors have been among the most vocal critics of status quo drug policies and a driving force behind legal reforms and cultural shifts regarding marijuana in Latin America. Cannabis activists have taken to the streets, engaged in civil disobedience, organized as collectives and lobbied decisionmakers. Despite a long-standing recognition that that “efforts to change drug policies have often taken the form of social movements…” (Room 1991:37), cannabis activism has seldom been studied explicitly as social movement and making use of the vast body of social movement theory.

Objectives: To advance the empirical study of cannabis activism and provide it with a more solid conceptual footing, the paper compares and contrasts cannabis activism across Latin America using social movement theory and concepts. Besides analyzing the state of cannabis activism in Latin America, the aim of the paper to showcase that paying attention to cannabis activism and studying it using social movement theory holds great potential.

Methods: By drawing on original research from Mexico, Uruguay and Chile, extant studies of cannabis activism and social movement concepts, the paper unearths similarities and differences in political opportunity structures, resource mobilization, membership characteristics, degrees of professionalization, repertoires of action, framing and mobilization practices and outcomes of activism across Latin America. In doing so, the paper presents a comparative and theoretically grounded analysis of the variegated practices, processes and outcomes of Latin American cannabis activism.

Implications: The paper establishes that cannabis movements are important collective, societal actors involved in the making and unmaking of drug policies and highlights how social movement theory can contribute to describing, analyzing and explaining cannabis activism.

“Harm reduction and pleasure in sexualized substance use interventions”

Maxime Blanchette, Mathieu Goyette, Karine Bertrand, Jorge Flores-Aranda; Talk

Background. Interventions addressing sexualized substance use (SSU) among gay, bisexual, and other men who have sex with men (gbMSM) often focus on biological risks like HIV and STIs, emphasizing substance use reduction or abstinence. This approach may not be universally suitable, especially when considering sexual and substance use pleasure. A harm reduction strategy rooted in a global health perspective offers an opportunity to reconsider interventions, embracing pleasure in recovery rather than focusing on biological consequences.
Objective. This presentation aims to outline the contribution of integrating sexuality into the original harm reduction definition in SSU interventions.
Methods. In-depth interviews were conducted with 20 gbMSM adults engaged in SSU practices within the past year. Thematic analysis of their experiences and perspectives on SSU practices and their intervention needs was conducted.
Results. Participants highlighted the need for healthcare providers (HCPs) to possess specific knowledge, skills, and attitudes when addressing gbMSM with SSU practices. They emphasized the importance of HCPs having knowledge about both sexuality and addiction and understanding how these components influence each other. The study identified a crucial competency—attitude (e.g., non-judgment, acceptance)—within the context of SSU. HCPs should empower individuals engaged in SSU practices, recognizing their self-determination by allowing open discussions about positive elements, including pleasure.
Implications. Assessment and intervention must address inequalities, fostering an inclusive, anti-oppressive approach. Revisiting harm reduction's initial conceptualization is vital, acknowledging diverse identities and characteristics in SSU practices, often overlooked in certain health services with persistent inequality factors.

“Harm reduction in a post-conflict setting: An ethnographic study of “Total Peace” and the war on smokeable cocaine in Colombia”

Sam Shirley-Beavan; Talk

Background
Harm reduction has primarily developed in response to the needs of people who use drugs, notably injected opioids, in the Global North. In Bogotá, Colombia the primary drug of concern is neither injected nor opioid, rather it is a form of smokeable cocaine, known as basuco. In this Global South, post-conflict setting, drugs and drug policy have played a major role in both violence and attempts at peace. This study contributes to the development of harm reduction policy in this context.

Objectives
To define ‘harm reduction’ in a context of smokeable cocaine use and identify potential harm reduction responses; to understand the production of drug-related harm using lenses of violence and zemiology; to understand how harm and harm reduction relate to the Colombian peace process.

Methods
Ten months of ethnographic fieldwork with street-based people who use basuco in central Bogotá from May 2022 to April 2023, including 41 semi-structured interviews with a purposive, stratified sample designed to include diversity of gender, age, race, displacement status, and drug use history.

Results and implications
There are causal links between the Colombian conflict and basuco-related harm across four zemiological categories (physical, economic, emotional and cultural harm). Framing drug-related harm in terms of violence (direct, structural and cultural) helps to identify generative mechanisms that produce harm. Drug policy must be included in peace processes, and this must extend to people who use drugs.

“Help-Seeking Behaviours Among Cannabis Consumers in North America: Findings from the International Cannabis Policy Study”

Samantha Rundle; Talk

Background: Little is known about the characteristics and predisposing factors of individuals who seek help to manage problems associated with cannabis use.
Objectives: The current study examined the percentage of cannabis consumers who sought help to manage cannabis-related problems, the most common sources of help sought, and factors associated with seeking help.
Methods: A total of 13,612 past 12-month cannabis consumers completed the 2022 wave of the International Cannabis Policy self-report online survey in Canada and the US. Whether participants sought help to manage cannabis-related problems, what sources of help were sought, perceived addiction to cannabis and the WHO ASSIST scale for problematic cannabis use was also assessed. Logistic regression models examined correlates of help seeking and sources of help.
Results: A total of 9.2% (n= 1211) of individuals sought help from any source and was more common among consumers who perceived themselves to be more addicted to cannabis, were younger, female, ‘White/Caucasian’, less financially stable, and those with less education (p<.05 for all contrasts). Consumers who sought help were most likely to seek help from a doctor/physician (44.9%), followed by online information (29.18%) and other health professionals (i.e., psychologist, 26%). Consumers who resided in a state where cannabis is recreationally legal were more likely to seek help than those in nonlegal jurisdictions.
Implications: Few consumers report seeking help to manage their cannabis use problems with higher levels of help seeking in jurisdictions with more permissive cannabis laws.

“Heroin Assisted Treatment: An Intervention Whose Time Has Come.....Again”

Mark Monaghan; Talk

Background
Several randomised controlled trials (RCTs) show that supervised heroin assisted treatment (HAT) is effective for people with long-term heroin addictions for whom the standard opioid substitution treatments (OST), such as methadone maintenance treatment (MMT), have not worked. Little is currently known about why and how HAT works.
Objectives
This paper reports on three inter-related studies undertaken by the author to assess what works for whom, in what circumstances and why in HAT.
Methods
The first study is a recently published systematic review and meta-analyses analysing the effectiveness of supervised HAT. The second study is a small-scale evaluation of a HAT programme in the UK. The third study is a living, realist synthesis of HAT.
Results
The systematic review concluded that when compared to MMT, supervised HAT more consistently retains people in treatment and reduces their consumption of illicit drugs. This finding is re-affirmed in the evaluation. Missing from both these studies is a detailed understanding of the mechanisms of action in HAT. Consequently, the third study presents some emerging findings from a living realist synthesis to understand the generative mechanism(s) of HAT focusing on the key realist question of what works, for whom, in what circumstances.
Implications
The paper concludes that HAT is by its nature a complex intervention, but one that should be re-invigorated as part of the repertoire of options and policy makers disposal to address record and rising levels of drug-related mortality in the UK and elsewhere.

“How accurate are drug cryptomarket listings by content, weight, purity and repeat purchase?”

Monica Barratt; Talk

Drug cryptomarkets may increase information available to market actors, which should reduce information asymmetry and increase market efficiency. This study aims to determine whether cryptomarket listings accurately represent the advertised substance, weight/number and purity, and whether there are differences in products purchased from the same listing multiple times. A 2016-17 dataset of law enforcement purchases from cryptomarket vendors (n=38) was matched with a dataset of cryptomarket listings (n=23). Almost all (92%) samples contained the advertised substance (mainly cocaine, methamphetamine, MDMA and heroin). In most of these cases (85%) drugs were either supplied as advertised weight/number or over-weight/number. All six listings that quantified purity over-estimated the actual purity, which varied from 11% to 58% less than advertised. There was no consistent relationship between advertised purity terms and actual purity (e.g., “free base pure cocaine” was 95% cocaine, whereas “purest cocaine available. pure uncut” was 58-66% cocaine). Across the six listings purchased from multiple times, repeat purchases from the same listing varied in purity, sometimes drastically (e.g., 18% vs 73% heroin), and while this was to be expected with long gaps between purchases, wide variation was also detected on listings purchased from only one month apart. In conclusion, cryptomarket listings are mostly accurate, but the system is far from perfect, with purity typically over-estimated. Community-led attempts at market self-regulation have been reported and warrant further investigation with more current data including a larger and less biased sample.

“How do prescription drug monitoring program alerts and other factors influence pharmacists' decisions to supply opioids? A randomised controlled factorial experiment”

Louisa Picco; Talk

Background: Prescription drug monitoring programs (PDMP) provide medication-related information about high-risk medicines to support clinical decision-making. This study aims to determine how PDMP alerts and other patient, pharmacy and medication-related characteristics influence pharmacists’ decisions to supply opioids.
Methods: Australian pharmacists completed an online randomised controlled factorial experiment. They were randomly allocated six clinical vignettes, describing a pharmacy patient and asked to indicate on a 0-10 scale, how likely they were to supply the opioid prescription within the vignette. Mixed-effects linear regression models were used to explore the association between vignette and pharmacy-related characteristics and the likelihood to supply opioids. Results: 598 pharmacists provided data relating to 3370 vignettes. The high-dose and multiple prescribers (4 or more prescribers in the past 3 months) PDMP alerts were the strongest predictors of reduced likelihood to supply, with a respective 2.8- and 3.8-unit decrease on the likelihood to supply scale (p=0.001). Unemployment (β=-0.42, p<0.001), and comorbidities of Hepatitis C (β=-0.26, p=0.009) and Depression (β=-0.30, p=0.003) were also significantly associated with decreased likelihood to supply opioids. Medication-related characteristics including high opioid dose (40mg twice daily) and a co-prescription of opioids with benzodiazepines saw a reduced likelihood to supply of 0.26- and 0.48-units, respectively. Implications: PDMP alerts were the most influential factor associated with reduced likelihood to supply, while other factors associated with economic disadvantage and stigma were also associated with a reduced likelihood to supply. It is important that PDMP-related unintended consequences observed elsewhere, including medication refusal or rapid tapering, are avoided locally.

“Ignored Inequities: Analyzing the Development of British Columbia’s “Stop Overdose” Campaign”

Tia Greto; Talk

Background: Due to inequities fuelled by racism and classism, substance use stigma and overdose death disproportionately impact those from non-White, low-income groups. In response, government and public health organizations across Canada have released anti-stigma campaigns featuring images of people who use drugs (PWUD). Ironically, the majority of these images appear to be of PWUD belonging to White, middle-class groups. This effectively ignores intersecting roles of racism and classism in the experience of stigma, shifting attention away from those worst affected by the drug toxicity crisis.
Objective: To better understand this troubling trend, we examined the development process of the BC Government's high-profile Stop Overdose campaign. We aimed to identify key factors that explained how and why White, middle-class PWUD came to dominate the campaigns’ imagery and messaging.
Methods: Through a Freedom of Information (FOI) request we obtained 320 pages of government documents outlining the real-time development, testing and evaluation of the Stop Overdose campaign. These documents were analyzed using reflective thematic analysis.
Results: We identified that campaign developers’ goal of shifting the focus away from the “stereotypical” marginalized drug user, and the prioritization of campaign “relevance” can explain the Stop Overdose campaign’s focus on White, middle-class PWUD.
Implications: This analysis highlights wider social implications of anti-stigma messages that under-represent PWUD most affected by overdose mortality. It also provides a critical perspective on using campaigns to address substance use stigma, and by extension, the drug toxicity crisis.

“Impact of prescribed “safer supply” on psychosocial outcomes: a prospective cohort study”

Karen Urbanoski; Talk

Background: British Columbia, Canada introduced the Risk Mitigation Guidance to support the prescription of pharmaceutical alternatives to the toxic unregulated drug supply in 2020. This provincial prospective cohort study evaluates the impact of prescriptions on self-reported psychosocial outcomes, including health-related quality of life, depression, anxiety, frequency of unregulated substance use, COVID-19 protective behaviours, and reliance on criminalized income sources.
Methods: Data were collected using a longitudinal survey of people who had received a prescription or were seeking one out (n=161), with up to 5 time points per participant over 3 months. Generalised estimating equations (GEE) were used to assess the effects of time-varying prescription exposure on outcomes over follow-up period, controlling for encounters with police and bylaw officers, service use, social support, and sociodemographic characteristics.
Results: There was no evidence of an effect of prescription receipt on the change in any outcome over time. There was also no evidence of change in outcomes over the 12-week follow-up period independent of prescription status. The one exception was for COVID-19 protective behaviours, which showed a very small increase over time (adj. β = 0.0044, 95% CI = 0.001, 0.008). Point estimates suggested small overall protective effects of prescription status on depression (adj. β=-0.34, 95% CI=-0.82-0.14) and frequency of unregulated substance use (adj. β = -0.21, 95% CI = -0.48-0.061) over the follow-up period, although confidence intervals included the null value.
Discussion: Findings signal the potential promise of prescribed safer supply, along with the need for improvement. Further work is needed to inform the development of service models that combine prescriptions with comprehensive services and supports to maximize positive outcomes.

“Impacts of the COVID-19 pandemic on drug availability in Vancouver, Canada: An interrupted time-series analysis of drug market trends from 2018 to 2022”

Anmol Swaich; Talk

Objectives: Although the COVID-19 pandemic is believed to have impacted unregulated drug markets globally, precise impacts in North America have not been characterized. We sought to estimate potential changes in availability and price of unregulated drugs pre- vs. post-pandemic in Vancouver, Canada.

Methods: Data were derived from two prospective cohorts of people who use drugs in Vancouver from 2018-2022. We utilized interrupted time series analyses to identify changes in monthly prevalence of immediate availability (within 10 minutes) and median street price of crystal methamphetamine, cocaine, crack cocaine, and ‘down’ (unregulated opioids), post-pandemic (i.e. post-March 2020) among 739 participants.

Results: Monthly prevalence of immediate availability significantly decreased for all drugs immediately post-pandemic (all p<0.05). Cocaine declined most by -18.1% (95% confidence interval [CI]:-25.9, -10.4) and ‘down’ declined least by -13.0% (95% CI:-18.8, -7.3). There were no significant changes in trends of monthly prevalence of any drugs post-pandemic (all p>0.05). The only significant change in median street price was for cocaine which increased by $3.46 per 0.5 grams (95% CI:1.0, 5.9).

Discussion: For all drugs examined in this study, except for cocaine, the stagnant price amidst decreased availability may reflect increased contamination of unregulated drugs post-pandemic in our study setting. These findings may have implications for drug policy and practice approaches, particularly in regions where synthetic psychoactive substances are emerging in the drug supply.

“Impacts of the COVID-19 pandemic on supervised consumption service delivery in Vancouver and Surrey, Canada during overlapping emergencies: Challenges and emergent worker resistance”

tyson singh kelsall, Michelle Olding; Talk

Background: After the onset of the COVID-19 pandemic, an increased number of people were killed by the toxic drug supply in Canada. Emerging evidence suggests that reduced access to harm reduction services was a contributing factor.

Objective: To explore the impacts of the pandemic-related regulations on supervised consumption site (SCS) service delivery in Vancouver and Surrey, Canada.

Methods: Between October 2021 and March 2022, in-depth, semi-structured interviews were conducted with staff from two SCS: SafePoint in Surrey (n=12) and Insite in Vancouver (n=9). Thematic analysis focused on key changes to SCS delivery after the emergence of the COVID-19 pandemic, with a focus on associated challenges and emergent staff responses.
Results: Participants described key challenges as: capacity restrictions hindering service access and quality of care; exclusion of frontline perspectives from evolving SCS policy and practice decision-making; intensified hierarchies between staff and service users; and issues related to overdose presentations, response policies and procedures. Emergent staff responses to these challenges included: collective staff resistance to policy changes; individual frontline staff non-compliance with emerging policies and procedures; and staff disengagement from their roles at SCS.
Implications: This study highlights how COVID-19-related changes to service delivery produced challenges for SCS staff and service users, while identifying strategies employed by staff to address these challenges. Additionally, the findings point to opportunities to improve care and supports for people who use drugs in the context of intersecting public health crises.

“Increased availability of non-prescribed hydromorphone not observed to coincide with increased initiation into use among street-involved young people who use drugs in Vancouver, Canada”

Kora DeBeck; Talk

Background: In the context of the COVID pandemic and drug poisoning deaths, prescribed “safer supply” (PSS) of pharmaceutical medications was introduced in 2020 in BC as alternatives to toxic street drugs. The most prescribed opioid was hydromorphone. This study examined trends in non-prescribed hydromorphone availability, price, and initiation.

Methods: Between 2015 and 2022, data was collected from a cohort of street-involved young people in Vancouver. Extended Cox proportional hazards models were used to assess if COVID and the introduction of PSS were associated with non-prescribed hydromorphone initiation among participants age <30 years.

Results: During the study period, the street price of hydromorphone dropped from $10 to $1 per 8mg pill. The proportion of participants who reported being able to obtain non-prescribed hydromorphone within 90 minutes increased from 15% in December 2018 to 55% in 2021. Of the 293 participants included in the Cox analyses (who had no history of hydromorphone use at baseline), the mean baseline age was 23.3 and 29 (9.9%) participants initiated non-prescribed hydromorphone use. In the multivariable extended Cox model, the COVID/PSS era was not associated with initiation.

Discussion: The reduction in non-prescribed hydromorphone price and increased availability suggests a surge in supply. However, among this study sample, no significant increase in the rate of initiation was observed. Despite increased availability and low price, street-involved young people who use drugs were not more likely to start using non-prescribed hydromorphone after the pandemic and introduction of PSS.

“Individual-level harm reduction intervention coverage among people in Australia who inject drugs”

Olivia Price; Talk

Background: Programmatic data suggests Australia has high coverage of harm reduction strategies; individual-level data can indicate whether these programs are implemented effectively.
Objective: To determine individual-level harm reduction intervention coverage among people who inject drugs in Australia and compare coverage across intersectional risk factors (gender, housing, main drug injected, and lifetime incarceration).
Methods: We used data from the 2023 Illicit Drug Reporting System, in which 820 people who inject drugs and reside in an Australian capital city were interviewed. Individual-level needle/syringe coverage was defined as the percentage of injecting episodes ‘covered’ by at least one sterile needle/syringe per participant in the past month. Coverage for other harm reduction interventions (opioid agonist treatment [OAT], naloxone) was defined as the percentage of participants who reported recent access.
Results: Most participants had sufficient needle/syringe coverage (90%; 95% confidence interval [CI]: 83-97%). Among those who recently used opioids (n=607), half accessed naloxone during the past year (53%; 47-58%). Among those with possible opioid dependence (n=296), 62% (53-72%) had recently been in OAT. Needle/syringe coverage was lowest among people who predominantly injected methamphetamine (p=0.013). There was no evidence for difference across intervention coverage by gender, housing, or incarceration.
Implications: Individual-level needle/syringe coverage is high in Australia but gaps remain in the implementation of other interventions. Ensuring those who predominantly inject methamphetamine have access to sufficient needles/syringes should be prioritised, especially in the context of increasing use in Australia.

“Institutionalised stigma in Canadian judicial decisions and implications for drug policy”

Niki Kiepek; Talk

Background
The United Nations calls for humane and effective “science-based and evidence-based policy decisions.” Existing criminal drugs laws, conventions, and policies are heavily influenced by populist politics. This study examines how drug-related harm is constructed in Canadian case law and examines potential impacts on policy.

Objectives
The purpose of this research was to explore how drug-related harm is understood and represented in Canadian case law pertaining to the importation, possession, production, and/or trafficking of drugs.

Methods
Critical discourse analysis methodology was used to examine judicial reasoning about harm. Westlaw, Lexis Nexis, CanLII, and Supreme Court of Canada databases were used to identify Canadian relevant cases prior to January 30, 2023.

Results
A total of 129 cases were included, with moralization language – defined as “the usage of language cues referencing moral values” (Malik, et al., 2021) – appearing in 64% of the cases. Institutionalized stigma was produced through heavy reliance on judicial tropes (e.g., “scourge to society,” “unfortunate addict,” “predator,” “parasite”) and insufficient integration of evidence-informed law. Reliance on tropes legitimizes value judgments, exacerbates perceptions of harm, and overshadows the need to accurately use empirical research.

Implications
When recorded in judicial decisions, stigmatizing language becomes viewed as appropriate, legitimate, professional truths that are subsequently cited in textbooks, journal articles, and news reports, become embedded in legal curricula, and inform policy and legislation. I conclude with recommendations to promote i) improved research literacy, ii) accurate understanding and representation of harm, and iii) reduced legitimization of stigmatizing language and practices.

“International drug policy constellations: exploring the role of power and morality in international drug policy debates at the 2024 Commission on Narcotic Drugs”

Alex Stevens; Talk

Background: At national level, it is possible to identify multiple competing constellations of policy actors and policy positions that come together around shared ethico-political bases. The outcome of policy debates can be explained by examining the forms of power that these constellations deploy (Stevens, 2024). It should also be possible and useful to do this for the international level of drug policy making.
Aim: To identify international constellations of policy actors and positions and explore how this helps explain the outcomes of international policy discussions.
Methods: This paper uses discourse analysis of international policy documents and debates at the 2024 Commission on Narcotic Drugs (CND) to inform two-mode social network analysis of the ties between policy actors (individuals, organisations, and countries) and policy positions expressed at the CND. This will be compared to existing frameworks for the analysis of the distribution of moral values across countries (e.g. the World Values Survey Cultural Map).
Findings: Assuming it is possible to identify such international policy constellations, the presentation will show sociograms which display the most prominent policy constellations in international discussions. It will show the links between these policy constellations and their ethico-political bases. It will use these links to suggest a provisional and critical explanation of the outcomes of policy discussions at the 2024 CND.

“International Drug Policy Study Trends With Psychedelic Drugs: A Spotlight on Psilocybin LSD, and MDMA”

Myfanwy Graham; Talk

Background: There is renewed interest in the therapeutic applications of psychedelics. Australia was the first country to permit authorized psychiatrist-prescribed psilocybin and 3,4-methylenedioxymethamphetamine (MDMA) from July 1st, 2023. Canada permits use via a Special Access Program and the U.S. FDA has permitted use in clinical trial settings since 2017 as “breakthrough therapies”.

Aims: To assess the difference in levels and purpose of use of psychedelics across countries with different policy approaches.

Methods: Data are from the 2023 International Cannabis Policy Study (ICPS): cross-sectional data from national surveys conducted among 16-65 year-olds in Canada (n=19,984), the U.S. (n=39,778), and Australia (n=3,054). The survey examined the prevalence of past year and lifetime use for psychedelics, including use for therapeutic reasons, sources, and perceived benefits.

Results: Despite jurisdictional policy variance, across the three countries approximately one-fifth of respondents reported using a psychedelic in the past 12-months. North American participants who reported using psychedelics were most likely to report using psilocybin containing-substances, followed by LSD, and MDMA. Australian participants were most likely to use MDMA. While there is heightened interest in therapeutic applications, most respondents used psychedelics for recreational purposes or overlapping therapeutic purposes across all countries. There was a large degree of variance in the frequency of use by substance and country.

Conclusions: Our study provides global insights into the potential impact of drug policy changes on psychedelic use patterns for recreational and therapeutic purposes.

“Investigating trends among people who inject drugs: Longitudinal analysis of the drug content of used injecting paraphernalia in Sydney, Australia”

Harrison Fursman; Talk

Background: Understanding drug use trends among people who inject drugs (PWID) is frequently based on self-reported data. Whilst insightful, it can be subjective and provides limited specifics on the drug composition. The chemical analysis of the residual drug content in used syringes has been shown to complement self-reported information. Chemical analysis can confirm the main drug injected and detect other components, such as adulterants. Injecting drug use is a dynamic; hence a longitudinal analysis might provide greater insight into market behaviours and the preferences of PWID.
Objectives: This study aims to examine the residual drug content of used syringes over time to observe trends in injecting drug use.
Methods: Used syringes were collected through multiple periods from July 2022 until early 2024 from the Medically Supervised Injecting Centre (MSIC) and four needle and syringe program (NSP) locations in Sydney. The residual content was extracted before gas chromatography - mass spectrometry (GC-MS) detection; the results were compared to the drugs self-reported by MSIC clients.
Results: Heroin, methamphetamine and pharmaceutical opioids were the most common drugs injected; sample dependent. Adulteration (for example, with 2’-fluoro-2-oxo PCE) and polydrug mixtures (heroin/methamphetamine mixtures) remained low throughout all samples.
Implications: This research aligns well with Australia’s harm minimisation approach to drugs. It holds great potential for harm reduction at the individual level for PWID by providing insights into the current drug market. This could be further enhanced by the provision of a drug-checking service at MSIC.

““It just doesn’t stop”: perspectives of women who use drugs on increased overdoses during the COVID-19 pandemic”

Kelsey Speed; Talk

Background: Public health guidelines designed to reduce the transmission of COVID-19 (eg: social distancing) directly contradicted guidance developed in response to the ongoing overdose crisis (eg: never use drugs alone), exacerbating harms associated with reliance on the unregulated drug supply and criminalization of people who use drugs. While existing literature outlines the evolving risk environment associated with consuming unregulated drugs during COVID-19, less is known about the impact on women. Objectives: We explored the perspectives of women (cis-gender, transgender, gender-diverse) who use drugs on how the COVID-19 environment shaped their overdose risk in British Columbia, Canada. Methods: We conducted semi-structured interviews remotely with 45 women who use unregulated drugs between May 2020 and September 2021, and analyzed the data thematically. Results: ‘Social distancing’ guidelines, administered via guest restrictions in housing and reduced capacity in harm reduction services, resulted in more women using drugs alone with less chance of timely intervention in the case of overdose. This risk was exacerbated by changes in the unregulated drug supply, including increased toxicity and unpredictability of available drugs. Participants identified practices they applied to mitigate harms associated with these conflicting guidelines, with a particular emphasis on acts of caregiving they engaged in to support other women in their community (eg: establishing informal networks that regularly check on each other). Implications: Women who use drugs experience harms associated with oppressive social and structural environments, which are further intensified by policies that are developed without consideration of their unique circumstances.

“Lay Perspectives on Drug (De)Criminalization and the (De)Stigmatization of People Who Use Illicit Drugs”

Hamnah Shahid; Talk

Background: We theorize the political function of drug criminalization as contributing to stigma systems exerting social control over people who use illicit drugs (PWUID). Consequently, drug decriminalization may be a potential destigmatizing solution. Since decriminalization is often positioned as an anti-stigma intervention targeting the public, it is important to understand how laypeople conceptualize decriminalization. Objectives: We aimed to explore: (1) how laypeople conceptualized drug (de)criminalization and its relation to the (de)stigmatization of PWUID; and (2) the potential implications of the various conceptualizations of (de)criminalization for the autonomy of PWUID. Methods: We acquired, via a Freedom of Information request, 221 deputations sent to the City of Vancouver regarding Motion B.4, which would advance decriminalization. These deputations were analyzed using reflexive thematic analysis. Results: Supporters of Motion B.4 commonly assumed decriminalization would destigmatize PWUID, and often argued that the drug toxicity crisis is a public health problem, not a criminal one. Meanwhile, those opposed commonly positioned criminalization as a necessary stopgap to avoid community harm. This view was echoed by some proponents, notably those who argued for public health models of decriminalization. Finally, some proponents asserted that PWUID should be included in policymaking, though few deputations came from self-identified PWUID. All PWUID argued that decriminalization must exclude police. Implications: Our analysis of lay perspectives on decriminalization highlights the importance of models that adequately address all levels of stigma for PWUID. Models that fail to preserve the autonomy of PWUID are likely to reproduce their stigmatization.

“Local cannabis policy and retail availability and risk of adolescent psychosis, depression, suicidal ideation and dropping grades”

Lynn Silver; Talk

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“Longitudinal analysis of social norms towards cigarettes and HTPs among adult smokers and HTP users in Japan: Findings from the 2018-2021 ITC Japan Surveys”

Giang Vu; Talk

Background: A significant number of people who smoke have adopted heated tobacco products (HTPs), either concurrently with cigarettes or exclusively through switching. This study investigates the influence of social norms on the transition between cigarette and HTP use.
Methods: Data were collected from people who used tobacco products in at least two consecutive waves of ITC Japan study (2018 – 2021). The association between social norms at baseline wave and tobacco product use in the follow-up wave were assessed using mixed effect multinominal logistic regressions on weighted data, controlling for demographics.
Results: While most perceive HTP use as less harmful than cigarettes, 29.6% of those who use cigarette exclusively lack awareness of HTP harm. Across groups (exclusive cigarette, exclusive HTP, dual product uses), many have smoking friends (84.7%, 83.3%, 85.3%) and perceive disapproval of smoking from close circles (49.3%, 52.5%, 57.2%) and society (67.2%, 67%, 65.5%). Those who use HTP exclusively more often have friends using HTPs (78.16%) and perceive disapproval of HTP use from friends (39.1%) and society (38.9%). While most continue product use in the follow-up wave, those who use HTP exclusively were more likely transition to non-current users. Perceived positive social norms towards cigarette use were significantly associated with continued exclusive cigarette use in the next wave. Having friends using HTPs increased the likelihood of using HTP in the next wave, either exclusively or concurrently with cigarettes, or reducing tobacco product use to non-current level, relative to exclusive cigarette use. However, perceiving that the public was approved of or being neutral towards HTP use was also associated with increased likelihood of continued cigarette use in the next wave, mostly concurrently with HTP.
Implications: To address these dynamics, public health interventions should focus on clear communication, targeted education, and promoting healthier social norms, while simultaneously dispelling misconceptions about HTP harm and creating supportive environments for smoking cessation.

“Measurement of drug harms in existing survey data: Example from a New Zealand cohort”

Jennifer Whitehill; Talk

Background: Current survey data that could be used to identify and prioritize interventions to reduce drug harm often focus on prevalence of substance use (and use disorders) rather than measurement of harms.
Objectives: To assess the extent of drug harms measurement in a New Zealand cohort study and estimate prevalence of specific harms from alcohol, cannabis, tobacco and other drugs.
Methods: Survey data came from the Christchurch Health and Development (CHDS) birth cohort. We used data from age 18-40 regarding drug use and DSM-IV criteria for abuse and dependence of alcohol, tobacco, cannabis, and 9 other drugs. We classified survey items into relevant harm criteria categories (e.g., drug-specific damage to heath, loss of tangibles) then generated substance-specific prevalence estimates for harm.
Results: The most common harms were alcohol-related loss of tangibles (e.g., loss of employment) as reported by 37.0% of the cohort, tobacco withdrawal-related impairment of mental functioning (28.0%), alcohol-specific health damage (27.3%), alcohol-related loss of relationships (27.8%). Cannabis-related health damage was reported by 20.4% of the cohort, followed by cannabis related impairment of mental functioning, loss of tangibles, loss of relationships (11.8%, 11.6%, 10.2%, respectively).
Implications: Harms from alcohol were more common as compared to harms from other drugs. Though drug-related mortality was not considered, these data nonetheless support a need to better align drug policy with the specific types of harm that drugs contribute at a population level.

“Misrepresentation and Adulteration of MDMA in the United States, 1999-2021”

Eric L. Sevigny; Talk

Background: The misrepresentation and adulteration of illicit drugs is an enduring feature of illegal drug markets. The use of unregulated drugs increases the risk of overdose, adverse health events, and other unwanted effects. Objectives: We used data from DrugsData, an anonymous drug checking service, to investigate deception in the US ecstasy market between 1999-2021. We documented trends and patterns in the misrepresentation and adulteration of MDMA and compared the nature and extent of deception across different forms of ecstasy. Methods: We operationalized various metrics of misrepresentation and identified specific MDMA adulterants, including timing of market entry and exit. Analytically, we employed descriptive statistics, trend analysis, and tests of bivariate associations to investigate trends and patterns of deception. We also assessed the criterion validity of DrugsData against law enforcement seizure data collected by NFLIS-Drug. Results: Most (58%) of the alleged ecstasy in our sample was misrepresented in some manner. Patterns of misrepresentation varied across time, as exemplified by periods of decline (1999-2009, MDMA concentration decreased from 51% to 11%), rebound (2009-2018, MDMA concentration increased from 11% to 59%), and stabilization (2018-2021, MDMA concentration stabilized between 71% and 75%). We also documented 179 known substances other than MDMA in alleged ecstasy items and found that “molly” was more likely to contain novel psychoactive substances. Conclusions: Drug checking services can play an important role in monitoring these dynamics to reduce these harms. Increasing funding for drug checking services and removing bureaucratic barriers to their operations should be a US drug policy priority.

“Modeling choices and change in choices of polysubstance use.”

Georgiy Bobashev; Talk

Changes in drug availability, price, law enforcement activities and pressures form social networks and drug markets can force people who use drugs to change their polysubstance use patterns. An agent-based model was developed to simulate such changes. We considered six drugs: heroin, methamphetamine, crack cocaine, powdered cocaine, marijuana, and “other” which is a proxy for new drugs such as fentanyl, xylazine, or any other substance with known properties. “Other” could also serve as a proxy for alternative non-drug reinforcements, e.g. recreational activities, that could be potentially introduced. The model was calibrated to represent qualitative changes in drug use (methamphetamine and heroin co-use patterns) in rural Ohio. Ethnographic data was used to estimate the relative role of these factors in the choices of drug combinations. Scenarios dealt with law enforcement actions on methamphetamine, heroin, and both: heroin and methamphetamine. The model replicated historic (baseline) patterns of use and changes from methamphetamine to heroin to both in rural Ohio. Analysis of the scenarios illustrated the adaptive nature of individual choices leading to short- and long-term changes depending on the length and the strength of the interventions. The role of “other” reinforcer depends on its properties and the length and strength of the interventions. It is possible to temporarily switch to the “other” reinforcer, but the sustainability depends on its properties and correlation with other drugs. We identified gaps in knowledge and data that could be filled with ethnographic research.

“Monitoring Public Health in a Transforming Drug Policy Landscape: Oregon, USA”

Julia Dilley; Talk

Background. In 2020, the state of Oregon, USA, passed two major drug policies: decriminalizing possession of small amounts of illicit drugs while increasing behavioral health resources and legalizing the facilitated use of psilocybin.

Objectives. We examined multiple public health data systems to assess associations between policy changes and drug-related health outcomes for Oregon and other states.

Methods. We assessed monthly counts of Oregon drug-related hospitalizations, emergency department (ED) visits, poison center cases, and deaths over an up to 13-year period, including 2 years after policy changes. Outcomes were defined by drug group (stimulants, depressants, psychedelics, alcohol) and specific drug (e.g., fentanyl, psilocybin). We used Joinpoint software to identify breaks in trend. When possible, we disaggregated data for specific populations (e.g., by gender, age group, race/ethnicity, and region) and compared outcomes for 2 years pre- and post-policy. We compared Oregon Poison Center trends to those of other Western states.

Results. Poison center data indicate significant increases in fentanyl exposures in Oregon during 2021-2023. Although coinciding with the spread of fentanyl to the Western US, these Oregon increases are greater than in most surrounding states. However, hospitalization, ED, and death outcomes for opioids and fentanyl show less extreme increases. Oregon psilocybin cases increased before the start of facilitated use; other states showed increases too.

Implications. Our findings show the importance of examining outcomes from complementary data systems and comparison to other jurisdictions. Longer-term study is needed to understand full policy effects.

““More Doctors Smoke Camels”: Developing guidelines for cannabis researchers working with industry”

Daniel Bear, PhD, Kari Layne Kramp, PhD; Talk

Background: Corporate influence on research is nothing new, with numerous examples highlighting the role that sugar, oil, tobacco, alcohol, and other industries have played in shaping public health science and messaging. In 1946 the RJ Reynolds Tobacco company famously gave physicians cartons of Camel cigarettes to solicit their endorsement that Camels were the safest ones on the market. In response to the long history of industry influence efforts, guidelines have been established for how academic researchers and others engage with and report their activities in partnership with industry.
Objectives: This paper seeks to identify established guidelines for researchers in other industries and consider how they can be applied or modified for use with the nascent cannabis industry. We will then present a model set of guidelines for cannabis researchers.
Methods: An environmental scan of current regulations, rules, and best practices in the alcohol and tobacco industry’s interactions with researchers. A literature review on the history of industry engagement with academic researchers, the methods by which industry tries to shape research findings, and the trajectory of best practice guidelines for researchers.
Implications: By developing best practice guidelines early in the history of legalized cannabis we can help both researchers and industry avoid the conflicts that undermine trust in scientific findings about these products and industries. While these guidelines are designed for the commercial nature of the Canadian industry, it has applicability to other international models and relevance to researchers in countries that legalize non-medical cannabis.

“Naloxone-on-release as a tool to address race/ethic disparities in naloxone access”

Peter Davidson; Talk

Recent research in California suggests non-White people who use drugs are less likely than White people who use drugs to receive naloxone, carry naloxone, or get refills after naloxone use.
In January 2020 the Los Angeles County Sheriff's Department implemented a naloxone-on-release program in which all inmates being released from the Los Angeles County Jail system (average nightly population 13,232) are exposed to a video training on overdose recognition and response, and are able to take as many doses of naloxone as they wish from a no-cost vending machine at the point of release. Between January 2020 and June 2023, 217,163 individuals were released and 126,820 doses of naloxone were distributed (average 3020 doses/month).
The primary aim of the program is to increase naloxone access among individuals being released from incarceration, a group at particularly high risk of opioid-related overdose death. However, naloxone-on-release may also help improve access to naloxone among non-White people who use drugs, given that the LA jail system, like most in the US, disproportionately holds non-Whites (87% of the jail population is non-White, compared to 30% of the county population). In this paper, we describe initial findings from vending machine data and cross-sectional surveys with 478 individuals conducted immediately after release, with an emphasis on uptake of naloxone by non-White people who use drugs and/or have witnessed overdose in the past.

“Navigating harm reduction in Hong Kong’s ‘drug-free’ society.”

Verity Smith, Cynthia Wing Nga LAM; Talk

Hong Kong’s drug policy was once described as ‘enlightened prohibition’, characterised by its emphasis on rehabilitation and a low-threshold, high-coverage methadone maintenance programme for heroin users (Cheung & Ch’ien, 1997). At the turn of the millennium, with a shift and diversification towards psychotropic drugs, the government had to identify new ways of addressing the needs of the broader range of people who use drugs (PWUD) and the types of drugs used. At the same time, it has remained firm in its goal of a ‘drug-free’ society. Through interviews with PWUD (n=75) and 5 focus groups with social workers (n=17), we sought to understand how, in Hong Kong’s abstinence-oriented policy context, PWUD manage drug-related risks. With a lens of drug, set and setting (Zinberg, 1984), we found that PWUD consider moderation to be the most important aspect of harm-reduction, and attending rehabilitation centres provides an opportunity for a ‘circuit-break’ in their drug-using careers, yet the abstinence-orientation dissuades some from seeking treatment. While PWUD adopt self-directed strategies for quality control and drug administration, they face a plethora of risks relating to the social setting of their use. In conceptualising harm-reduction as ‘well-being’ maintenance (Boucher et al, 2017), we found that different groups of PWUD have varying levels of acceptance of health-related risks in pursuit of other well-being interests. Our findings have implications for the acceptability of harm-reduction interventions in Hong Kong.

“Navigating the myriad of analytic choices for policy evaluation studies”

Megan Schuler; Talk

Drug policy laws vary widely across states, providing a unique opportunity for policy evaluation studies to shed light on which policies are most effective. These studies employ a range of analytic methods, including difference-in-differences, interrupted time series, synthetic control, and autoregression models, among others. Recent advances in difference-in-differences methods have addressed issues such as staggered policy adoption and heterogeneous treatment effects, making them increasingly popular in policy evaluation studies. However, with so many methods available, selecting the most appropriate one for a given context can be challenging for applied researchers.

This talk will provide a brief overview of the most commonly used analytic methods in policy evaluation studies, highlighting the relative advantages and shortcomings of each method. In addition, a methodological "decision tree" framework will be presented to help researchers identify the most appropriate method(s) for their specific policy evaluation context. This framework will highlight key decision points regarding study design (e.g., presence of a comparison group?, more than one state adopted the policy?, staggered policy adoption across states?) that impacts which method(s) may be appropriate. A case study evaluating state opioid policy laws will be used to demonstrate the decision tree framework.

Overall, this talk will provide valuable insights for researchers who are interested in conducting policy evaluation studies. No prior experience with policy evaluation studies is assumed.

“Netchain Analysis of Cocaine Trafficking in Colombia: Patterns and Policy Implications”

Siddharth Chandra; Talk

Netchain analysis is a useful approach to understanding cocaine trafficking in Colombia because cocaine trafficking networks combine features of supply chains and networks, and hence can be characterized as netchains. As cocaine moves across Colombia, it can be transformed from cocaine paste to cocaine base to cocaine hydrochloride, giving cocaine trafficking a supply chain like structure. Cocaine paste, base, and hydrochloride can also move across the country without being transformed into downstream products, giving cocaine trafficking a network like structure.

The present study uses data on the prices of cocaine paste, base, and hydrochloride across administrative regions of Colombia over time to extract the netchain structure of cocaine trafficking. The data were obtained from the Colombian Narcotic Police. We analyze this netchain structure using methods adapted from network analysis, which is used for homogeneous product flows, for netchain analysis, which allows for the product to be transformed as it moves across space. This netchain analysis enables us to identify structural features of the cocaine netchain in Colombia, providing insights into its properties and possible policies and strategies to disrupt the netchain. A by-product of this exercise is the creation of netchain-analytic statistics that are analogous to network-analytic statistics.

“Non-medical Cannabis & international law: compliance and controversies”

Kenzi Riboulet Zemouli; Talk

The 1961 Single Convention on Narcotic Drugs (C61) establishes the core international legal regime for cannabis, which has often been described as mandating a prohibition of non-medical (recreational) uses. In 2022, a study was published discussing these international provisions in light of the ongoing calls recreational cannabis regulation. The study contends that the C61 is not a prohibition treaty, but rather Framework medical/pharmaceutical Convention. Presented at the Commission on Narcotic Drugs (CND) and International Narcotics Control Board (INCB), it generated intense debates among scholars and policymakers.

The study is an applicatory contestation of C61 relying on a classical text-based interpretation compared with intention-based and teleological interpretations. Treaty provisions on cannabis are analysed, highlighting the separation between medical and non-medical and conditions for exemptions. Recent legal changes (2020 rescheduling) and language evolution at CND are also reviewed.

All schools of interpretation coincide in giving relevance to existing C61 exemption clauses, in particular article 2(9), for non-medical uses, which are not exclusive of recreational uses. There are conditions. The study argues that this existing international legal environment provides a compliant pathway for decision-makers in legalizing non-medical cannabis.

In conclusion, the presentation will discuss the reception, introduce the criticisms received, and address them. The influence of the study, in particular over recent national legislative reforms, but also its impact on changing language at the INCB, would be put in perspective to conclude the session.

“Peer harm reduction on the darknet: a mixed-methods transnational research”

Richard Frank, Ákos Szigeti, Kiss Tibor; Talk

Background: Amid the opioid overdose crisis, communities have formed around darknet markets to reduce the risks of darknet drug trade, including the harms of substance use. However, the nature and quality of harm reduction efforts by darknet market operators, drug vendors and substance users have not yet been examined.
Objectives: The aim of this research was to gain a deeper understanding and to evaluate this community-based peer-to-peer harm reduction activity.
Methods: A mixed-methods study was conducted to first explore the harm reduction topic of a darknet forum through qualitative content analysis, and then to further evaluate the results through focus group interviews involving harm reduction practitioners from Budapest, Hungary and Vancouver, Canada.
Results: The results showed that peer harm reduction among darknet operators, drug vendors and substance users is supported by both experts and professional organisations present in the darknet forum. The main theme of the darknet forum was drug testing, the availability of which depends on national legislation and the resources of local harm reduction organisations.
Implications: These findings highlight transnational variations in the role of global darknet markets in harm reduction and call on decision and policy makers to increase the cross-border availability of harm reduction programmes, the resources of harm reduction organisations and re-evaluate local drug policies.

“Police-led Drug Diversion Policies in Action: Mapping Mechanisms of Change in Varied Contexts”

Charlie E Sutton; Talk

The UK Parliament Home Affairs Committee report on drugs (August 2023) recommended that the UK Government adopt a broader range of health-based harm reduction methods alongside efforts to shrink the illicit drugs market. Central to these health-based harm reduction approaches are an expansion of diversionary schemes, often referred to as out of court disposals or resolutions. These are intended to channel people who use drugs away from the criminal justice system and into treatment, education and support. More recently the use of diversionary approaches in England and Wales have become increasingly police-led. Most police forces now use diversionary approaches to drug possession offences and/or drug-related crime, but only some areas have formalised policy and practice. Evidence on the impact of these programmes in the UK remains limited.
This paper adds to this evidence-base, discussing the emerging results from a large-scale, multi-site, realist evaluation of police drug diversion (PDD) programmes, funded by the UK Cabinet Office. PDD policy implementation is explored in data collected from interviews with 60 police officers involved in the implementation or use of established PDD programmes in three forces in England. We focus on the way in which PDD policy is implemented in policing contexts, with differing attitudes and varied circumstances affecting the mechanisms that change attitudes and behaviour, leading to diverse outcomes. We reflect on the policy and practice implications arising from these findings, considering how these compare to the intended policy aims.

“Policy Alienation and Police: Early Signs of policy challenges with decriminalization in BC, Canada”

Sarah Ferencz, Alissa Greer; Talk

Drug policy implementation depends on the actions of public servants designated to apply the policy. This can be examined in the implementation of decriminalization in British Columba, which was enacted on January 31, 2023. This qualitative study consisted of 36 semi-structured interviews with active police officers in British Columbia prior to its implementation between September and January 2023. Interview questions focused on officers’ views of decriminalization and the policy process. One area that police officers discussed was policy planning and its potential impact on implementation. In the analysis, we used policy alienation theory to examine police officers’ views of the planning stages of policy implementation. Findings show that police officers experienced policy powerlessness from a lack of influence in the process of designing BC’s decriminalization model. This powerlessness was linked to a perceived loss of operational power, such as the ability to respond to public drug consumption. Police also expressed policy meaninglessness as they anticipated decriminalization would not have an impact on addressing the overdose crisis and complicate their ability to meet the needs of the public, including people who use drugs. These study findings have implications for the potential compliance and engagement with implementing the policy among the professionals designated to translate the policy it into practice – police officers. Evidence of policy alienation, via operational powerlessness and meaninglessness may be an indication that the policy will fail to achieve its intended objectives – to reduce stigma and redirect people who use drugs away from the justice system.

“Possible Effects of Cheap Fentanyl on Drug Markets, Use, and Harm: A Theoretical Analysis”

Peter Reuter; Talk

Background: The spread of illegally manufactured fentanyl (IMF) has been a public health disaster in Canada and the United States, driving overdose deaths to unprecedented levels. It has also changed the production function for drug traffickers, most notably by radically reducing raw materials costs for those producing illegal opioids.
Objectives
Examine the consequences of the reduction in opioid production costs and the elimination of seasonal variability in supply on all the categories of market participants, from Chinese firms who supply Mexican Transnational Criminal Organizations (TCOs) with the precursors of fentanyl, the TCOs responsible for manufacturing fentanyl and shipping it across the U.S. border, the multiple layers of the domestic drug distribution network, to the users themselves.
Methods
Application of economic reasoning and the risks and prices model to the scattered information available on technology, enforcement, prices, trafficking organizations and user behavior.
Results
Inter alia: (1) Though production costs per dose are dramatically cheaper for fentanyl than heroin, the street price may not decline much because the retail price is determined largely by the costs of compensating distributors for incurring risks from enforcement and violence. (2) The consequences for the resilience of the supply chains are ambiguous, depending on how many Chinese firms are willing to sell precursors to Mexican customers.
Implications
High level opioid seizures are even less likely now to cause short-term disruptions than in the past. The chain of opioid distribution may also be shortened.

“Pre-Legalization Perspectives: Cannabis Retailers' Insights”

Catherine Arseneault; Talk

The presentation meticulously examines a study involving 21 cannabis vendors conducted several months before the landmark cannabis legalization in Canada in 2018. Its primary objective is to comprehensively capture the unique perspective of these pivotal players in the illicit market, providing a nuanced view before a significant regulatory transformation. The study delves into the depth of their knowledge concerning the imminent legalization, shining a light on the critical information that profoundly shaped their anticipations.

The survey findings intricately delineate the specific changes these cannabis vendors foresaw in their business operations post-legalization. This includes nuanced modifications in distribution models, the array of products offered, and the dynamics of customer interactions. The presentation goes beyond the surface, offering valuable insights into these actors' perceptions of the potential impacts on the black market, thereby illuminating the multifaceted challenges and opportunities they envisioned with the advent of legalization.

In summary, this comprehensive study presents a vivid and distinctive snapshot of the Canadian cannabis landscape, precisely capturing the intricate details before a pivotal regulatory shift. By articulating the depth of knowledge and anticipations of cannabis vendors, the presentation significantly enriches our understanding of the intricate dynamics of the black market. These insights are poised to provide pertinent and actionable information for policymakers, researchers, and industry stakeholders within the broader context of cannabis legalization.

“Provincial differences before and after ‘recreational’ cannabis legalization: Quebec’s ‘public health framework’ vs. the rest of Canada.”

David Hammond; Talk

Background: Canada legalized ‘recreational’ cannabis at the federal level in 2018; however, there are differences in the strength of cannabis regulations across provinces, most notably in Quebec, which has implemented the most comprehensive restrictive legal market based on a ‘public health’ framework.
Objectives: To examine provincial-level differences in Canada in the frequency of cannabis use, product forms, and other patterns of cannabis use among consumers.
Methods: Population-level data from the Canadian component of the International Cannabis Policy Study, consisting of repeat cross-sectional data from national surveys conducted with 94,278 respondents aged 16-65 over 6 annual survey waves (2018-2023), as well as prevalence estimates from national and provincial monitoring surveys (CCS, CCHS, and the Quebec Cannabis Survey).
Results: The prevalence of cannabis use is lowest in Quebec versus the rest of Canada, with fewer increases in prevalence post-legalization. Cannabis consumers in Quebec are substantially less likely to use edibles, drinks, vaping liquids, and solid concentrates, all of which are subject to stronger regulations than in other provinces. Support for cannabis policies are high in Quebec, with similar levels of legal market capture compared to other provinces.
Implications: Comprehensive cannabis regulations in Quebec, including higher minimum legal age, greater restrictions on cannabis marketing, lower retail density and more restrictive product standards are associated with lower frequency of use than other Canadian provinces since ‘recreational’ cannabis legalization.

“Psilocybin Use and Supply in the U.S.: Nationally Representative Insights & Some Policy Implications”

Beau Kilmer; Talk

MOTIVATION. An increasing number of U.S. states/localities are loosening or considering changing their policies about psychedelic substances such as psilocybin. To project the health and economic consequences of policy changes, we need better information about use patterns, supply sources, and expenditures. Because detailed information about psilocybin consumption/supply is not collected as part of nationally representative surveys in the U.S., we fill this gap. DATA. Our main survey was fielded as part of NORC’s AmeriSpeak panel which is representative of the entire U.S. adult population because it leverages the NORC National Frame, an area probability sample used for landmark studies like the General Social Survey (N=3,500). We supplement this with a national convenience sample of approximately 2,000 people who used psilocybin in the past year (>25% reported using in the past month). Both surveys include detailed questions about psilocybin prevalence, frequency, product type, supply source, expenditures, intensions for use, and whether the most recent experience was supervised. RESULTS. Forthcoming. Data collection started in 11/2023 and will be finished by 1/2024. Analyses will be completed by 4/2024. In addition to presenting descriptive statistics about psilocybin use and supply, we will generate the first national estimates of the U.S. psilocybin market and compare it with what is known about markets for cannabis and other substances. DISCUSSION. We will offer thoughts about what these results mean for conducting policy analyses and ideas about how to improve data collection on psilocybin/psychedelics.

“Punitive Drug Policies and foreign mothers’ prison experiences in Chile”

Alejandra Zúñiga-Fajuri; Talk

The war on drugs has negatively affected communities worldwide, with women bearing much of the burden. Chile is the country in Latin America with the highest proportion of women in prison and most of them are due to drug offenses. This presentation features the results of a qualitative study among foreign mothers’ prisoners in the northern border city of Arica, Chile. Participants -foreign mothers incarcerated for drug-related crimes- were invited to attend a face-to-face interview. The majority have an indigenous background and were the main financial support in the homes. The results confirmed that women have a low level of participation within criminal networks with absence of violence in the commission of their offenses. But, more importantly, it showed that prisons can have a severe impact on their personal and family life, especially when it separates a mother from children who depend on her and have low support networks. The latter is particularly devastating for foreigners, as they are separated from their children not only by prison bars, but also by the border, making it almost impossible for them to have any contact with them. Our research found that separation is the first detrimental aspect of female incarceration. They suffer the psychological burden of not fulfilling their caregiver function and the break of the maternal bond. From a gender and human rights perspective, these are extreme sanctions for people with low criminal profiles, born and raised under structural disadvantages, that most likely will affect the lives of the next generations.

“Quantifying and expanding alternatives to arrest for use and possession offences in Australia”

Caitlin Hughes; Talk

See notes.
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“Québec's not-profit distribution regime and public health: a comparison with six other north american jurisdictions”

Francois Gagnon; Talk

Background. Cannabis legalization resulted in different models. Quebec’s provincial authorities have opted for a singular, not-for profit, distribution regime. Some prospective analysis have outlined some potential benefits and undesirable consequences for public health.

Methods. Québec’s public health outcomes are compared to those of Colorado, Oregon and Washington (USA) and Alberta, British Columbia, and Ontario (Canada). A vote-count synthesis is performed on the 97 selected evaluative documents. The 1070 measures of public health indicators contained in these are classified into five categories: cannabis consumption; consumption of other psychoactive substances; perceptions of consumption; mortality, morbidity and associated situational and behavioural risk factors and; social determinants of health. They are also classified according to whether they are favourable, neutral or unfavourable to public health. A complimentary content analysis is also performed.

Results. The distributions of measures regarding ‘cannabis consumption’, ‘perceptions of consumption’ and ‘mortality, morbidity and associated behavioural and situational risk factors’ suggest less unfavourable outcomes for public health in these regards in Quebec. The distributions of outcomes related to the ‘consumption of other substances’ are largely neutral in all jurisdictions. A general comparison of ‘social determinants’’ distributions is impossible.

Discussion.The less unfavourable outcomes in Québec are probably related to regulatory choices regarding cannabis products, place, promotion and governance. Price-related choices could have played a moderating role. For comparisons to prove more complete, research efforts are needed to address knowledge gaps. Knowledge synthesis methods that can characterize the magnitude of the changes could also be deployed.

“Reimagining subjectivities in place: Safer supply and housing in Vancouver’s Downtown Eastside”

Taylor Fleming; Talk

Background: Prescribed safer supply, providing regulated alternatives to criminalized drugs, has emerged in response to the overdose crisis in Canada. A high concentration of safer supply programs are located in Vancouver’s Downtown Eastside (DTES), a socioeconomically marginalized neighbourhood often characterized by housing vulnerability, political-economic neglect, and health disparities.

Objectives: This paper examines how safer supply makes possible new subjectivities for structurally vulnerable people who use drugs (PWUD), situating this within the context of single room occupancy (SRO) housing in the DTES. In doing so, we highlight how experience of place frames a “safer supply subject.”

Methods: In-depth qualitative interviews were conducted with 25 safer supply participants living in SROs. Informed by the broader analysis, this paper draws on three participant narratives to better explore the complexities of these new subjectivities.

Results: Cases illustrate three different expressions of a “safer supply subject” constructed through oral (case 1) and injectable (cases 2 and 3) safer supply interventions. Analysis highlights how continued access to safer supply requires that PWUD reconfigure space and time in fulfillment of a more healthful and responsible subject position. However, this is undermined by the social-structural realities of SRO living and the ways SROs symbolically reinforce an “addict” identity.

Implications: Findings demonstrate how safer supply constructs a subject who is simultaneously out-of-place and stuck-in-place within the context of SRO housing. We explore the implications for policy and praxis that aligns experience of place with the subjecthood produced through safer supply.

“Results from Simulated Fentanyl Test Strip Use on Non-Heroin Drugs”

Megan Reed; Talk

Fentanyl test strips (FTS) are increasingly recommended for non-heroin drugs due to overdose clusters from stimulants and counterfeit pharmaceutical pills. Misuse of FTS can lead to false positive FTS results.
We report here on results from two studies. First, a cross-sectional survey was administered from January to May 2021 to 86 participants of a syringe service program in Philadelphia, PA who had ever used a FTS on a non-heroin drug. In a follow-up qualitative study conducted between September-October 2023, 40 participants conducted a mock use of FTS on a simulated drug in a real-world environment and interpreted photos of FTS results. Data were analyzed in RedCap, SPSS and Nvivo.
Among survey participants, 70.9% reported a positive result the last time they had used a FTS on a non-heroin drug. During the simulation study, none used FTS as recommended. Most under-diluted the sample (e.g., using less than a full teaspoon of water) or used in another manner not indicated. Forty-five percent correctly interpreted a positive test, 55.0% a negative test with clear lines, and 29.5% a negative test with a faint second line.
FTS were used incorrectly by every study participant during the simulation, errors that would likely lead to false positive test results when using FTS in real world settings. Findings highlight the need to develop educational approaches to ensure people use FTS properly to optimize the harm reduction impact of FTS.

“Rhetoric instead of evidence? The role out of BC's decriminalization and future considerations for other regions”

Brittany Graham; Talk

The Vancouver Area Network of Drug Users (VANDU) have been meeting for 25 years to educate and empower our members to improve the lives of people who use drugs (PWUD). VANDU has identified prohibition as a key component for many harms associated with drug use. Decriminalization is an acknowledgement that prohibition is harmful and that drug use is a health issue. Policy changes should reflect the needs of PWUD. VANDU has been disappointed to see that both the decriminalization and the more recent public use legislation policies have been heavily influenced by rhetoric rather than evidence. This presentation will give a brief overview into recent history of how the decriminalization exemption was created in BC and review the experiences of PWUD related to the creation and implementation of decriminalization and more recently the proposed public drug use legislation. VANDU has found that very little has been done to educate the general public on what decriminalization is, why our entire society benefits from it and the current success of BC's decriminalization 10 months in. Limited communication has allowed uninformed rhetoric to flourish based on stigmatizing stereotypes leading to the new public use legislation. VANDU will present recent research and anecdotal evidence to demonstrate how drug policies like decriminalization have the potential for positive change for all and when not executed correctly can have devastating consequences on the lives of PWUD.

““Safer supply is the thing that changes everything”: The role of prescribed safer supply in rebuilding trust following experiences of medical abandonment”

Gillian Kolla, Karen Urbanoski, Nancy Henderson; Talk

Background:
Prescribed safer supply (PSS) provides people dependent on street-acquired opioids with pharmaceutical opioids - including hydromorphone and fentanyl formulations – to reduce overdose risk. People dependent on unregulated opioids frequently experience significant medical and social complexity, and are disconnected from healthcare services. Our objective was to examine these experiences on client trajectories before and after initiating safer supply.

Methods:
Using comparative case study methods, qualitative interviews and focus groups were conducted with 38 clients and 20 staff members from safer supply programs in two Canadian provinces in 2022. Thematic analysis identified frequent histories of deprescribing among participants prior to initiating PSS, coupled with experiences of rampant stigma/discrimination in healthcare settings.

Results:
Prior to safer supply, many participants experienced medical complexity necessitating high-dose, long-term opioid pain management. Describing stability until abrupt discontinuation of opioid prescriptions, participants were left feeling abandoned by the medical system, with no option but to source opioids from the unregulated drug supply. Participants tried conventional addiction treatment system options that were not helpful, and experienced significant discrimination within the healthcare system. Staff and clients describe successful re-engagement in healthcare through accessing PSS, with clients describing a slow rebuilding of trust in healthcare providers.

Implications:
The role that deprescribing high-dose opioids has played in the overdose crisis is often overlooked, despite previous research documenting how concerns about over-prescribing fueled abrupt discontinuation of prescriptions. Participants experienced deprescribing as medical abandonment, with PSS repairing trust and re-engaging people in healthcare services.

“Shaping a model for Incentivised Drug Free Living wings in prison”

Lucinda Strang; Talk

An Incentivised Substance Free Living (ISFL) wing is a dedicated prison unit that uses incentives to support prisoners who want to carry out their sentence drug-free. In practice, the design and operation of ISFLs vary considerably. This study sought to shape the ISFL model by taking a case study approach to understanding the lived experience of staff and prisoners in three prisons in England and Wales. The research team conducted 21 interviews with prison staff, 18 interviews and five focus groups with ISFL residents and prisoners in other wings, and observations in ISFL wings.
Key findings include:
Among the incentives, opportunities for talking therapies, particularly peer-led, were reported by residents to be the most effective
Positive relationships between residents and wing staff and opportunities for socialising and constructive activities contributed to a sense of community
Stability in the ISFL environment could be disrupted by inconsistent application of policies around referral criteria for recruitment of prisoners to ISFLs and in dealing with positive drug tests
Study recommendations for an ISFL model include:
Incentives focused on a support offer tailored to residents’ needs for their recovery.
Consistent staffing by experienced, appropriately trained officers who are committed to the ISFL ethos.
Clear and transparent processes for the recruitment of new residents to ISFLs and responding to positive drug tests established and implemented consistently by prisons.
Sex-specific guidance on the design and implementation of ISFLs, informed by evidence on the needs of women who use drugs in prison.

“Should heroin carry a quality label? - Concern for fentanyl-laced heroin negated through the RADAR-heroin-23 project.”

Margot Balcaen; Talk

The ongoing opioid crisis in the United States raises concern about a possible shift of the issue towards Europe. Concomitantly, severe intoxications and deaths in Canada and Australia, among others, have been atributed to fentanyl-laced heroin. As heroin remains the most frequently consumed opioid in Europe, information on composition of retail heroin is of high value. Despite being valuable, the statistics coming from customs and police do not provide a comprehensive view of retail heroin. A questionnaire was conducted through grassroots organisations among people who use drugs (PWUD). It included questions on current heroin use and poly-drug use and also details of purchase and experienced unforeseen effects after consuming heroin. In addition, participants were required to hand in a sample of 100mg heroin for quantitative and qualitative analysis by GC-MS and UPLC. Data (n =128) shows that the average purity of heroin has an average of 13.0%. Few adulterants were found, including acetaminophen, diacetamate, caffeine, cocaine, bromazepam, pseudococaine and ketamine. None of the samples showed the presence of fentanyl. Furthermore, 8% of participants pointed out having experienced mild unexpected effects, including nausea, enhanced effect, itchiness and local irritation. The study confirms the absence of fentanyl-laced heroin on the Belgian drug market. Knowing that the production of heroin is evolving and this type of PWUD is extra vulnerable, the continuous monitoring of retail heroin quality and involvement of PWUD, as done in RADAR-heroin-23, remains of high priority.

“Social acceptability and harm reduction: an unbalanced tandem”

Louis Letellier de St-Just; Talk

Contexte
Encore relativement jeune et davantage associée à des projets environnementaux, la notion d' acceptabilité sociale a déjà fait son entrée dans le secteur des politiques sur les drogues. Mise en relief dans le cadre de projets misant sur la réduction des méfaits, elle servira tantôt de bouclier afin de s’opposer à ceux-ci, tantôt pour justifier les réticences des politiciens à soutenir la réalisation de ces projets. Une notion dont les contours demeurent encore flous mènant à un mélange des genres entre « contestation sociale », « acceptation sociale » et acceptabilité sociale ».

Or, si l’approche de réduction des méfaits sert à la mise en place de projets privilégiant l’accès aux soins et services de santé et dès lors à la reconnaissance de droits fondamentaux, recourir à l’acceptabilité sociale pour les mettre en échec s’avère pour le moins inopportun. Trop souvent la controverse créée autour de la notion de l’acceptabilité sociale viendra mettre en péril des projets en devenir ou même existant, ce qui est le cas notamment des services de consommation supervisée.
Objectifs
À partir de situation concrètes et de décisions judiciaires, la présentation cherchera à mieux définir cette notion dans le cadre des politiques sur les drogues au Canada, sachant que les approches suggérées ont, en définitive, une portée universelle.

Il sera plus particulièrement discuté des réponses à la contestation citoyenne, de l’impact des projets sur les milieux de vie, du maintien du dialogue et des chances de succès de possible contestation judiciaire.

“Social Policy Reform as Drug Policy Reform: Removing Policy Barriers to Adaptive Economic Models that Make Work “Work” for People Who Use Drugs”

Lindsey Richardson; Talk

Background: Research identifies the importance of social determinants of health for people who use drugs (PWUD), implicating social policy in the arena of “drug policy” requiring critical attention. Yet, little research focuses on policy dimensions that affect the participation of PWUD in employment opportunities.

Objectives: Given the importance of income generation to socioeconomically disadvantaged PWUD, we sought to assess participation, outcomes and experiences of social-policy-relevant barriers to low-threshold employment.

Methods: We employed a parallel explanatory mixed-methods design using data from the Assessing Economic Transitions (ASSET) Study, a Vancouver, Canada-based mixed-methods, longitudinal cohort involving quarterly interviews with 332 quantitative participants and annual interviews with 169 qualitative participants (2019-2023). Exploratory descriptive analyses, combined with thematic analyses of participant experiences, identified social policy dimensions impacting health, social and economic dynamics of economic engagement.

Results: Findings demonstrate that despite transformative impacts of economic engagement on participant health, social, and economic outcomes, (1) employment standards regulations that restrict drug use, periodic absences and skills development; and (2) income assistance policy that constrains earnings and ancillary benefit eligibility (e.g., substance use disorder treatment) are central barriers to economic engagement for PWUD engaged in low-threshold employment.

Implications: Social policy reform specifically designed to support economic engagement for PWUD could decrease policy and regulatory hurdles impacting economic opportunity development and labour market disengagement for PWUD. There is considerable opportunity to expand the scope, scale and benefits of meaningful, supportive economic engagement to reduce drug-related harm.

“Speaking with one voice: third sector coordination around drug policy windows”

Alison Ritter; Talk

Background: There are many opportunities for third sector organisations (including community organisations, peak bodies, advocates, and researchers), to influence drug policy. In the Australian context, these non-government organisations largely operate independently, avoiding potential conflicts in agendas and goals. At times though, some forms of coordination may be required, especially when a policy window of opportunity arises. Third sector collaboration and coordination in response to a policy window of opportunity has been rarely studied.

Objectives: This research examined the ways in which third sector organisations coordinated and collaborated in relation to an up-coming state Drug Summit, seeking to analyse the enabling factors and constraints to effective coordination.

Methods: The project used qualitative research methods including semi-structured key informant interviews; auto-ethnography; and documentary analysis.

Results: Historical evidence of strong coordination by the sector around a previous Summit occurred in the context of a shared external threat to established evidence-based measures. In the current period, however, there was no shared threat, compromising the impetus and ability to coordinate in this context. While the advantages of coordination were seen as “speaking with one voice” amplifying the messages, and providing the opportunity to share resources, the perceived disadvantages included the constraints it could place on individuals or organisations from acting independently and the requirement to manage diverse differences in agendas and goals. In the early stages, reaching agreement on a coordinating mechanism or body was stymied by the lack of perceived mandate by any one group.

Implications: Globally, there are many opportunities for third sector coordination; identifying and managing differences in agendas and goals and establishing a mandate are crucial for “speaking with one voice”.

“State cannabis policy effects on law enforcement efforts to disrupt drug markets”

Barrett W Montgomery; Talk

Background: Legalizing cannabis impacts law enforcement strategies on drug deterrence. While cannabis possession arrests have fallen post-legalization, findings on racial disparities are mixed. No research has yet investigated cannabis legalization effects on police behavior in the form of drug seizures, or how it may influence the enforcement of other drugs.
Objectives: We sought to evaluate the effect of cannabis legalization on drug seizures and their related disparities by race to understand how law enforcement have adjusted to this rapidly shifting legal landscape.
Methods: Drug seizure data including state, race, and drug types from 18 states with over 95% National Incident Based Reporting System (NIBRS) coverage for 2017-2022 were analyzed. Log rates and log black-white risk ratios were calculated using census data. Two-way fixed effects difference-in-differences models evaluated the effect of adult-use cannabis legalization on the logs of seizure rates overall, cannabis only, non-cannabis drugs, and black-white risk ratios.
Results: Our findings indicate that cannabis legalization significantly reduced overall drug seizures, particularly those involving cannabis. However, the data reveal persistent racial disparities, with Black individuals consistently experiencing higher drug seizure risk ratios compared to White individuals. Unexpectedly, methamphetamine seizures increased post-legalization, potentially indicating a shift in law enforcement focus or drug market dynamics.
Implications: Cannabis legalization in Connecticut, Montana, Virginia, Michigan, Vermont, and Rhode Island was associated with reduced drug seizures overall driven by a large reduction in cannabis seizures. There were no significant changes to disparities, Black individuals retained higher drug seizure risk ratios compared to White individuals. Though expected to decrease without cannabis smell to prompt seizures, non-cannabis drug seizures were unchanged, potentially due to shifting enforcement priorities. These results suggest that cannabis policy reform can alleviate law enforcement burdens. Nonetheless, the ongoing racial disparities in drug seizures highlight the necessity for policies addressing systemic biases in drug enforcement.

“Substance Use Disorders facility mapping and opioids epidemiology in West Africa”

Anselme Sanou; Talk

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“Systematic Review and Meta-Analysis on the Impact of Opioid Prescribing Guidelines for Opioid Prescription Initiations and Discontinuations”

Parker Tope; Talk

Increased opioid prescribing for pain management has brought surges of opioid misuse and overdose. Prescribing guidelines for chronic non-cancer (CNC) pain intended to limit opioid volume and dosage and mitigate repercussions of over-prescribing.

This systematic review aims to summarize the impact of prescribing guidelines on the prevalence, incidence, and dosage of opioid prescribing across multiple jurisdictions.

We systematically searched PubMed/MEDLINE, Scopus, Web of Science, and PsycInfo for literature estimating the effects of opioid prescribing guidelines on adult populations irrespective of study design, geography, or comparator. Our primary outcomes were opioid use prevalence and incidence, and dosage of opioids dispensed. We will perform two-step meta-analyses to calculate study-level effect estimates using interrupted time-series analyses and the pooled effect of guidelines on prescribing outcomes.

After screening, we included 42 of the 9,868 records identified in our search. Retained articles covered four patient categories: CNC, acute, cancer, and palliative pain. Among most studies included, prescribing guidelines decreased opioid use dosage and prevalence among people with CNC pain. Prevalence of opioid use also declined among guideline-exempt populations – those with cancer-related or acute pain.

While studies demonstrated decreased post-guideline prescription opioid use for CNC pain, the population-level effects of opioid prescribing guidelines remain unclear. Opioid prescribing reductions among patients with cancer-related or acute pain suggest unintended consequences of guideline implementation. Quantification of such spillover effects through our meta-analyses will inform the utility and appropriate use of prescribing guidelines across healthcare settings.

“The framing of cocaine crack phenomenon in France. From social to racial issues”

Marie Jauffret-Roustide; Talk

Background. In France, crack use has considerably increased and has given rise to open drug scenes followed by political controversies over the best type of policy to implement.

Objectives. To analyze the evolution of the framings of cocaine crack and their intersections with public policies implemented over time.

Methods. The methodology includes a press analysis from 1986 to 2023 (1,560 articles), a documentary analysis, ethnographic observations and semi-structured interviews conducted between 2019 and 2023 (54 with drug-treatment and harm reduction providers, police officers and politicians and 56 with crack users).

Results. The media and political framings contribute to construct crack users under the figure of the "undesirable", described by recurring terms such as the "madman", the "zombie" and the "crackhead". This terminology anchors social imaginaries of crack associated with danger and dehumanization, that are used to justify their social and political control. In France, it is the social precarity dimension of crack use that is highlighted in the public debate, instead of the ethno-racial dimension, which is almost never mentioned in public. At the opposite, our qualitative ethnographic data demonstrates an intersection between crack users and migrants- another term that elicits proxy terminology and highlights racial and ethnic inequalities from postcolonial France. Interviews with crack users show the extent to which they are subject to racial discrimination, both in their interactions with the police and in their access to healthcare.
Conclusions. It is important to build drug policies on scientific-evidence and not on discriminatory imaginaries.

“The Impact of Drug Possession Decriminalization on Racial Disparities in Arrests: Evidence from Oregon’s Measure 110”

Roland Neil, Beau Kilmer; Talk

Motivation: Decriminalizing drug possession is a potential tool to disentangle the racial inequalities caused by drug prohibition. While possession decriminalization has been implemented in multiple countries, it had never been adopted in the US except for cannabis possession offenses. That changed when voters in Oregon passed Measure 110 (M-110) in 2020. M-110 made the personal possession of controlled substances a noncriminal offense that could be resolved by paying a fine or undergoing an assessment. While M-110 also increased funding for services for people who use drugs, there was a delay in new expenditures which created a natural experiment where the primary change was just decriminalization. This study examines whether decriminalization changed racial disparities in arrests.

Methods: Incident-level and aggregated arrest data are drawn from the Federal Bureau of Investigation’s National Incident Based Reporting System and Uniform Crime Reports. Synthetic control and difference-in-differences designs will be used to evaluate how M-110 affected arrest patterns by race, along with sensitivity analyses to test modeling assumptions. Comparing these results across race, such as looking at how arrest rates changed in absolute and relative terms, will reveal whether M-110 affected racial inequality in arrests. Analyses will be conducted for arrests overall and by offense (e.g., drug possession and supply by substance; violent crime; property crime.)

Results: Analyses will be completed in April.

Implications: Results will provide evidence on whether decriminalization leads to a reduction in racial disparities in arrests for drugs and other offenses.

“The impact of opioid policy implementation on opioid-related emergency department presentations in Victoria, Australia: an interrupted time series analysis”

Suzanne Nielsen; Talk

Background
This study aimed to understand the combined effect of two opioid policies (mandatory prescription drug monitoring and restrictions on subsidised opioid prescribing, introduced between April and June 2020) on the rates of emergency department (ED) presentations and hospital admissions attributed to opioid and non-opioid related harms, in Victoria, Australia. We hypothesized that policies would reduce opioid harms, while resulting in unintended effects including increased non-opioid harm and increased presentations related to mental ill-health.
Method
General practice health records obtained with approval from three Primary Health Networks in Victoria collected via the POpulation Level Analysis and Reporting (POLAR) platform were linked with person-level data from three large hospital networks in Victoria, Australia. We identified a cohort of people prescribed opioids between April 2018 to March 2022 (n = 179,091). Propensity score matching was used to match each patient in the opioid group with one unique control. Interrupted time series analysis was used to examine changes in trends in the rates of ED presentations and hospital admissions due to a range of harms, including substance use (opioid and non-opioid) and mental ill-health following periods of policy change.
Results
Following an implementation window where two key opioid policies, mandatory prescription drug monitoring and restrictions on subsidised opioid prescribing, were introduced (between April and June 2020), opioid-related ED presentations and hospital admissions reduced, relative to trends observed prior to their implementation. A significant step change in the rates of non-opioid related ED presentations was seen among people prescribed opioids, compared to the control group (β = 11.1, 95%CI 1.7-20.5). We did not find an effect of these opioid policies on outcomes relating to mental health or self-harm.
Conclusion
When compared to a control group matched on age, gender, co-morbidity and socioeconomic status, we found ongoing reduced opioid-related ED presentations, combined with a short-term increase in ED presentations related to other substance use with no effects on ED presentations or hospital admissions related to mental ill-health following opioid policy implementation.

“The influence of quantity discount and market share for setting legal market cannabis price”

Yanick Charette; Talk

The legalization of cannabis marked a paradigm shift, making the state less of a repression-driven entity and more of a competitor to the illegal market. Recent reports suggested that the Canadian legal market failed to be competitive as the price per gram was twice higher than on the illegal market. One of the main issues for offering competitive prices is the presence of significant quantity discount on the illegal market. Therefore, the objectives of the present study were twofold. On the one hand, to identify the impact of the quantity of cannabis purchased on the price per gram of illegal cannabis, and on the other hand, to determine the market share in function of the quantity purchased. Using a survey of 2,425 persons who declared having purchased illegal cannabis in the past year, regressions were conducted to determine if and how quantity of cannabis purchased predicted the price-per-gram. Then, predicted values of the model were used to identify buyers' market share and the threshold price for which legal cannabis becomes less competitive. Findings suggest that the relationship between the quantity and price-per-gram was statistically significant and curvilinear. Furthermore, results suggest that larger purchases were more advantageous on the illegal market. This implied legal market prices were not competitive among large quantity buyers who, despite their small number, represent the largest share of the cannabis market. Accordingly, pricing guidelines should consider quantity discounts to encourage a larger share transfer to the legal cannabis market.

“The Initial Impact of Decriminalization of Illicit Drugs in British Columbia on People Who Use Drugs (PWUD): A Qualitative Exploration”

Cayley Russell; Talk

Background/Objectives:
On January 31 2023, the Canadian province of British Columbia (BC) decriminalized the personal possession of illicit drugs. This policy reform is a monumental shift away from prohibition, and carries significant impacts. As the key population this policy will impact, it is imperative that people who use drugs (PWUD)’ initial experiences with decriminalization are explored.
Methods:
As part of a national evaluation of the decriminalization policy, between October 2023 and February 2024, we qualitatively interviewed 100 PWUD recruited from across BC. Participants partook in a structured socio-demographic survey, followed by a semi-structured 40 minute interview where they described their initial experiences with decriminalization. Interviews were analyzed using a thematic approach.
Results:
Preliminary results demonstrate that most PWUD consider decriminalization as a positive step forward as they are less concerned about being arrested and are more comfortable to carry the drugs they need without fear of repercussions. PWUD were mostly aware of the policy, although the specifics (drugs included, threshold amount, and duration) were not always known. Results will focus on police interactions, drug use and purchasing patterns, access to services, stigmatization, and the potential impacts of public consumption legislation.
Implications:
This qualitative study sheds light on the initial impacts of the decriminalization of illicit drugs in BC among PWUD. Results are preliminary but have the potential to inform public policy. Results also underscore the importance of continuing to evaluate this policy as it evolves.

“The logics of strengths-based approaches in drug treatment for young people”

Joanne Bryant; Talk

In youth drug treatment, and other sectors, there is growing reference to the language and practices of ‘strengths-based approaches’. These are thought to offer an alternative to biomedical models of care because they signal a shift away from deficit-based biomedical approaches, giving attention to the social conditions of young people’s lives. Yet, the utility of ‘strengths-based approaches’ really depends on how ‘strengths’ are understood and, to date, this has received little critical attention. In this paper we critically review how marginalized young people’s ‘strengths’ are understood in the research literature, so to better understand the logics on which ‘strengths-based approaches’ are built and, relatedly, how such approaches can be made more relevant to the experiences and social conditions of marginalized young people in drug treatment.
The analysis reveals a range of assumptions. ‘Strengths’ were commonly articulated as individual traits (cognitions, attitudes, skills) that can be drawn on to improve one’s health and social condition, but also learned and moderated through the social environment, which itself was understood in terms of the interpersonal (peer, family and community bonds). This framing reveals a view of the youth subject as rational and self-managing, compelled to draw on their strengths to practice personal transformation despite seemingly overwhelming marginalisation. Thus, while ‘strengths-based approaches’ may offer disruption to entrenched biomedical models, their common articulation in research remains aligned with biomedical logics of self-management. However, strengths as conceived in terms of collective identities and practices for living well may offer more opportunity for reshaping youth drug treatment approaches.

“The ongoing criminalizing effects of COVID-19 infringement notices on people who use drugs”

Shelley Walker; Talk

Introduction: During the COVID-19 pandemic governments worldwide applied legal sanctions to ensure compliance with pandemic-related restrictions on movement/social gathering. Reportedly sanctions such as fines were disproportionately issued. Our study extends understandings of how COVID-19 fines were issued to people who use drugs and the impact this had on their lives. Methods: This mixed methods study involved participants of two prospective observational cohort studies (n=2,156) of people who drugs, in Victoria, Australia. We analysed: 1) COVID-19-related quantitative survey responses; 2) in-depth interview transcripts of 76 cohort participants; and 3) brief follow-up interviews with participants who had received COVID-19 fines. Key Findings: Participants observed increased police presence in street-based drug markets and poorer neighbourhoods where they lived/spent time. Many believed policing practices were discriminatory and targeted. Thirty-eight participants received fines for non-compliance of COVID-19 restrictions - not wearing facemasks, travelling outside 5km-restriction zones, or being outdoors for “non-essential” purposes. Although some breached laws to purchase drugs, when fined some were homeless or travelling to get methadone or sterile injecting equipment with documentation proving they required these services. All said they lacked funds to pay the fines; although some applied to have them waived, few have have been successful, potentially impacting future criminal justice trajectories. Conclusion: Findings highlight how COVID-19 legal sanctions were differentially directed towards people who use illicit drugs in arbirtrary and inconsistent ways; an approach that worked to further criminalise and marginalise.

“The representation of ‘voice’ within the UK Drug Policy Voices project: the opportunities and challenges of engaging PWUD into debates about drug policy.”

Rebecca Askew; Talk

Background
The participation and representation of those with lived and living experience is vital for drug policy legitimacy, but engagement can be challenging. Firstly, who identifies as a Person Who Uses Drugs (PWUD) is a subjective and personal matter. Many people are not willing to ‘exposed,’ or do not identify as a PWUD, even if they consume illicit substances. This highlights ethical and definitional barriers in participation. Secondly, drug policy knowledge varies, and processes of participation must consider diverse levels of knowledge (Askew and Bone, 2020). Thirdly, attitudes towards drugs are influenced by a variety of factors, in addition to lived experience (Askew et al. 2022). Finally, methods of engagement must be meaningful, recognise which voices are marginalised, and should avoid tokenism (Lancaster et al. 2018; Stowe et al, 2022).

Methods, Results, and Implications
This paper critically reflects on how these challenges were navigated in the UK Drug Policy Voices project. This project used a mixed methodology, which included a novel attitudinal survey, creative outputs (poems, drawing, and letters) workshop debates and narrative interviewing. This multimethod approach allowed for variation in ‘voice’ and promoted inclusivity via a participant-led approach. However, methodological challenges were navigated in relation to the method adopted, data collection within the Covid epoch, and the synthesisation of multiple voices and experiences. The paper concludes by critically reflecting on the conceptualisation and representation of ‘voice’ of those with lived experience within drug policy debates and processes.

“The Role of a Changing Illicit Drug Market in the Differential Trends in Black and White Overdose Death Rates in Ohio”

Daniel Rosenblum; Talk

Background: Although provisional overdose data from the CDC shows that overall overdose deaths in the US may be plateauing, these numbers hide divergent trends in overdose death rates by specific demographic groups. This study focuses on the state of Ohio, where White overdose death rates have recently declined, while Black overdose death rates are rising quickly, surpassing White overdose death rates.

Objectives: We investigate the relationship between the changing composition of illicit drugs in Ohio and the changing demographics of overdose deaths. Specifically, we seek to understand whether increasing combinations of fentanyl with stimulants (e.g., cocaine) can partially explain recent disparate trends in drug overdose deaths among Whites and Blacks.

Methods: Content of the illicit drug supply, measured using crime lab data, 2009-2022, from Ohio’s Bureau of Criminal Investigation, and the Ohio Department of Health’s mortality data to estimate the county-month relationship between overdose death rates by race and the presence of fentanyl, other illicit drugs, as well as fentanyl-cocaine and other combinations.

Results: The presence of fentanyl as well as fentanyl-cocaine combinations predict increases in White and Black overdose deaths. However, fentanyl-cocaine mixtures are related to relatively higher Black overdose death rates.

Implications: Fentanyl-cocaine mixes have increased substantially in Ohio. This change in the illicit drug risk environment appears more strongly associated with Black overdose deaths. It may be partially responsible for driving increasing Black overdose deaths at a time that fatal overdoses have fallen among Whites.

“The Swiss cannabis trials: an opportunity to promote a public health-oriented approach to legalisation”

Frank Zobel; Talk

Swiss parliament and citizens voted against cannabis legalisation in 2004 and 2008 respectively. A few years later, some cities asked for local cannabis sales studies to evaluate an alternative to prohibition. In 2021, an article allowing such studies was added to the narcotics law and first trials started in 2023. In parallel, in line with international developments, the Swiss parliament is developing a law to legalise and regulate cannabis in the future.
Federal authorities have defined the purpose and content of local cannabis trials. In essence, a few thousand adults already using the drug can access controlled cannabis locally for a few years. The model differs between projects with cannabis sales made in pharmacies, user clubs, private shops, etc. While the initial projects were initiated by local authorities, private players increasingly use the trials for branding purposes or for taking market shares in view of a future legalisation. Such players include companies having the tobacco or the alcohol industry among their shareholders.
In opposition to this trend, the project of the city of Lausanne (Cann-L) has been designed to test and promote a not for profit and non-commercial sales model for a future cannabis legalisation. Such an approach is unusual in very liberal Switzerland, but the pilot trials provide an opportunity to test and promote a model that makes cannabis available without selling and promoting it like alcohol, tobacco, or medicines. The presentation will review the dynamics of the local trials and present first findings of Cann-L.

“THE XTC-SHOP in Ghent (Belgium): An 'Experiential' Public Research on XTC Regulation in Belgium”

Tom Decorte; Talk

Belgium, a major global MDMA producer alongside the Netherlands, faces profound social repercussions from XTC production and trade, including violence, tax evasion, and environmental damage. Despite this, MDMA is resurging for therapeutic use amidst a heated public debate. In response, Belgian researchers, inspired by Dutch initiatives, plan an 'Ecstasy shop' in Ghent to explore alternative MDMA sale scenarios.

This initiative aims to gauge stakeholder perspectives on MDMA sales via immersive experiences in a simulated XTC-shop. Participants engage in simulated transactions, discussions, and explore various regulatory models and harm reduction strategies.

THE XTC-SHOP at Ghent embodies an intersection of academia, public engagement, and policy advocacy. It pioneers experiential research to understand societal, health, and legal dimensions of MDMA use and regulation. The presentation at the conference will detail the project's framework, design, and methodologies, emphasizing how such experiential research informs evidence-based policymaking and public discourse.

Anticipated outcomes include nuanced insights into public views on MDMA regulation, guiding policymakers on regulatory frameworks, and enriching harm reduction debates. The presentation aims to prompt dialogue on the role of experiential research in shaping drug policy.

This project showcases innovative methodologies bridging public opinion, policy, and societal impact. It stands as a model for collaborative, participatory research on sensitive socio-political issues, emphasizing the imperative role of such approaches in shaping public policy.

“Towards 2029: Learnings from unified Australian involvement in drug-related United Nations fora”

Penny Hill; Talk

In the sidelines of the 2019 United Nations High-Level Ministerial Segment taking stock of the world drug problem, the Australian Civil Society Committee on UN Drug Policy was established. Throughout the past five years the Committee has strengthened, bringing together civil society and academic perspectives and increasing community, First Nations, and youth voices in UN sessions on drug-related matters.
The Committee brings together expert academic and civil society advice to the Australian Government and within international drug-related fora advocating on a range of key thematic areas: health-led approaches for drug policies (including prevention, treatment, and harm reduction approaches), human rights, stigma and discrimination, alternatives to arrest and incarceration, and access to essential medicines.
This paper will present a case study of the work of the Committee leading into the 2024 Mid-Term Review of all international drug policy commitments, and key milestones and successes including an increasing number of joint government and civil society side events at the UN; more timely provision of draft resolutions to the committee for feedback; the first joint civil society and government strategic planning day; and obtaining government funding to support the work of the committee. We also provide an overview of lessons learned for other countries, including on how to build trust and strong partnerships between government and civil society groups with differing priorities, perspectives, and thematic expertise, while also strategically setting the way forward towards the 2029 UN high-level review of progress in implementing all international drug policies.

“‘Tranq burn’: Exploring the etiology of tranq-related soft tissue injuries”

Daniel Ciccarone; Talk

Introduction: ‘Tranq dope’ is a combination of xylazine and fentanyl that is increasingly common in the US. Typically injected, its use appears related to severe skin and soft tissue injury (SSTI) through an unknown mechanism. Previous research suggests that the high acidity of certain heroin source-forms contributes to vein damage and SSTI. We explore the possibility of an etiologic role between the acidity of tranq dope and SSTI.

Methods: A convenience sample (30) of persons who use drugs participated in semistructured interviews. Observations of wounds/injection locations were made. We analyzed narrative data for perceptions of wound causation. Our partner lab analyzed the pH of independently obtained tranq dope samples (6).

Results: Observed SSTI were extraordinarily severe. Several themes emerged related to wound etiology: 1) Tranq dope injection caused burning sensations; 2) vein loss occurred following chronic use of tranq dope; 3) vein loss resulted in increased injection attempts, the use of large central veins (e.g., jugular and brachial), as well as more frequent ‘skin-popping’; and 4) wounds, called ‘tranq burns’, rapidly followed vein loss. The average pH of samples was 4. Lab work is ongoing to test additional samples and replicate “real-world” solution preparation conditions.

Discussion: Combined use of xylazine and fentanyl leads to vein loss which increases the risk of subsequent SSTI. The acidity of the combination likely plays an etiologic role. Possible harm reduction interventions include dilution and buffering. Stigma reduction and enhanced wound care are required in harm reduction and clinical settings.

“Trends in attitudes to drug policy in Australia between 2001-2019: What does this mean for drug policy reform in Australia?”

Amanda Roxburgh; Talk

Please see internal notes.
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“Trends in toxicological findings of unintentional overdose deaths in Québec, Canada, 2012-2021: Has Québec entered a new era?”

Sarah Larney; Talk

Background: The impact of Canada’s overdose crisis has not been as extreme in Québec compared to other provinces, but recent data suggest the situation may be deteriorating.
Methods: We estimated annual age-standardised rates of fatal opioid or stimulant poisoning per 100,000 of population, 2012-2021, and the proportions of deaths in which specific drugs were detected.
Results: Opioid mortality rates increased sharply in 2020, from 1.9 to 2.7 per 100,000, and 2.5 per 100,000 in 2021. Pharmaceutical opioids were detected in ≈80% of opioid deaths until 2019, declining to 55% in 2021. The proportion of deaths involving fentanyl varied; 2020 and 2021 were the only consecutive years where the proportion of deaths with fentanyl increased (38% to 52%). There was an increasing trend of methamphetamine in opioid deaths, from 6% to 41% and a rapid increase in illicitly manufactured benzodiazepines from <5% of deaths in 2019 to 41% in 2021. Stimulant mortality rates steadily increased from 0.7 to 2.0 per 100,000. Cocaine detection declined from 80% to 58% of stimulant deaths, while methamphetamine detection increased from 29% to 62%.
Conclusion: Québec is experiencing significant drug market disruption and may be in the early stages of a sustained period of escalating overdose mortality. Throughout Canada, overdose mortality rates have remained high even in the presence of multiple interventions. Radical policy reform is essential to address root causes of overdose including an unpredictable drug supply, strained health systems, and socioeconomic precarity.

“Understanding and addressing transport refusals in EMS responses to opioid overdoses”

Jirka Taylor; Talk

Background: EMS responses to nonfatal opioid overdoses represent an opportunity to engage people who use opioids and facilitate their linkage to various treatment, social, and other services. However, a notable share of patients refuse to be transported to the emergency department (ED). Non-transports prevent the continuation of care in a hospital setting, potentially inhibiting the initiation of or referral to treatment and other services, and are associated with increased risks of a subsequent overdose. They also cause hospital claims data to miss a non-trivial share of overdoses.
Objective: This paper examines what patient- and event-level characteristics are associated with increased odds of patients refusing transport after an overdose and discusses possible policy responses.
Methods: The paper is a cross-sectional analysis of the latest (2022) data from the National EMS Information System, a nation-wide database of EMS activations. It uses multiple logistic regressions with a binary outcome measure of whether the patient was released against medical advice. Patient-level predictor variables include age, gender, and race/ethnicity. Event-level predictors include patient acuity, system response time, scene time, prior naloxone administration, type of EMS agency, location type, urbanicity, and census region.
Implications: Identifying factors associated with transport refusals can improve our understanding of the overdose crisis in the United States by examining events not included in hospital data. It is also critical for designing policy and practice interventions that would either reduce transport refusals or mitigate their negative impacts, e.g., via pre-hospital treatment induction.

“Unveiling the Impact of Punitive Prenatal Substance Use Policies toward Pregnant Individuals Using Drugs: A Systematic Review on Healthcare Access, Maternal, and Child Health Outcomes”

Sugy Choi; Talk

In the context of the opioid epidemic and racial inequities in maternal and child health outcomes, there is a growing interest among clinicians, patients, and health policymakers in understanding the impact of punitive state policies on pregnant individuals using drugs on healthcare access and outcomes. This systematic review investigates the types of punitive policies towards pregnant individuals using drugs and their impact on maternal and child health outcomes. Following the PRISMA guidelines, we screened 408 studies, including 26 relevant studies, to examine the prevalence and impact of punitive laws targeting pregnant individuals using drugs. The findings reveal an increase in states implementing punitive policies over the years, such as considering substance use as child abuse, mandated reporting with positive toxicology testing, reporting of opioid exposed infants (including clinician-prescribed opioid therapy), and cannabis-related regulations, including prohibiting breastfeeding when using cannabis. Our results show mixed findings on neonatal abstinence syndrome (NAS) and mandatory reporting outcomes. While some studies suggest an increase or decrease in NAS following punitive policy implementation, some report reduced mandatory reporting may be attributed to heightened stigma perception resulting from the laws, provider distrust of child protective services, and confusion about reporting procedures. Additional consequences of punitive policies include an increase in out-of-state births and a decrease in the receipt of prenatal and postpartum care, deterring pregnant individuals from seeking substance use treatment during pregnancy. Furthermore, the implementation of policies allowing the incarceration of people using substances during pregnancy is associated with an increase in out-of-state births, potentially placing pregnant individuals and infants at greater risk. This study describes the pernicious, if unintended, consequences of punitive policies across states, within hospitals and society. It discusses the implications for intervention, providing examples of theory application in research and practice. Addressing challenges in tailoring deimplementation strategies to specific contexts and suggesting future research directions are included.

“Unveiling the Shadows: Quantitative Analysis of Illicit Drug Trade on Telegram”

Jack Cunliffe; Talk

Background:
In recent years, the internet has experienced a surge in illegal activities, notably the proliferation of online illicit drug markets across digital platforms. The evolution from cryptomarkets to a social media-enabled trade has been observed, yet comprehensive information remains elusive for understanding the size, scale, and characteristics of these illicit activities.
Objectives:
This research focuses on Telegram, a privacy-oriented text messaging application known for encryption, anonymous channels, and user-friendly interface, creating an environment conducive to discreet information exchange. Despite emerging evidence suggesting its significance in drug transactions, no quantitative analysis of the platform has been undertaken. The primary objective is to systematically capture and analyze data from pivotal channels within Telegram, shedding light on the nature of the illicit drug trade.
Methods:
Our study employs systematic data capture and analysis methods, specifically targeting key channels within Telegram.
Results:
The findings of this research will contribute a quantitative understanding of Telegram's role in facilitating illicit drug activities. The results provide insights into the size, frequency, and formats of drug transactions within the platform, offering a comprehensive overview of the nature of the illicit trade.
Implications:
By delivering valuable insights into Telegram's involvement in the illicit drug trade, this study holds implications for online security and policy development. The structured analysis aids in understanding and addressing the challenges posed by the digitally enabled drug trade, providing a more informed and effective approach to understanding illicit activities on online platforms.

“Use of Photovoice Method with Marginalized People Who Use Opioids : Pearls and Perspectives”

Andrée-Anne Paré-Plante, Christine Loignon; Talk

Context: In Longueuil, a city outside of Montreal, Canada, a new clinic opened in 2022 to offer opioid agonist treatment and harm reduction interventions. Like elsewhere in North America, the overdose crisis, and the increasing need for addiction treatment after the pandemic has had considerable consequences on marginalized people. A photovoice method was used in the project to evaluate the implementation of this clinic.
Objective: This publication describes the methodology of the photovoice used with marginalized people who use opioids and discusses it as a innovative and efficient way to involve them in research.
Methods: Four meetings (preparation, photo discussions (2) and results discussion) with the 15 participants. Each participant took 3-5 photos around the research question.
Results and conclusions: Photovoice meetings with marginalized people living with OUD allowed us to better understand their experiences with institutions and conventional care structures. The method stimulated discussions and critical dialogue. It allowed sincere expression on the research question. Challenges faced: 1- Participants did not have cell phones for taking photos; 2-Respecting speaking turns was difficult; 3-Traditional method of verbatim and Nvivo coding was not possible; 4-Participant commitment over the 4 meetings was difficult. Strategies put in place: 1- Involvement of a peer researcher with experiential knowledge to promote participant involvement; 2- Meeting and discussion site in proximity with community organizations; 3- Discussion room layout in circle and serving of beverages and food made it possible to meet basic needs and provide a welcoming atmosphere favoring egalitarian exchanges.

“Using Policy Codesign to Develop Local Strategies to Improve Interactions Between Law Enforcement and People Who Use Drugs”

Mandy Owens, Dana Pearlman; Talk

Background: Policies addressing crisis response to drug use are complex and should involve coordinated efforts with multiple partners, including people who use drugs and law enforcement. Policy codesign brings together diverse stakeholders to build policy from the “ground up” to fit local needs.
Objectives: The objectives of the current study were to a) describe the policy codesign process used to codevelop local solutions to crisis response to drug use focusing on calls with law enforcement, and b) evaluate this process.
Methods: Policy codesign was used in three Washington State regions with law enforcement, people with lived experience of drug use, and service providers. Evaluations were conducted via semi-structured qualitative interviews. Interviews were audio-recorded, transcribed, and analyzed via a Rapid Analysis Process.
Results: Eight policy codesign sessions were conducted with 8-12 participants in each region across 2022-23. Sessions were led by a researcher, facilitator, and law enforcement consultant. Sessions focused on building relationships, understanding the local context of law enforcement and drugs, and prioritizing and piloting solutions. Solutions were an officer wellness program, community educational videos, letters to increase referrals to reentry peer services, and building a community coalition. Thirty-two virtual interviews were conducted in March-April 2023. Participants cited strengths such as organized facilitation, high engagement from community members, and an open environment to discuss crisis response that included diverse perspectives.
Implications: Policy codesign can be a helpful approach to build complex policies, like drug policy, to prioritize the needs, values, and interests of communities.

“Using Public Education to Decolonize U.S. Cannabis Policy”

Jane Appleyard Allen, Shaleen Title; Talk

Background
U.S. cannabis policy has been shaped by racism and produced racist outcomes. The legalization of cannabis for adult use represents an opportunity to end harmful policies and repair some of the damage caused by the War on Drugs. However, this opportunity may be slipping away. Large corporations with histories of exploitation are steering cannabis policy to maximize profits.

Objectives
Parabola Center for Law and Policy created videos to educate the public about these issues and promote cannabis policies that benefit regular people. We conducted an online survey with an embedded experimental design to determine whether the videos would resonate with U.S. adults and influence beliefs about cannabis policy.

Methods
In September 2023, we conducted an online survey of 404 U.S. adults. We showed half of the participants six videos featuring cannabis policy experts before asking them to answer survey questions. The other participants answered survey questions before seeing the videos.

Findings
Participants who saw the videos had greater agreement that cannabis legalization should not benefit the tobacco industry, the pharmaceutical industry, and alcohol companies (all p<0.05). They also had greater agreement that legalization should create space for small businesses, create a sharing community, and benefit people from communities that have been harmed by the Drug War (all p<0.05).

Implications
Public education could be a powerful tool to decolonize U.S. cannabis policy by raising awareness of corporate influence, promoting community-centered regulatory models, and building support for an equitable approach to federal legalization.

“US national rises in smoking and sniffing as preferred routes of administration of heroin and synthetic opioids, 2000-2021”

George Karandinos; Talk

Background: Data from California and Washington note decreases in heroin and synthetic opioid injection and increases in smoking (previously thought rare). The full US national extent of these changes is unknown.

Objectives: 1) examine US national and regional trends in injection vs non-injection (i.e., smoking and sniffing) routes of administration (ROA) of heroin and synthetic opioids; and, 2) identify associations with ROA preferences.

Methods: We analyzed 7,881,318 admissions for heroin or synthetic opioid treatment in the SAMHSA Treatment Encounter Data Set from 2000 to 2021. The primary outcome was ROA preference. We calculated annual ROA proportions nationally and by region. We performed regressions to identify associations with injection versus non-injection use and among non-injection ROAs.

Results: In 2021, injection ranged from 46-56%, down across all regions from earlier peaks. From 2000 to 2021, smoking increased sharply in many western states and grew modestly elsewhere. Regression analysis confirmed the strong association between region and smoking. Being indigenous, younger, unstably housed, and having fewer prior treatment admissions increased odds of smoking, while being Black or Latino decreased them.

Discussion: Smoking is now common across western states and growing in eastern states. It should reduce injection-specific morbidity (e.g., HIV, HCV, endocarditis, skin infections, and vein damage); however, there is an urgent need to understand the unique health risks associated with smoking heroin and its adulterants including fentanyl and xylazine. Clinicians, researchers, and harm reductionists should be alert to these shifting ROA preferences.

“Values in drug policy documents: Applying Schwartz’ values theory to the report of the Special Commission of Inquiry into the Drug ‘Ice’ (NSW, Australia)”

Paul Kelaita; Talk

Background: Surfacing values underpinning drug policymaking has been gaining traction as a strategy to understand and possibly resolve impasse. Documents have an important role in shaping drug policy debates, and as such are important data for understanding what is significant about values in policy.
Objectives: This research examined how values emerge and are used in the report of The Special Commission of Inquiry into the Drug ‘Ice’ held in NSW, Australia (2018-2020). The objectives were two-fold: to understand if and how values are present in policy documents, using the values theory developed by Shalom H. Schwartz; and how values in documents are present and mobilised in drug policy debates.
Methods: This research used documentary analysis as the primary qualitative method. Data was coded using reflexive thematic analysis.
Results: Values are present in the Ice Inquiry report, primarily security and universalism values. Schwartz’ values theory is useful as a shared vocabulary and heuristic device in documentary analysis. However, there are shortfalls in how his individual and cultural theories apply to documents, including individual interpretations of values meaning, underlying motivations, and the authorship of policy documents. Policy documents can reveal conflicting values, and these should be interpreted through a broader understanding of the strategic utilisation of values in the document’s content, production, and use.
Implications: Analysing documents is useful for understanding the significance of values in drug policy debates. Attention to the political, value-laden field of engagement is vital to understand what values do in policy.

“Versatility amidst Constraint: transitions in fentanyl modes of administration”

Sarah Mars, Jeff Ondocsin; Talk

Background
In unregulated, illicit drug use, transitions from injecting opioids to non-injecting modes of use, e.g. smoking or snorting, are historically unusual. However, this is changing with the potent synthetic opioid fentanyl. We investigate transitions between routes of administration, their patterns, motivations and perceived effects.
Methods
We used rapid ethnography to investigate fentanyl administration routes in San Francisco, California, conducting 32 interviews and ethnography with people using fentanyl in 2022. We conducted thematic analysis using a Grounded Theory approach.
Results
Multiple transition patterns emerged, from: a) injecting to smoking fentanyl; b) injecting other opioids to smoking fentanyl; c) smoking to injecting fentanyl and d) both smoking and injecting fentanyl. Participants who had previously injected other opioids could achieve comparably intense effects from smoked fentanyl. This allowed some to cease injecting entirely, often following vein loss or overdose. Others found smoking fentanyl provided greater choice in how to use and navigate the constraints of an unpredictable supply and the challenges of street living. Smoking was favored over injecting when in public, for convenience, considering sensitivity to non-injecting peers, or when seeking a milder experience enabling productivity or vigilance. Injecting was chosen for intimacy, to avoid sharing drugs/equipment with others or for particular drug batches or combinations.
Implications
Participants capitalized on fentanyl’s versatility for greater control over their health and embodied and social experiences while living in highly constrained conditions. People injecting fentanyl may be receptive to policies promoting smoking as a harm reduction practice.

“What is a ‘public health approach to substance use’? A scoping review”

Elaine Hyshka, Holly Mathias; Talk

Background: Substance use-related morbidity and mortality is a major population health problem. However, there is currently no consensus definition of a ‘public health approach to substance use’ and the term is applied inconsistently in research and practice. A comprehensive framework is urgently needed to guide public health action.

Objectives: This review synthesizes academic and practice literature to outline the core values, concepts, activities, and goals underlying a public health approach to legal and illegal substance use.

Methods: We conducted a systematic scoping review of both grey and peer-reviewed literature focused on conceptualizing, defining, or describing a public health approach to substance use. A total of 244 articles covering international literature from 1950 to 2023 are included in this review.

Results: The key values of the framework include equity, person-centered care, cultural safety, social justice, human rights, decolonization, and evidence-based practice and policy. Several frameworks are emphasized, including sex/gender-specific approaches and social determinants of health. Key goals of the framework include harm reduction, benefit maximization, prevention, and improvement of health and wellbeing. Key activities include decriminalization; regulation (of access, distribution, supply, promotion and production); improvement of environmental and social conditions; provision of supports; health promotion and public education; and research and evaluation. The importance of multi-pronged interdisciplinary approaches at all socioecological levels is emphasized.

Implications: This research provides a comprehensive and evidence-based path for policymakers, practitioners, researchers, and community members looking to design and implement public-health-based approaches to substance use.

“"With COVID-19 we saw an opportunity, a window where we felt we could capitalize on": Problem representation of BC's Risk Mitigation Guidance during dual public health emergencies”

Daniel Gudino; Talk

Background: In response to the dual public health emergencies of COVID-19 and a longstanding overdose crisis in British Columbia (BC), Canada, interim-clinical Risk Mitigation Guidance (RMG) was released in March 2020, enabling a form of prescribed safer supply for individuals at risk.

Objectives: Provide insights into the construction, interpretation, and implementation of RMG from the perspective of health planners (policymakers, managers, health authority actors) in BC.

Methods: We conducted qualitative interviews (n=28) with health planners from across BC. We used Carol Bacchi’s “What’s the Problem Represented to be?” (WPR) approach as an analytical tool to critically examine the construction of problems and solutions in the RMG.

Results: RMG is a product of an emergency context that opened a window of opportunity for the provision of prescribed safer supply as a policy alternative. The problematization of RMG revealed that it was created in response to the problem of COVID-19, exposing how fear of disease transmission drove a response not seen with escalating overdose deaths. Deprioritizing the overdose crisis created a variety of implementation problems, which led some to question the efficacy of the guidance.

Implications: This study underscores the need for safer supply policy solutions that directly prioritize the unique aspects of the overdose crisis. Using COVID-19 as a primary driver for intervention highlights the limitations of consolidating multiple health crises into a single approach. Findings emphasize the need for alternative ways of thinking about the problem (i.e., non-prescriber models).

“"Working in a relational way is everything": Perceptions of power and value in a drug policymaking network”

Naomi Zakimi, Martin Bouchard; Talk

Background. Inspired by current drug policy developments in North America, the current study examined stakeholders’ experiences and perceptions of power and value in a drug policymaking process in a North American city.

Methods. We conducted semi-structured interviews and administered social network questionnaires (n=17) to people involved in the development of a new drug policy in a North American city. Participants included people with lived experience, policy advocates, researchers, law enforcement, and government officials. Data were analyzed using social network analysis and qualitative thematic analysis.

Results. The policymaking network showed that connections could be found across groups of participants, with government officials being the most central. Qualitative data showed that inclusion in the network and diversity of connections did not necessarily translate into feeling powerful or valued. Many participants were dissatisfied with their roles in the process despite having structurally advantageous positions or self-reporting moderately high quantitative value scores. Participants who viewed themselves as more valued saw the process as more balanced or fair than those who felt undervalued.

Implications and Conclusion. While participation aims to make stakeholders and communities feel valued and empowered, our findings highlight that relative importance in a drug policymaking network doesn't, in and of itself, guarantee these outcomes. The lines that divide the powerless and undervalued from the powerful and valued are complex. Our study demonstrates the utility of combining social network, questionnaire, and qualitative data to better understand and identify the ways in which experiences of participation are perceived and how they can be improved.