Organized by the Government of the United States.

Richard Baum, U.S. Office of National Drug Control Policy: Neither supply or demand can solve the problem itself. Both new initiates and heavy users are impacted by price and availability. Supply tools have not been able to keep prices as high as we would like. There is a risk premium built into the cost, so we must not forget how low these prices would fall without law enforcement. All types of supply reduction and policing strategies are not equally effective. Must replace ineffective approaches with those that are more promising. We are no longer conducting drug enforcement the way we did decades ago. Legislative approaches in response to synthetic drugs threat. At times, one legislative change follows another in response to trends. Coordinated task forces now used to bring together law enforcement agencies across the nation. Avoid wasting resources and bumping into each other in investigations. US has benefited from focused operations on agreed targets. Agencies come together as a group to decide targets that pose the biggest threat and pool resources to maximize impact. Community policing helps to address specific concerns of citizens. Get to know the neighbourhood where they work. Foot and bike patrols, neighbourhood bases, etc. Information flow increased due to establishment of trust. Success not measured by number of arrests, but by citizen perceptions of safety. Drug market intentions program has enforcement efforts carefully designed to disrupt drug markets with minimal number of arrests. Collaborative process involving social service agencies, city managements, etc. Only most violent drug dealers are arrested. Others given the choice to have treatment and social services and to stop their illegal activity. If they do not stop, they are arrested. Doesn’t require wide scale arrests. These are some innovations occurring in the US. Drug enforcement cannot stand still or be satisfied with the tools we have.

Nora Volkow, Director, U.S. National Institute of Drug Abuse (NIDA): Alcohol and nicotine produce much more harm to individuals than those using other drugs. Higher the cost of a particular drug, the less likely it will be used. Can have a particularly big effect among teenagers. Cannabis legalized in different places in US and the world. State that has led efforts in legalization is Colorado. First state with medical cannabis, and then recreational. Anyone could get a prescription under the medical system. In 2009, steep increase in number of cannabis prescriptions made cannabis more available. Hospital increases and poison centre calls went up dramatically. Policy of legalization meant people who otherwise would not have used cannabis did so, and perhaps taking it in higher doses. Opioid prescription epidemic has transferred into heroin epidemic and now synthetic opioid epidemic. Number of prescriptions went up in 2000 when hospitals were required to screen for pain in their patients. Increase in opioid prescriptions facilitated diversion. Increasing the number of prescriptions was done in a way that did not control these substances, which can be very addictive. Overdose deaths caught attention. Prescriptions went up and overdose deaths occurring from those prescriptions rose and rose. Now we have the highest number ever recorded. Tragedy is that it did not stop there because as people become addicted, they start accessing in the illegal market, where heroin had become of much higher purity. It was less expensive and more available. Now we have a four to five fold increase in number of people overdosing from heroin. Indication of how access and supply allowed the epidemic to emerge. Created an opportunity for drug dealers to expand the heroin market. Challenge we face now is synthetic opioids. More potent than heroin. Volume for trafficking is much smaller. Easier to transfer it without being caught, and also greater profits. Going from heroin to fentanyl. Fentanyl emerged in 2007. Was controlled and use decreased. However, over the past four years, we are seeing an increase in fentanyl, associated with steep increases in overdose. If we do not control the supply, we can have catastrophic consequences. Carfentanil also emerging and is very lethal. Challenges of supply are unprecedented. How can we as an agency contain these emerging trends and educate the public on the dangers of these substances?

Jamie McLellan, Head of Drugs Legislation, Drugs & Alcohol Unit, Home Office, United Kingdom: Since 2009, there was an emergence of the open sale of new psychoactive substance (NPS) through head shops. Synthetic substances being sold completely openly outside of traditional Misuse of Drugs Acts control. Sold relatively freely. Police forces worked closely with trading standards officers to use consumer protection legislation, but could not prevent proliferation of head shops. Following the Psychoactive Substance Act, there was a blanket ban of anything that it defines as a psychoactive substance capable of producing a psychoactive effect in a person. Took a multiagency approach, with a national multi-agency working group, cross agency workshops, and forensic testing regime. Police mapped out head shops, built on relationships with trading standards to persuade sellers to stop selling and warn them about upcoming legislation. When the act commenced, focused on remaining suppliers. Prisons, border officials, and prosecutors involved at early stages. In terms of online market, started to engage with website in run up to the legislation to warn them to cease trading. Broad compliance, but an issue of relocation of sites outside UK and over to the dark net. Consistent communications helped to keep things coordinated across police. In first six months of the Act coming into force, 332 shops stopped selling. Only 31 closed down. Rest moved into other types of business. Nearly 500 suppliers were arrested in the first six months of Act coming into force. Anecdotally, there are still problems in prison and rough sleeping communities with NPS. Less than a year into the Act. Full review to come in late 2018.

Harry Matz, Criminal Division, U.S. Department of Justice: Made great progress in addressing the lab problem, but not so much the methamphetamine abuse problem. Had two kinds of problems, namely large labs and small labs. Solution has been all action and reaction. Moving by baby steps. Trouble legislating by broad strokes. Beginning was with legislation in 1988. Legal drug exemption in this law allowed for traffickers to transit ephedrine tablets. Ended this exemption in 1993 by regulating drugs with just ephedrine. Traffickers turned to combination ephedrine products. 1996 legislation controlled the combo products, but had a blister pack exemption. Trafficker response was to use blister packed products. 2000 legislation retained the blister pack exemption. Business continued as usual for traffickers. Shift to foreign source of pharmaceutical regulations. Went to Canada, who then tightened their regulations. Then went to Mexico. 2006 legislation got it right. Enforcement as part of the picture. All enforcement is not guns and badges. DEA operations going after sellers of chemicals and prosecuted them with sometimes quite long sentences. CVS paid a civil penalty because they were permitting back to back below threshold sales. Number of children killed or injured in meth labs is way down, and same with law enforcement offices. “Super labs” are almost a thing of a past in US.

Antonio Guzman, Drug Enforcement Agency (DEA), U.S. Department of Justice: Methamphetamine is the second most trafficked drug that we see, after cannabis. Traffickers have moved on from PSE and EPH. Traffickers moved south and to the P2P method. Two critical factors are chemistry and availability. How easy is it to manufacture, and the costs of production, are also relevant. Methamphetamine seizures along US and Mexico border has increased every year. Meth problem never went away, just took a different form. Must share information rapidly and try to be evidence-based.

Harry Matz, Criminal Division, U.S. Department of Justice: International cooperation also important.

Question: Other types of dangerous adulterants emerging in illegal drugs?

Antonio Guzman, Drug Enforcement Agency (DEA), U.S. Department of Justice: Sometimes there is misinformation. Drug trafficking organizations are often poly drug organizations, and there is cross contamination. Haven’t seen enough data that fentanyl in cocaine, for example, is a deliberate effort to contaminate.

Nora Volkow, Director, U.S. National Institute of Drug Abuse (NIDA): NIDA surveys show that methamphetamine use is going down, but it is the second most trafficked. So where are these drugs going? Perhaps the surveys are not as accurate as we thought.

Question: Butane use in creation of cannabis shatters?

Harry Matz, Criminal Division, U.S. Department of Justice: If they use something other than butane, far less dangerous.

Question: Inverse relationship between overdose deaths and medical cannabis use?

Nora Volkow, Director, U.S. National Institute of Drug Abuse (NIDA): Rate of increase of overdose deaths is slower in places that have medical cannabis. Using medical cannabis instead of opioids. Opioids are worse than cannabis because of addictive potential, but also have high therapeutic benefit. We started over prescribing and there was an aggressive market to sell this product. However, this shouldn’t be used to say we should use medical cannabis for pain. Need randomized clinical trails on medical cannabis. Have to be cautious. Can extract ingredients from cannabinoids. Trying to have researchers provide the evidence that it is therapeutic in order to support possibly rescheduling cannabis.

Question: Veterans are not accessing cannabis because they do not have the qualifying conditions. Specifically, PTSD is not a qualifying condition. Laws on medical cannabis are not so permissive in Colorado.

Nora Volkow, Director, U.S. National Institute of Drug Abuse (NIDA): System did favour the use of these licenses for recreational purposes. Need randomized clinical trials to determine what cannabis is effective in treating.