Side Event: Treatment and Care of People with Drug Use Disorders in Contact with the Criminal Justice System: Alternatives to Conviction or Punishment

Organised by the Government of the United States, Colombia, Norway, United Kingdom, the UNODC Justice Section, the UNODC Prevention, Treatment and Rehabilitation Branch, and the World Health Organisation. Conference Room M3; 2.20-3.10pm.

Opening remarks:

Update on UNODC/WHO Initiative on Treatment as Alternative to Conviction or Punishment

Gilberto Gerra (Chief, Drug Prevention and Health Branch, UNODC)

Thank you and welcome. It is so nice to have so many people here. Punishment is not good for those with drug use disorders.

Vladimir Poznyak (Coordinator, Management of Substance Abuse, WHO)

Thank you, it is my pleasure to welcome you on the part of the WHO. Dr Margaret Chan siad this morning – nearly everyone in this room will know someone who uses drugs. All parents would prefer their children to be in treatment rather than prison. What is tragic is that dependent drug users do not have adequate access to treatment. 80% of crime is drug-related. Availability of treatment in prison and after release is very important – treatment of dependence can be an effective measure in reducing recidivism, but are not used to it’s potential in many countries. Treatment can be offered as an alternative to punishment by the international drug conventions. Treatment as an alternative is a must in both high and low income countries. This generally requires significant political investment. The presence of the WHO Director General at the Opening Ceremony this morning signifies strong collaboration between UNODC and WHO.

Gilberto Gerra (Chief, Drug Prevention and Health Branch, UNODC)

No prison for drug users. In closed setting, there is: increased severity of addictive behaviour/stress, prescription drugs misuse, risks of overdose, high rates of suicide, aggrevation of health disorders/overcrowding/food, risk for HIV, Hepatitis, TB. What is the gain for putting this people in prison?

Panel I

Statement from Colombia – Carlos Medina Ramirez, Minister of Justice and Law

Thank you. It is my honour to represent my country. There are some weakest links in our responses to drug treatment – this exposes people to risk – not only the prisoners, their opportunity to treatment is very low. Drug dealing sanctions have lead to a very high rate of people in prisons in Colombia. Women engaged in drug dealing activities – 25000 people in prison – 4000 of these are women, involved with drug dealing. They didn’t have any other possibility but to go to prison. People in corrupt environments have no choices. 3 programs – on judiciary program for youth – in our legal framework, justice is to limit the amount of exposure to criminal activities, and open up opportunities for alternative activities. Colombia, after the Peace Agreement, have a new way to solve these problems. For one year, those who try to change into other crops, we will help them try to do this. They were confronting the government with weapons and illicit crops – we would have to put 300000 people into prison.

We want to decriminalise the use and provision of drugs – through different acts – Colombia is going to regulate personal doses, we will have a different approach for users, and for users in prison. Drug use makes some people go into prison. We have a challenge ahead of us. This new vision with an alternative approach with strengthen our weakest links, although this is widely debated by other countries. We think the future is to confront this problem. This has to go hand in hand to prevent other crime.

Alternatives to conviction or punishment in theory and in Belgian practice – Charlotte Colman, PhD, University of Ghent

Thank you. My presentation consists of research in the area of systems and recovery, and how we translate this into Belgian practice.

When people enter the criminal justice system, it’s important to focus on recovery. Recovery and desistance have common grounds – personal identity translations, societal stigma of drug users and offenders. Some also have a criminal record, which makes it difficult to

Drug courts – not mixing high risk/need offenders with low risk/need offenders. Focus on empowerment. Social balance involves alternatives to incarceration – drug treatment is effective. We see reductions in recidivism – not always partnered with reduction in drug use. E.g they could be a daily injecting heroin user, but after treatment they are a monthly cannabis smoker.

Progress in every life domain – positive and successful outcomes are shown from treatment over incarceration.

In Belgium – we have several alternatives at each level of justice system. We have pilot projects – diversion to treatment programs and drug treatment courts. These are bottom-up projects to support a balanced approach. There is room for improvement. We need to invest in data collection and monitoring programs and evaluation.

Clinical Foundation for the Use of Agonist Opioid Treatment in Dual Diagnosis Patients Outside the Prison – Icro Maremmani, Professor of Addiction MedicineUniversity of Pisa, Italy

Dual diagnosis in Italy. We must apply psychopharmacotherapy – with methadone, buprenorphine, naltrexone and so on – to address craving. This also applies with the treatment of mentally ill patients. Good linkage between substance use disorder (SUD) and bipolarity. The other link noted is between SUD to psychosis. We are convinced that the problem of use of antipsychotics arrives in reward deficit syndrome. We are using antipsychotic medication for a long time. Mood stabilisers are important in treating cocaine/heroin addiction – they are good to help people stabilise their lives. We should not use benzodiazepines – it is not a good idea to put patients in this treatment.

First of all we must stabilise SUD, then treat mood disorders with mood stabilisers (rather than antipsychotics or antidepressants), then work towards relapse prevention. Drug addiction is a relapsing disease. We need a long term treatment coordination.

Statement from Norway – Torbjorn Brekke, Specialist Director, Dept of Public Health, Ministry of Public Health and Care Services, Norway

From the Norwegian government – the ban on narcotics and personal use will be maintained. On the other hand, the government is very supportive of alternative measures to incarceration. This is for both younger and older offenders. Sometimes, treatment may occur inside the prison, and sometimes it may occur outside in different services. Regardless of policies and sanctions, we need to focus on who these people are. What characterises them, what needs do they have? Inmates have limited access to health services, including mental health services. The health and care services in in prisons Norway should be equal to any other community. Access to housing and good friendships is limited. On average, inmates have somatic disorders, up to 10 times more than the general population. In one study, 65% of participants had used narcotic drugs or medications. As many as 92% of inmates showed signs of mental health issues. Alternatives are obvious – are these people being punished for their illnesses?

Panel II

Statement by Portugal – Ambassador Alvaro Mendoca e Moura, Permanent Representative of Portugal to the United Nations (New York) and former Chairman of the Bureau of the Prepartory Body of the UNGASS 1998 on the World Drug Problem

Thank you. I bring three perspectives – always a pleasure to return to Vienna. Looking back (on 1998) it’s a pleasure to see a more balanced approach to public health and drug use than 20 years ago. Then, we wanted a balance between supply and demand reduction. Now, the Director of the WHO was part of the Opening Ceremony – this would not have been possible 20 years ago. The speech of the INCB was remarkable, to show how far we’ve come in 20 years. For us from Portugal, it is very relevant that is side event is taking place. It allows us to reflect on the tremendous challenges that face us in the future. National action and international cooperation have helped shape Portugal’s drug policy, since July 2001 when our main law came in. One main aspect of change then was a push away from punishment of those with drug use disorders, to prioritise treatment. It is only one aspect of the policy, which incorporates harm reduction. Incarceration is ineffective. UNGASS 2016 provided us with better instruments to treat drug use and addictions with a public health and human rights centred approach. Portugal firmly believes that our efforts are in line with rights based approaches for sustainable development. It is our belief that the UNGASS document will be regarded as the prime document for the UNODC. The outcome document was a major achievement. You cannot look at the drug issue alone by itself – everything now at the UN is how this will be incorporated with the 2030 Sustainable Development Agenda – Goals number 3 (health and wellbeing) and 16 (peace justice and strong institutions). It is up to you to bring this debate and discussion to New York.

Joao Goulao, National Coordinator for Drug Problems and President of SICAD – General directorate for Intervention on Addictive Behaviours and Dependencies

Thank you – I am very proud to be here. We are happy to have the current Secretary General of the UN as the Prime Minister of Portugal at the time that we decriminalised drugs. We have the unique opportunity to take steps forward.

The Portuguese approach encompasses the political and social acceptance of decriminalisation in Portuguese society at the time. Prevention and treatment occurred at the time, but drug use still increased. Our system highlights the opportunity for health intervention before justice intervention of people using drugs. It focuses on the needs and motivations of people using drugs. Decriminialisation is essential to decrease the immediate effects Implementation of the law is based on interactions of all stakeholders. The coordination of services is fundamental to improving health benefits to Portugal. We do not establish a negative causal effect of decriminalisation. Decrease of drug use in adolescents since 2003. Drug users do not fear the criminal justice system, and are more likely to attend harm reduction and employment services. This policy significantly resulted in the decrease in drug related health disorders. The Portuguese policy focuses on a balanced approach to drug, inclusive of proportionality and respect to human rights.

Statement from the United Kingdom – Andrew Johnson, Head of Drugs and Alcohol, UK Home Office

The UK’s diversion scheme. Many people come into contact with the justice system with many needs. Diversion out of the criminal justice is sometimes appropriate. UK piloted a new diversion program between 2014-2016. The pilots were broadly successful identifying vulnerable people in the system. Staff could better access health and case histories, which could be provided to police and courts, which meant that those involved in sentencing could take in all accounts.

Statement by the USA: USG Priorities in the Area of Treatment as Alternative to Criminal Justice Sanctions – Richard Braum, International Division Director, White House Office of National Drug Control Policy, USA

Health and justice interventions – health services and alternative sanctions. The most important is screening/assessment. Not all people need treatment, and treatment needs vary. As an aspiration, a combination of health services and sanctions will be better to support the community in general. The health system is vital – getting it right is critical. The justice system is important too – as many drug users are arrested – their cases must be adjudicated based on both clinical assessment and public safety risk. There is a lot of work that must be done on alternatives to incarceration. As we move forward, we need to make sure our experiences and knowledge are available to everyone to learn from each other.

Panel III

Statement from the VNGOC/NYNGOC – Sergio Chaparro Hernandez, Centro de Estudios de Derecho, Justicia y Sociedad – Dejusticia (NGO)

Despite political declarations, and even some advances in law, population imprisoned for minor drug offenses in several countries, continues to rise at higher percentage rates than the overall population. For example in Latin America, even the countries that have championed less punitive approaches to address drug related crime, have experienced an explosive growth of people incarcerated for drug offenses. As the last report made by the Research Consortium on Drugs and Law has pointed out, in eight out of nine Latin American countries analyzed, the population incarcerated for drug offenses increased more rapidly than the overall population, at between eight and thirty three times a greater pace. In Colombia, for instance, the prison population grew 141% in the last fifteen years, but the population incarcerated for drug offenses rose 289%. Incarceration as a drug policy tool is no longer a solution but an expensive, ineffective and harmful problem. So the question is what concrete and accountable commitments will governments do to stop this perverse trend?

This debate has focused mainly on treatment and care for people with drug use disorders as an alternative to incarceration. It is clear that evidence based voluntary treatment and health care servicers of the highest standards, including harm reduction interventions, must be available for those who are in need of it, whether they are or not in contact with the criminal justice system. This is not a discretionary option, but a human rights obligation. Drug dependency, once again, should be treated as a public health –not criminal issue. Drug courts are only one out of many possible answers, facing mixed evidence about its effectiveness and other serious problems, for people who commit crimes because of their drug dependence. But, what happen with other minor offenders who also need a more humane and effective response? What happen with women paying long sentences for serving as couriers, what happens with poor peasants who are in prison for sewing coca leaves, or with young people without job opportunities incarcerated for selling drugs on the streets?

A number of alternatives to incarceration have been developed in different countries, and can provide a wide range of options fot these populations according to national circumstances, as the Organization of American States has shown in its report on alternatives to incarceration where more than forty alternatives were analyzed. Some are limited to one phase of justice involvement, such as police forces or problem‐solving courts, while others are available to be accessed at various stages of the criminal justice system. The options available include diversion mechanisms, adoption of administrative sanctions, as well as treatment and educational services, among others. These alternatives are compatible with international drug conventions as well as an unbeatable way to effectively develop UNGASS declaration commitments. So, what can be done by governments today?

First, decriminalize drug consumption and put an end to all de facto persecution against users. In the case of people who have substance abuse or dependency (whether they commit other crimes or not), offer services for voluntary treatment of the highest standards that is centered on a public health approach and is not subject to the threat of criminal sanctions.

Second, remove all legislative and practical obstacles that keep those who commit minor drug offenses excluded from alternatives to incarceration or from being granted a suspended sentence, probation, or parole. Ideally, minor drug offenders should be sent to a comprehensive public network providing services to prevent recidivism and address the socioeconomic factors that led to the commission of the crime, following the example of Costa Rica that developed a succesfull program for women who introduce drugs into prisons.

Third, carry out the reforms needed to implement alternatives to incarceration based on an adequate assessment of which measures would allow optimizing the available resources in each country to reduce prison overcrowding and recidivism. An efficient use of resources may imply a preference for pre-procedural measures over those that are applied during the criminal process or after the conviction, allowing judicial systems to focus on most serious crimes. A fundamental aspect of evidence‐based approaches is the creation of monitoring and evaluation mechanisms that allow States to build a basis for evidence when this is lacking.

Fourth, governments must guarantee the meaningful participation of civil society in the design, implementation and evaluation of alternatives to incarceration. In addition, a more detailed consideration of the role and characteristics of the offenders – such as gender, age, socio‐economic status or national origin– can help authorities recognize and more effectively respond to certain such vulnerabilities.

Political declarations are at disposal of governments, and studies are also evidence to support and sustain the reforms needed. If those two elements are available, we are in need of real political will to move from discourse to practice, and the post UNGASS world is precisely the time to make that transition.

Statement by the OAS/CICAD – Adam Namm, Ambassador, Executive Secretary of the Inter-American Drug Abuse Control Commission (CICAD), Secretariat for Multidimensional Security, Organization of American States (OAS)

Good afternoon and thank you. This is a very important issue for OAS member states. We need to find alternatives to incarceration, especially for low level drug offences. The 2015 report highlighted that the large number of people incarcerated in the Americas is due to disproportionality of drug related offences. This system focuses on the weakest links in the drug control chain. The current system does not hold up the human rights of those with drug related offences. A number of organisations are working towards finding alternatives to incarceration.

Statement by the EU – Lambert Schmidt, Principal Administrator, European Commission, Directorate General Migration and Home Affairs, Security Directorate, Unit on Organised Crime and Drug Policy

Thank you for highlighting the importance of this event and holding it on the first day of the CND session. Alternatives to incarceration are very important to the EU. This issue is highlight by the lack of data, and we are trying to bring more light to this issue. All of our member states have and apply alternatives to incarceration – the last member state applied alternatives this year, which we are happy about. Thank you.

Preventing recidivism in drug abuse and criminality – Nikolaos Paraskevopoulos, Minister of Greek Parliament, former Minister of Justice, Transparency & Human Rights, Greece, Emeritus Professor of Criminal Law

Thank you. There are many types of programs offering to address drug dependence through substitute treatments, but not to tackle social issues. Greece has introduced a new instrument to address these issues – I will show you a short film of it’s implementation in prison. The individual is prosecuted of any crime related to drugs (with the exception of serious crimes related to supply or murder/rape etc). The individual could already be in therapy, and could benefit from this new 3 step process. 1st step – three course in which rehabilitation is offered. Psychological dependence from drug is decreased. 2nd step – included in program in an open and supportive environment, and can be combined with substitution treatment. 3rd step – opportunity to abstain from illicit drug use. The participant participates in an open society program which will benefit the wider community.

Typology of treatment as an alternative to conviction to punishment – Michael Trace, Rehabilitation of Addicted Prisoners Trust, UK

Thanks. I’ve had a long involvement in the diversion discussion in the UK. In Europe in the late 1990s, governments had money to invest in diversion programs, which is different to now. They are very complicated and difficult to get right. Incarceration of drug users has been overused around the world. This year, hundreds of thousands, if not millions, of drug users will be sent to prison around the world. This is not a good use of public money, and is ineffective. There is a political window in which we can advocate to our governments for alternatives to incarceration. OAS CICAD have produced great resources on how to address these problems. It’s very risky when in the design process. Well intentioned but failed programs could lose you decades of achievements – be very clear – what are your policy objectives? Who is your target group? Producers, dependent populations? At what stage are you trying to intervene? And finally, diversion to what – what are you trying to divert people to? You don’t want to divert people to treatment that they don’t need. Be very careful when you design these programs. Thank you.

Questions from the Floor – Lee Edson P. Yarcia, NoBox Transitions Foundation, Inc (NGO)

Thank you – this conversation on alternatives is very important from a country that has a very harsh, punitive drug policy. Our prohibitionist policy has resulted in the loss of 8,000 lives, and our prisons are vastly overcrowded. If we do not focus in a punitive framework, but sees people who use drugs as partners, leads to better health and social outcomes. Public health does not just apply to medical programs, and we do not need to medicalise all forms of drug use. Policy needs to be evidence based and well informed. We know that harm reduction saves lives. Drug use is a public health issue. Harm reduction, or kindness simply put, save lives. Isn’t that all that matters?

Closing Remarks – 

Aldo Lale-Demoz, Deputy Director and Director of Division for Operations, UNODC

Thank you for attending this side event, sorry that it has gone over time. We will now show the video mentioned by Nikolaos Paraskevopoulos. Thank you.

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