Criminal Justice Barriers to Treatment of Opioid Use Disorders in the United States: The Need for Public Health Advocacy.

Expanding access to treatment of opioid use disorder (OUD) is central to addressing the US overdose mortality crisis. Numerous barriers to OUD treatment are encountered in criminal justice institutions and processes, with which people with OUD are disproportionately involved. OUD treatment access is severely limited in US corrections facilities, with few exceptions. Drug treatment courts, which in principle provide court-supervised treatment as an alternative to prison, have also unduly limited treatment options, particularly medication-assisted treatment. The voice and expertise of health professionals are urgently needed to remove these barriers and ensure that criminally accused persons are systematically linked to the care they need.

Experiences with policing among people who inject drugs in Bangkok, Thailand: a qualitative study.

BACKGROUND: Despite Thailand's commitment to treating people who use drugs as "patients" not "criminals," Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012. METHODS AND FINDINGS: Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample. CONCLUSIONS: This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.

Reports of police beating and associated harms among people who inject drugs in Bangkok, Thailand: a serial cross-sectional study.

BACKGROUND: Thailand has for years attempted to address illicit drug use through aggressive drug law enforcement. Despite accounts of widespread violence by police against people who inject drugs (IDU), the impact of police violence has not been well investigated. In the wake of an intensified police crackdown in 2011, we sought to identify the prevalence and correlates of experiencing police beating among IDU in Bangkok. METHODS: Community-recruited samples of IDU in Bangkok were surveyed between June 2009 and October 2011. Multivariate log-binomial regression was used to identify factors associated with reporting police beating. RESULTS: In total, 639 unique IDU participated in this serial cross-sectional study, with 240 (37.6%) participants reporting that they had been beaten by police. In multivariate analyses, reports of police beating were associated with male gender (Adjusted Prevalence Ratio [APR] = 4.43), younger age (APR = 1.69), reporting barriers to accessing healthcare (APR = 1.23), and a history of incarceration (APR = 2.51), compulsory drug detention (APR = 1.22) and syringe sharing (APR = 1.44), and study enrolment in 2011 (APR = 1.27) (all p < 0.05). Participants most commonly reported police beating during the interrogation process. CONCLUSIONS: A high proportion of IDU in Bangkok reported having been beaten by the police. Experiencing police beating was independently associated with various indicators of drug-related harm. These findings suggest that the over-reliance on enforcement-based approaches is contributing to police-perpetrated abuses and the perpetuation of the HIV risk behaviour among Thai IDU.

Methadone treatment providers' views of drug court policy and practice: a case study of New York State.

BACKGROUND: Specialized drug treatment courts are a central part of drug-related policy and programs in the United States and increasingly outside the U.S. While in theory they offer treatment as a humane and pragmatic alternative to arrest and incarceration for certain categories of drug offenses, they may exclude some forms of treatment-notably methadone maintenance treatment (MMT). We sought to understand from the perspective of treatment providers whether this exclusion existed and was of public health importance in New York State as a case example of a state heavily committed to drug courts and with varying court-level policies on MMT. Drug courts have been extensively evaluated but not with respect to exclusion of MMT and not from the perspective of treatment providers. METHODS: Qualitative structured interviews of 15 providers of MMT and 4 NGO advocates in counties with diverse court policies on MMT, with content analysis. RESULTS: Courts in some counties require MMT patients to "taper off" methadone in an arbitrary period or require that methadone be a "bridge to abstinence". Treatment providers repeatedly noted that methadone treatment is stigmatized and poorly understood by some drug court personnel. Some MMT providers feared court practices were fueling non-medical use of prescription opiates. CONCLUSIONS: Drug court practices in some jurisdictions are a barrier to access to MMT and may constitute discrimination against persons in need of MMT. These practices should be changed, and drug courts should give high priority to ensuring that treatment decisions are made by or in close consultation with qualified health professionals.

So many harms, so little benefit: a global review of the history and harms of HIV criminalisation.

Since the early years of HIV, many jurisdictions have criminalised HIV non-disclosure, potential or perceived exposure, and transmission. Many of these laws and prosecutions are without a scientific basis and reflect an inaccurate understanding of HIV-related risk and harm. Numerous studies of HIV criminal prosecutions show that women, sex workers, racial minorities, gay and bisexual men, transgender people, immigrants, and Indigenous people are disproportionately charged and convicted, often resulting in long custodial sentences. Data from molecular HIV surveillance, used to track HIV outbreaks in marginalised populations, are prone to be misused in HIV criminal cases. Scientific consensus statements and international standards have helped to guide advocacy to repeal or reform a number of these laws, resulting in fewer prosecutions in some jurisdictions. Many successful reform efforts have been led by people living with HIV and are notable at a moment of reckoning on racism and inequality in global health.

People who use drugs, HIV, and human rights.

We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries.

Compulsory drug detention center experiences among a community-based sample of injection drug users in Bangkok, Thailand.

BACKGROUND: Despite Thailand's official reclassification of drug users as "patients" deserving care and not "criminals," the Thai government has continued to rely heavily on punitive responses to drug use such as "boot camp"-style compulsory "treatment" centers. There is very little research on experiences with compulsory treatment centers among people who use drugs. The work reported here is a first step toward filling that gap. METHODS: We examined experiences of compulsory drug treatment among 252 Thai people who inject drugs (IDU) participating in the Mitsampan Community Research Project in Bangkok. Multivariate logistic regression was used to identify factors independently associated with a history of compulsory treatment experience. RESULTS: In total, 80 (31.7%) participants reported a history of compulsory treatment. In multivariate analyses, compulsory drug detention experience was positively associated with current spending on drugs per day (adjusted odds ratio [AOR] = 1.86; 95%CI: 1.07 - 3.22) and reporting drug planting by police (AOR = 1.81; 95%CI: 1.04 - 3.15). Among those with compulsory treatment experience, 77 (96.3%) reported injecting in the past week, and no difference in intensity of drug use was observed between those with and without a history of compulsory detention. CONCLUSION: These findings raise concerns about the current approach to compulsory drug detention in Thailand. Exposure to compulsory drug detention was associated with police abuse and high rates of relapse into drug use, although additional research is needed to determine the precise impact of exposure to this form of detention on future drug use. More broadly, compulsory "treatment" based on a penal approach is not consistent with scientific evidence on addressing drug addiction and should be phased out in favor of evidence-based interventions.

Consumer protection in drug policy: The human rights case for safe supply as an element of harm reduction.

The dramatic increase in overdose mortality in North America since 2000 and spikes in harmful drug use in other parts of the world in recent decades challenge drug policy-makers to broaden their definition of harm reduction. Ensuring access to a safe supply of drugs for those obtaining adulterated drugs from illegal markets must be an essential element of preventing overdose and reducing the harms of overdose. Safe supply initiatives, including but not limited to the provision of legally regulated medical-grade heroin or hydromorphone in humane and non-stigmatizing ways, are well justified by the state obligations to protect the right to life and the right to health. Such initiatives go beyond established harm reduction measures that may protect against infectious disease transmission but do not address the problem of toxicity of drugs obtained from unregulated illegal markets. It is argued here that the safe supply obligations of governments with respect to psychotropic drugs are analogous to other state responsibilities in the area of consumer protection and extend to all people using any kind of psychotropic substance. Safe supply measures, as with all health and harm reduction programmes, must be designed, implemented and evaluated with meaningful participation of people who use drugs.

United States drug courts and opioid agonist therapy: Missing the target of overdose reduction.

•Agonist therapy for opioid use disorder (OUD) is often inaccessible in the US at a time of high overdose mortality.•OUD therapy could be offered by drug treatment courts as an alternative to criminal prosecution for some drug offenses.•Many drug courts, however, reject gold-standard agonist therapies, seeing them as "another form of addiction".•Drug courts often prefer to offer extended-release naltrexone, but it is costly and requires pre-treatment abstinence.•Drug courts have had limited success in improving access to OUD treatment at a time of high overdose mortality.

Vertical HIV transmission should be excluded from criminal prosecution.

Prevention of mother-to-child transmission of HIV (PMTCT) is an important part of global and national responses to HIV and AIDS. In recent years, many countries have adopted laws to criminalise HIV transmission and exposure. Many of these laws are broadly written and have provisions that enable criminal prosecution of vertical transmission in some circumstances. Even if prosecutions have not yet materialised, the use of these laws against HIV-positive pregnant women could compound the stigma already faced by them and have a chilling effect on women's utilisation of prevention of mother-to-child transmission programmes. Although criminal laws targeting HIV transmission have often been proposed and adopted with the intent of protecting women, such laws may disadvantage women instead. Criminal laws on HIV transmission and exposure should be reviewed and revised to ensure that vertical transmission is explicitly excluded as an object of criminal prosecution. Scaling up PMTCT services and ensuring that they are affordable, accessible, welcoming and of good quality is the most effective strategy for reducing vertical transmission of HIV and should be the primary strategy in all countries.

Male circumcision and HIV prevention: a human rights and public health challenge.

Three recent randomized clinical trials from Africa concluded that male circumcision can lead to a significant reduction in HIV risk for men. As a result, an exponential scale-up of services required to circumcise men is already figuring in the thinking of AIDS policy-makers at many levels. At this writing, the World Health Organization (WHO) is reviewing the three studies and other evidence, and is developing policy recommendations for making this HIV prevention intervention widely available. WHO says that this policy exercise"will need to take into account cultural and human rights considerations associated with promoting circumcision,"among other factors. In this article, Joanne Csete identifies some of the most important human rights questions that should be taken into account in the development of guidelines for national governments. The author argues that a scale-up of services to provide male circumcision provides an excellent opportunity to address issues concerning the subordination of women.

Seeing through the public health smoke-screen in drug policy.

In deliberations on drug policy in United Nations fora, a consensus has emerged that drug use and drug dependence should be treated primarily as public health concerns rather than as crimes. But what some member states mean by "public health approach" merits scrutiny. Some governments that espouse treating people who use drugs as "patients, not criminals" still subject them to prison-like detention in the name of drug-dependence treatment or otherwise do not take measures to provide scientifically sound treatment and humane social support to those who need them. Even drug treatment courts, which the U.S. and other countries hold up as examples of a public health approach to drug dependence, can serve rather to tighten the hold of the criminal justice sector on concerns that should be addressed in the health sector. The political popularity of demonisation of drugs and visibly repressive approaches is an obvious challenge to leadership for truly health-oriented drug control. This commentary offers some thoughts for judging whether a public health approach is worthy of the name and cautions drug policy reformers not to rely on facile commitments to health approaches that are largely rhetorical or that mask policies and activities not in keeping with good public health practise.

HIV, Sex Work, and Law Enforcement in China.

HIV prevalence in China is low in the general population but higher among certain key affected populations, including sex workers. Providing and purchasing sexual services are administrative offenses. Police engage in humiliating and repressive practices against sex workers. A study reported here based on the experience of over 500 sex workers highlights that the human rights abuses that sex workers face at the hands of the police directly undermine the country's HIV response toward sex workers. An important element of this phenomenon is the police's use of condoms as evidence of sex work, which impedes sex workers' possession and use of condoms. Whereas in some countries, sex worker collectives have helped empower sex workers to stand up to the police and safeguard their use of condoms, restrictions on civil society in China make such a strategy impossible. Removing sex work and related activities as offenses under the law in China, however politically difficult it might be, would ease this situation. Short of that, improving the coordination among and strategic harmony of public health and police roles and authorities would be useful.

Human Rights and the Global Fund to Fight AIDS, Tuberculosis and Malaria: How Does a Large Funder of Basic Health Services Meet the Challenge of Rights-Based Programs?

The Global Fund to Fight AIDS, Tuberculosis and Malaria was created to greatly expand access to basic services to address the three diseases in its name. From its beginnings, its governance embodied some human rights principles: civil society is represented on its board, and the country coordination mechanisms that oversee funding requests to the Global Fund include representatives of people affected by the diseases. The Global Fund's core strategies recognize that the health services it supports would not be effective or cost-effective without efforts to reduce human rights-related barriers to access and utilization of health services, particularly those faced by socially marginalized and criminalized persons. Basic human rights elements were written into Global Fund grant agreements, and various technical support measures encouraged the inclusion in funding requests of programs to reduce human rights-related barriers. A five-year initiative to provide intensive technical and financial support for the scaling up of programs to reduce these barriers in 20 countries is ongoing.

How Drug Control Policy and Practice Undermine Access to Controlled Medicines.

Drug conventions serve as the cornerstone for domestic drug laws and impose a dual obligation upon states to prevent the misuse of controlled substances while ensuring their adequate availability for medical and scientific purposes. Despite the mandate that these obligations be enforced equally, the dominant paradigm enshrined in the drug conventions is an enforcement-heavy criminal justice response to controlled substances that prohibits and penalizes their misuse. Prioritizing restrictive control is to the detriment of ensuring adequate availability of and access to controlled medicines, thereby violating the rights of people who need them. This paper argues that the drug conventions' prioritization of criminal justice measures-including efforts to prevent non-medical use of controlled substances-undermines access to medicines and infringes upon the right to health and the right to enjoy the benefits of scientific progress. While the effects of criminalization under drug policy limit the right to health in multiple ways, we draw on research and documented examples to highlight the impact of drug control and criminalization on access to medicines. The prioritization and protection of human rights-specifically the right to health and the right to enjoy the benefits of scientific progress-are critical to rebalancing drug policy.

"Second on the needle": human rights of women who use drugs.

Women likely experience drug use in ways that are different than men, and may face discrimination based both on their status as drug users and their status as women. In this article, which is based on a presentation at a satellite session prior to the conference, Joanne Csete reviews existing data on women's use of drugs, and discusses the barriers in accessing health services faced by women who use drugs. The author concludes that there is an urgent need for rights-based, women-centered services for women who use drugs.

Scaling up HIV testing: human rights and hidden costs.

The calls for provider-initiated routine HIV testing are growing more intense. In this article, Joanne Csete and Richard Elliott discuss the human rights and ethical issues raised by the routine testing approach. Some points in this paper are inspired by an international expert meeting on HIV testing and human rights convened by the Center for Health and Gender Equity, Gay Men's Health Crisis and the Canadian HIV/AIDS Legal Network in Montreal in October 2005. The meeting was attended by academic experts, UN officials, activists and people living with HIV/AIDS from around the world.