Organized by Transform Drug Policy Foundation.

Steve Rolles, Transform Drug Policy Foundation: Amphetamines and methamphetamines are both available as legal medicines and via the illegal market, either diverted or via unregulated production. Production around amphetamines is somewhat easy to answer, as we already have a scaled up legal model for medical use. Could expand the existing system. Largely synthetic production. No one-size-fits-all response. Different modes of administration, behaviours, products, range of risks, and environments. Broad spectrum. Policy needs to be sensitive to that complexity. Public health approach is a sensible one as far as you identify key amphetamine-related risks and vulnerabilities using an evidence-based approach. In terms of the scale of the challenge, 28.9 million people used amphetamines in the last year. Not a small phenomenon. Diversity between regions. Second most widely used illegal drug after cannabis. Do not get the attention they deserve given this data. Markets and demand are increasing. Need a rethink of our approach. Deterrence and eradication led approach has been used for decades and delivering exact opposite outcomes to what we would like to see. Need a rethink. Transform Drug Policy Foundation exploring options for regulated markets for non-medical use of amphetamines. Debate around regulation is difficult and contentious. Only one part of the jigsaw but regulation needs to be discussed. If we can’t get rid of the market, we either responsibly regulate in the hand of state agencies or it is left in the hands of organized criminal groups. Those are the two choices and there is no third choice in which it magically disappears. Need to accept reality and use public health pragmatism. Debate on regulation has moved from emerging into mainstream, although mostly around cannabis. Global consensus around blanket prohibition approach has been crumbling. Regulation of risky products and behaviours is a primary function of governments. Applying that thinking to illegal drugs. Regulation defines the parameters of what is and is not allowed. Activities outside the regulatory framework remain illegal. Stimulant regulation in practice includes New Zealand’s New Psychoactive Substances regulation bill and Bolivia’s legal coca market. Early discussions on MDMA in the Netherlands. Medical prescription models are the primary example. Opioids are widely prescribed in the UK like methadone, buprenorphine, and heroin assisted treatment. Amphetamines have been prescribed as part of maintenance or harm reduction programs, but less well developed than opioids. We can regulate production, product, vendors, outlets, marketing, and buyers/users. Can apply a flexible menu of options. Five models of regulated availability include medical prescription and supervised venues, specialist pharmacist sale models, licensed retail, licensed premises for sale and consumption, and unlicensed sales. Coming soon from Transform Drug Policy Foundation is a practical guide on how to regulate stimulants.

Gloria Lai, International Drug Policy Consortium: Expanding market for amphetamines. North America and Southeast Asia have greatest demand. Rate of increase has been very fast. Seizures have multiplied by five times from 2009-2017. Rate of seizures in past two years, particularly in Myanmar and Thailand, keep breaking past year records. No sense of decline. Prices of methamphetamine have dropped. Top drug of concern by government in all of Southeast Asia expect Vietnam. China has declined a bit in recent years but picked up in Southeast Asia, especially Golden Triangle. Escalation of supply due to operation of sophisticated crime networks in the region. Highly profitable trade. Made from chemicals that can be accessed cheaply. Doesn’t cost a lot to produce. Can afford to lose 90% of what they produce to law enforcement seizures and still make a significant profit. Unstable governance in production areas, like conflict zones in Myanmar. Low law enforcement capacity. Last time kingpin was prosecuted was three decades ago. Shadow Report on Asia from the International Drug Policy Consortium. Use of death penalty mostly in Southeast Asia. People killed in the Philippines came following a campaign by the president that specifically targeted methamphetamine. Demonized more than any other drug, especially in Philippines. Prisons have high rates of overcrowding. Most people in prison for drug offences. Women are more likely to be in prison for drugs than men, and increasing at a faster rate than men. Decriminalization in some countries in the region, but administrative penalties can sometimes be seen as worse than criminal offences, such as detention, forced labour, corporal punishment including canings, forced urine testing, or compulsory registration with law enforcement. Increase in compulsory detention in recent years in Vietnam. Myanmar removed penalties for consumption, but not possession, in 2017. Thailand legalized cannabis for medical and research purposes. Innovation in Indonesia pertaining to outreach with safer smoking kits, referrals to other services, and reminding people to eat, drink, and sleep. Reminder of how simple harm reduction messages can be.

Shaun Shelly, University of Cape Town: Methamphetamine framed as the most dangerous drug. Studies conclude methamphetamine leads to cognitive improvements. What makes methamphetamine so dangerous? Drug, environment, and mental health and physical health. Also known as drug, set, and setting. Harm reduction is a set of principles. Change just one of these factors, and you can change the outcomes of drug use. Quality of methamphetamine is very high in South Africa. Dose is very important. As soon as you climb in dose, you move towards problematic use. Economically, you want to maximize return on investment so do not want to keep dosing. Do not get any higher beyond a certain point. More doses mean less sleep, which is a key diver of negative outcomes. Pattern of use is very important. Binges increase risk of psychosis. Method of use is important. Discouraging injection. Culture of injection has increased. Harm reduction should have started with smokers, not injectors. Advise against polydrug use. Do not come down using cannabis, as this increases risk of psychosis. Try not to mix with alcohol. Use where you feel safe and with people who you are safe. Do not use in the evening. Consider your history of use and particular vulnerabilities. Risk of hepatitis C infection. Hepatitis C infection increases risk of psychosis. Remember to eat right. Remember to sleep, as this leads to reductions in incidence of psychosis. Stay hydrated. Trained peers on how to deal with psychosis. Often a learned behaviour that increases after the first incident. During early stages of psychotic event, you can talk somebody down. Trained people to do so.

Questions & Answers:

• Methamphetamine regulation is controversial in Southeast Asia. Do you think it is possible? If so, should decriminalization or regulation come first?
  • Gloria Lai: Not much prospect. Even where there has been some debate in the region, it is only happening because it is coming up elsewhere in the world. Until we see serious consideration elsewhere, like North America, doubt that it could have a chance to be discussed in the region. For medical use, it could. For adult use, working to at least open up space to debate it. So much hysteria and demonization of methamphetamine, yet so widely used.
• Is methamphetamine harm reduction the same as amphetamine harm reduction?
  • Shaun Shelly: Principles of amphetamine and methamphetamine harm reduction are the same. In a focus group of people in Atlanta, most prefer using a known dose of a regulated medication than an unregulated dose. Should be prescribing to people that had stimulant issues, not avoiding this.
• Prescribing amphetamine substitution in Cape Town?
  • Shaun Shelly: Model requires them to see a psychiatrist and pharmacist every month. Quite a mission and very expensive. Unregulated market is much more accessible.
• Medical amphetamines for ADHD. Risk of overprescribing?
  • Steve Rolles: Context is important. Can’t have a prescriptive model. Has to fit with culture, politics, as well as sets of risks and behaviours. Obvious place to start is greater focus and investment on research around substitution therapy using amphetamines. Substantial body of research around amphetamine substitution yet evidence base is conflicting. Did indicate it was promising. Habitual users prescribed an oral amphetamine did well on it. Inadequate evidence base with small sample sizes, patchy, and poorly linked across the world. Need research, academic investment, and political will. For people who use amphetamines once a year recreationally or those who use it as a functional tool to work, medical model won’t work. Is there a regulatory model that can cater to these lower risk users? Lower threshold access to lower risk products is other side of the coin to medical.
• UNODC Guidelines on HIV and Stimulants. Thoughts on sexual risk and stimulants?
  • Shaun Shelly: Cape Town has issues around this. Two markets do not intersect. Sex work, injecting, and non-injecting fit together in enmeshed and complex adaptive system. Cannot look at one and not the other.