Ernesto Cortes, ACEID, Costa Rica. Smokable cocaine in Latin America has been happening for the past 20 years but we still don’t know how to design interventions that help users. They are also highly stigmatised. There is a difference between smokable cocaine differs from the route countries of ‘crack cocaine’. Pasta base can be found in Uruguay and Argentina. Pasta base is before you get powder, whereas crack is after. Pasta base is very low quality and has a lot of harmful components. What we see is that most users are very poor. Some countries have started doing some research – including in Brazil, Argentina, Uruguay and Costa Rica. WHO and UNICRI also have a cocaine project. The UN, especially the WHO have started a process that was never published – it is not a formal project. But it is important to know what the research is about.

We need to understand how crack users or pasta base users consume the substance. The can was very common in Costa Rica, now they use a tube. They use a lot of metal. In Colombia, use is different, they use different pipes.

In terms of harm reduction, there are projects focused on crack cocaine where they provide hygienic paraphernalia. Another harm reduction approach is low-threshold services, such as in Bracos Abertos in Cracolandia in Sao Paulo in Brazil – they receive housing and other services without forcing them to stop using. Another one is CAMAD in Colombia. But unfortunately both services are no longer functioning. What we know is that it is marginalisation and stigma that affects these people.

There has been research in Brazil and Jamaica about therapeutic uses of cannabis by crack dependent users. In Saint Lucia, users consume amphetamines as substitution.

We have started a Latin America Smokable Cocaine specialist working group from across the region to build more information and get the users’ voice out – see how we can help drug users fight for their rights and raise their voice.

Apinun Armarattana, Chiang Mai University. My main experience is within Thailand. We have done some research. The way we did research but it may not be applicable to the general Asian context. I can share here the Thai situation and the harms occurring in Thailand. In Thailand, we classified meth and amphetamines in schedule II according to the conventions. But in 1996, we had an act lifting it to schedule I alongside heroin. Since then, there has been a reduction in heroin use but methamphetamine tablet use has increased from 10% to 60% of those seeking treatment in just a few years. In another household survey trend, you can see three major drugs in Thailand – methamphetamine, cannabis and kratom. Cristal ice was almost at zero in 2001 and it has significantly increased since then. Heroin and opium is maintained at similar levels.

Young methamphetamine users are mostly young males, vulnerable. There are around 910,000 ATS users in Thailand, they are at high risk of STIs, and many are in high risk of heavier drinking and higher prevalence of depression. Meth induced psychosis was also increased after the epidemic started.

Another harm occurred during suppressive policies.  Thailand declared a war on drugs in 2003 and this led to a large increase in prison overcrowding. Most are male, 74% related to drugs (19% for use, 81% for trafficking), mostly for yaba. We have over criminalised the methamphetamine problem, leading to health crises in prisons. The prison costs are over 50% of the Ministry of Justice budget and we still have a lot of drug trafficking and use.

We are now thinking about drug law reform in Thailand. After UNGASS in 2016, we issued a decriminalisation policy which aims to prevent drug users from being incarcerated. Drugs are still illegal, but users should not go to prison, the punishment would be proportionate to the behaviour. On treatment and rehabilitation, we increased investments on treatment, trying to improve access. We have a system of universal health coverage, so treatment is free of charge, and we try to scale up after-care and rehab services.

We don’t only focus on harm reduction, but on the entire healthcare system to reduce harms of methamphetamines.

Diego Olivera, Junta Nacional de Drogas, Uruguay. Uruguay includes in its strategy a focus on harm reduction based on health and harm reduction. This is focus on the fact that many may not be willing or able to stop using drugs. We recognise that we can’t apply a traditional form of treatment. We must apply a methodology that protects health and social inclusion. We recognise the principle of non discrimination in access to healthcare, personal security and the enjoyment of social and cultural goods. Secondly, smokable cocaine users must be treated in full respect of their rights and should focus on health and social inclusion. We must base ourselves on scientific evidence. There is a serious risk of stigma which may worsen health harms related to drug user. Uruguay seeks to develop interventions that aim to increase the quality of life of users of crack and pasta base. We have developed a network of treatment services, coordinated by the health sector to reach out to the greatest number of drug users. We have invested in low-threshold services at community level for the use of pasta base, working with social networks, and referrals to more formal systems. There are also mobile services, with support and care, HIV testing, STI information, access to treatment, etc. The objective is to facilitate access to the network of health and social services.

Finally, the regulation and control of the cannabis market is key. The law 19.172 is a policy that contributes to reducing the harms related to drug use, including the decriminalisation of drug users, and connections with the police.

We promote the participation of civil society and drug users. We recognise that the social organisations have contributed to the development and implementation of harm reduction policies. We aim to integrate drug users and civil society in the implementation of actions and projects. We have developed space for their inclusion and involvement, as forums for dialogue on a permanent basis. There is also an Honorary Board of IRCCA where users’ organisations are also involved.

Fabienne Hariga, UNODC HIV/AIDS Section. HIV risks are very complex. It’s difficult to get a bigger picture to help us define policies. And it is affecting us everywhere, not just in Asia and Latin America. ATS also affects most of the world. For cocaine use, it is mostly focused on the Americas and Europe. There has been a recent development – people are switching from injecting heroin to injecting other substances. In Hungary, data from PWID at an NSP service showed a surge in cocaine and ATS use.

We conducted a literature review on stimulant use and HIV. 4 parts: ATS, cocaine, NPS and interventions. We also had a 2016 scientific consultation at the margin of the CND and we covered the problem of cocaine, MSM and ATS in Asia and ARV among stimulant users. We have a large variety of HIV rates from country to country. There is a difference between non-injecting and injecting ATS users. There are also increases in sexual risk behaviours among stimulant users. There are also higher risks between injecting ATS users. Risks of HIV infection are also increased for ATS use among other key populations such as MSM and sex workers.

We have conducted a systematic review on ATS use and HIV injection among MSM, showing the increase in HIV risks. We have also conducted research among MSM using ice, and increased risks of HIV infection and unsafe sexual behaviours. There is also a link with hepatitis C and cocaine use – mainly in Latin America.

To summarise, there is a link between ATS/cocaine use and HIV, but there is little to quantify the size of this trend. The sue of cocaine and ATS increases the risk of sexual transmission. The way cocaine is injected is very different from the risk of injecting heroin – injection is much more frequent, and the needs are very different. There is also a need to focus on key populations like sex workers and MSM.

We have developed a guide on harm reduction and stimulant use. We must review interventions and we have no data on those. We have no evidence based treatment for stimulant use, there are only clinical trials of substitution treatment, it’s mostly cognitive behavioural therapy and clinical trials. We need more peer-based IEC and support, alternatives to incarceration to address stigma and discrimination.