With a thousand issues of Drug War Chronicle under our belts, we look back on the biggest international drug and drug policy stories of the past 20 years. (A companion piece looks at the biggest US domestic drug policy stories.) Here's what we find:

1. Global Prohibitionist Consensus Starts to Crumble

In 1998, the UN General Assembly Special Session on Drugs (UNGASS), with anti-prohibitionist voices in the room but metaphorically on the outside, pledged itself to eradicating drugs in 10 years. That didn't happen. Now, nearly 20 years later, it is duly chastened, and the chorus of critics is much louder, but the UN still remains a painfully slow place to try to make change in global drug policy.

Yet, despite the foot-dragging in Vienna and New York, albeit at a glacial pace. The 2016 UNGASS couldn't bring itself to actually say the words "harm reduction," but acknowledged the practice in its documents. It couldn't bring itself to resolve to be against the death penalty in drug cases, but a large and growing number of member states spoke out against it. It couldn't officially acknowledge that there is "widespread recognition from several quarters, including UN member states and entities and civil society, of the collateral harms of current drug policies, and that new approaches are both urgent and necessary," even though that's what the UN Development Program said. And the UN admitted to having dropped the ball on making opioid analgesics available in the developing world.

It certainly wasn't ready to talk about drug legalization in any serious fashion. But despite the rigidity within the global anti-drug bureaucracy, driven in part by the hardline positions of many Asian and Middle Eastern member states, the global prohibitionist consensus is crumbling. Many European and Latin America states are ready for a new direction, and some aren't waiting for the UN's imprimatur. Bolivia has rejected the 1961 Single Convention on Narcotic Drugs' provision criminalizing the coca plant, and Canada and Uruguay have both legalized marijuana with scant regard for UN treaty prohibitions. And of course there is Portugal's broad decriminalization system, encompassing all drugs.

There's a real lesson in all of this: The UN drug treaties, the legal backbone of global drug prohibition, have proven to be toothless. There is no effective mechanism for punishing most countries for violating those treaties, at least not relative to the punishing effects they suffer from prohibition. Other countries will take heed.

2. Afghanistan Remains the World's Opium Breadbasket

When the US invaded Afghanistan in late 2001, it entered into a seemingly endless war to defeat the Taliban and, along with it, the opium trade. Sixteen years and more than a trillion dollars later, it has defeated neither. Afghanistan was already the world's leading producer of opium then, and it still is.

According to the UN Office on Drugs and Crime, in 2000, the country produced more than 3,000 tons of opium. The following year, with the Taliban imposing a ban on poppy planting in return for US aid and international approval, production dropped to near zero. But in 2002, production was back to more than 3,000 tons, and Afghan poppy farmers haven't looked back since.

In the intervening years, Afghanistan has accounted for the vast majority of global opium production, reaching 90% in 2007 before plateauing to around 70% now (as production increases in Latin America). It has consistently produced at least 3,000 tons a year, with that amount doubling in selected years.

For years, US policymakers were caught in a dilemma, and drug war imperatives were subordinated to anti-Taliban imperatives. The problem was that any attempt to go after opium threatened to push peasants into the hands of the Taliban. Now, the Trump administration is bombing Taliban heroin facilities. But it hasn't bombed any heroin facilities linked to corrupt Afghan government officials.

3. Movement Toward Acceptance of Recreational Marijuana

Twenty years ago, only the Netherlands had come to terms -- sort of -- with marijuana, formally keeping it illegal, but, in a prime example of the Dutch's policy of gedogen (pragmatic tolerance), with possession and sale of small amounts allowed. (The Dutch are only now finally dealing with the "backdoor problem," the question of where cannabis cafes are supposed to get their supplies if it can't be grown legally).

The first entities to legalize marijuana were the US states of Colorado and Washington in 2012, and Uruguay became the first country in the world to legalize marijuana in 2014. Canada will become the second country to do so next year. In the meantime, six more US states and the District of Columbia have also jumped on the bandwagon.

While full legalization may yet be a bridge too far for most European and Latin American countries, marijuana decriminalization has really taken hold there, with numerous countries in both regions having embraced the policy. Marijuana has now been decriminalized in Argentina, Austria, Belgium, Belize, Bolivia, Brazil, Chile, Colombia (you can possess up to 22 grams legally), Costa Rica, Croatia, the Czech Republic, Equador, Estonia, Georgia, Greece, Italy, Jamaica, Luxembourg, Malta, Mexico, Moldova, Paraguay, Peru, Portugal, Slovenia, Spain, Switzerland, and Ukraine, among others. Oh, and Iran, too.

4. Andean Whack-A-Mole: The Fruitless Quest to Quash Cocaine

The United States, and to a much lesser degree, the European Union, have spent billions of dollars trying to suppress coca leaf cultivation and cocaine production in Bolivia, Colombia, and Peru. It hasn't worked.

According to the UN Office on Drugs and Crime (UNODC), coca leaf cultivation was just under 500,000 acres in 1998; this week, UNODC reported that coca leaf cultivation was at 470,000 acres last year -- and that's not counting the 75,000 acres under legal cultivation in Bolivia.

When it comes to actual cocaine production, it's pretty much the same story: Again according to the UNODC, cocaine production was at 825 tons in 1998, peaked at just over a million tons a year in 2004-2007, and is now at just under 800 tons. There have been peaks and troughs, but here we are, pretty much in the same place we started.

Military intervention didn't stop it. Military and anti-drug assistance hasn't stopped it. Alternative development programs haven't stopped it. The global cocaine market is insatiable, and nothing has been able to tear Andean peasant farmers from what is by far their best cash crop. Bolivia, at least, has largely made peace with coca -- although not cocaine -- providing a legal, regulated market for coca farmers, but in Peru and Colombia eradication and redevelopment efforts continue to spark conflict and social unrest.

5. Mexico's Brutal Drug Wars

During the 1980s and 1990s, accusations ran rampant that in a sort of pax mafiosi, the Mexican government cut deals with leading drug trafficking groups to not so much fight the drug trade as manage it. Those were the days of single party rule by the PRI, which ended with the election of Vicente Fox in 2000. With the end of single party rule, the era of relative peace in the drug business began to unravel.

As old arrangements between drug traffickers and political and law enforcement figures fell apart, so did the informal codes that governed trafficker behavior. When once a cartel capo would accept his exemplary arrest, during the Fox administration, the gangsters began shooting back at the cops -- and fighting among themselves over who would control which profitable franchise.

Things took a turn for the worse with the election of Felipe Calderon in 2006 and his effort to burnish his political credentials by sending in the army to fight the increasingly wealthy, violent, and brazen cartels. And they haven't gotten any better since. While American attention to Mexico's drug wars peaked in 2012 -- a presidential election year in both countries -- and while the US has thrown more than a billion dollars in anti-drug aid Mexico's way in the past few years, the violence, lawlessness, and corruption continues. The death toll is now estimated to be around 200,000, and there's no sign anything is going to change anytime soon.

Well, unless we take leading 2018 presidential candidate Andres Manuel Lopez Obrador (AMLO) at his word. This week, AMLO suggested a potential amnesty for cartel leaders, indicating, for some, at least, a pax mafiosi is better than a huge, endless pile of corpses.

6. Latin America Breaks Away from US Drug War Hegemony

The US imports its drugs and exports its prohibition-related violence, and the region grows tired of paying the price for America's war on its favorite vices. When once Latin American leaders quietly kowtowed to drug war demands from Washington, at least some of them have been singing a different tune in recent years.

Bolivia under Evo Morales has resolutely followed its own path on legalizing coca cultivation, despite bellows from Washington, successive Mexican presidents weary of the bloodshed turn an increasingly critical eye toward US drug war imperatives, Colombian President Juan Manuel Santos sees what Washington-imposed prohibitionist policies have done to his county and cries out for something different, and so did Guatemalan President Otto Perez Molina before he was forced out of office on corruption charges.

Latin American countries are also increasingly pursuing their own drug policies, whether it's constitutionally protected legalization of personal use amounts of drugs in Colombia, decriminalization of marijuana across the continent, or downright legalization in Uruguay, Latin American leaders are no longer taking direction from Washington -- although they generally remain happy to take US anti-drug dollars.

7.Safe Injection Sites Start Spreading

The notion of providing a place where intravenous drug users could shoot up under medical supervision and get access to referrals to public health and welfare services was derided by foes as setting up "shooting galleries" and enabling drug use, but safe injection sites have proven to be an effective intervention, linked to reduced overdoses, reduced crime, and moving drug users toward treatment.

These examples of harm reduction in practice first appeared in Switzerland in the late 1980s; with facilities popping up in Germany and the Netherlands in the 1990s; Australia, Canada, Luxembourg, Norway, and Spain in the 2000s; and, most recently, Denmark and France.

By now, there are nearly a hundred safe injection sites operating in at least 61 cities worldwide, including 30 in Holland, 16 in Germany, and eight in Switzerland. We are likely to see safe injection sites in Ireland and Scotland very soon.

It looks like they will soon be appearing in the United States, too. Officials in at least two cities, San Francisco and Seattle, are well on the way to approving them, although the posture of the federal government could prove an obstacle.

8. And Heroin Maintenance, Too

Even more forward looking as a harm reduction measure than safe injection sites, heroin maintenance (or opiate-assisted treatment) has expanded slowly, but steadily over the past two decades. The Swiss did the first trials in 1994, and now such programs are available there (after decisively winning a 2008 referendum on the issue), as well as Germany and the Netherlands.

Such programs have been found to reduce harm by helping users control their drug use, reducing overdoses, reducing drug-related disease, and promoting overall health and well-being, while also reducing social harms by reducing crime related to scoring drugs, reducing public use and drug markets, and promoting less chaotic lifestyles among participants, leading to increased social integration and better family life and employment prospects.

A Canadian pilot program, the North American Opiate Medication Initiative (NAOMI) produced similar results. Maybe the United States will be ready to get it a try one of these years.

9. New Drugs, New Markets

So far, this has been the century of new drugs. Known variously as "research chemicals," "designer drugs," or fake this and that, let's call them new psychoactive substances (NSPs). Whether it's synthetic cannabinoids, synthetic cathinones, synthetic benzodiazepines, synthetic opioids, or something entirely novel, someone somewhere is producing it and selling it.

In its 2017 annual review, the European Monitoring Center on Drugs and Drug Addictions (EMCDDA) reported in was monitoring 620 NSPs, up from 350 in 2013, and was adding new ones at the rate of over one a week.

These drugs, often of unknown quality or potency, in some cases have wreaked havoc among drug users around the world and are a prime example of the bad things that can happen when you try to suppress some drugs: You end up with worse ones.

The communications technology revolution that began with the world wide web impacts drug policy just as it impact everything else. Beginning with the infamous Silk Road drug sales website, the dark web and the Tor browser have enabled drug sellers and consumers to hook up anonymously online, with the drugs delivered to one's doorstep by Fedex, UPS, and the like.

Silk Road has been taken down and its proprietor, Ross Ulbricht, jailed for decades in the US, but as soon as Silk Road was down, new sites popped up. They got taken down, and again, new sites popped up. Rinse and repeat.

European authorities estimate the size of the dark web drug marketplace at about $200 million a year -- a fraction of the size of the overall trade -- but warn that it is growing rapidly. And why not? It's like an Amazon for drugs.

10.Massacring Drug Suspects in Southeast Asia

Philippines President Rodrigo Duterte has drawn international condemnation for the bloody war he unleashed on drug suspects upon taking office last year. Coming from a man who made his reputation for leading death squads while Mayor of Davao City, the wave of killings is shocking, but not surprising. The latest estimates are that some 12,000 people have been killed.

What's worse is that Duterte's bad example seems to be gaining some traction in the neighborhood. Human rights groups have pointed to a smaller wave of killings in Indonesia, along with various statements from Indonesian officials expressing support for Duterte-style drug executions. And most recently, a Malaysian member of parliament urged his own country to emulate Duterte's brutal crackdown.

This isn't the first time Southeast Asia has been the scene of murderous drug war brutality. Back in 2003, then Thai Prime Minister Thaksin Shinawatra launched a war on drugs that saw 2,800 killed in three months.

BC health officials present some revolutionary recommendations for dealing with the opioid crisis, Alaska officials defend marijuana legalization, a second Michigan legalization initiative is okayed for signature gathering, and more.

Marijuana Policy

Alaska Officials Defend Legalization in Letters to Sessions. Gov. Bill Walker (I) and Attorney General Jahna Lindemuth have sent two letters to Attorney General Sessions defending their state's marijuana law and the wishes of state voters. Their letters are a response to a letter Sessions sent to governors of legalization states in July. "Marijuana regulation is an area where states should take the lead," they said in the first letter, dated August 1. "We ask that the DOJ maintain its existing marijuana policies because the State relied on those assurances in shaping our regulatory framework, and because existing policies appropriately focus federal efforts on federal interests," they said in the second letter, dated August 14.

Second Michigan Legalization Initiative Gets Okay for Signature Gathering. The state Board of Canvassers on Thursday approved a second marijuana legalization initiative for signature gathering. The initiative, from a group called Abrogate Prohibition Michigan, would end "all prohibitions on the use of cannabis in any form by any person" and specify that no taxes could be imposed. Another group, MI Legalize, is already halfway through the signature gathering phase for its initiative, which envisions legalization, taxation, and regulation.

Los Angeles Gets a Cannabis Czar. The city council voted on Wednesday to approve Cat Packer as executive director of the city's newly fashioned Department of Cannabis Regulation. Packer is a former Drug Policy Alliance state policy coordinator for California. She was also a campaign coordinator for Californians for Responsible Marijuana Reform, part of the Prop 64 campaign. She will be charged with rolling out regulations for legal marijuana in the city.

Harm Reduction

Washington King County Initiative to Ban Safe Injection Sites Likely Won't Make Ballot. A measure to ban safe injection sites in Seattle's suburban King County is unlikely to be on the November ballot. Petition organizers handed in sufficient signatures on time, but it took two weeks for the petitions to get from the King County Council clerk to King County Elections, so the initiative has missed an August 1 deadline to be certified for the ballot. It could go on the ballot in a February special election, but initiative sponsors say they fear it will be too late to prevent safe injection sites by then.

International

British Columbia Health Authorities Call for Revolutionary Approach to Opioid Crisis. The BC Center for Disease Control has issued a set of recommendations for dealing with opioid use and overdoses that includes providing users with drugs they can take home with them and allowing people to grow their own opium. The current approach to addiction is backwards, BCCDC Executive Medical Director Mark Tyndall told the Globe and News: "We strongly advise people to stop using street drugs, and if they can't do that, then we offer them… Suboxone or methadone, and if that doesn't work, we basically tell them to go and find their own drugs even though there is a very real possibility of dying," he said. "What we should be doing -- especially in an environment of a poisoned drug supply -- is to start with access to uncontaminated drugs so at least people don't die, then move on to substitution therapy and eventually recovery."

Drugs, mainly opioids, are killing Americans at a record rate. The number of drug overdose deaths in the country quadrupled between 1999 and 2010 -- and compared to the numbers we're seeing now, those were the good old days.

Some 30,000 people died of drug overdoses in 2010. According to a new estimate from the New York Times, double that number died last year. And the rate of increase in overdose deaths was growing, up a stunning 19% over 2015.

The Times' estimate of between 59,000 and 65,000 drug overdose deaths last year is greater than the number of American soldiers killed during the entire Vietnam War, greater than that number of people killed in the peak year for car crash deaths, greater than the number of people who died in the year the AIDS epidemic peaked, and higher than the peak year for gun deaths.

In the first decade of the century, overdoses and addiction rose in conjunction with a dramatic increase in prescription opioid prescribing; since then, as government agents and medical professionals alike sought to tamp down prescribing of opioids, the overdose wave has continued, now with most opioid OD fatalities linked to illicit heroin and powerful black market synthetic opioids, such as fentanyl and carfentanil.

The Centers for Disease Control and Prevention says we are in the midst of "the worst drug overdose epidemic in history," and it's hard to argue with that.

So, what do we do about it? Despite decades of failure and unintended consequences, the prohibitionist reflex is still strong. Calls for more punitive laws, tougher prosecutorial stances, and harsher sentences ring out from state houses across the land to the White House. But tough drug war policies haven't worked. The fact that the overdose and addiction epidemic is taking place under a prohibition regime should make that self-evident.

More enlightened -- and effective -- approaches are now being tried, in part, no doubt, because today's opioid epidemic is disproportionately affecting white, middle class people and not the inner city black people identified with heroin epidemics of the past. But they are also being tried because for the past quarter-century an ever-growing drug reform movement has articulated the failures of prohibition and illuminated more effective alternatives.

The drug reform movement's most powerful organization, the Drug Policy Alliance, this spring published A Public Health and Safety Approach to Problematic Opioid Use and Overdose, which lays out more than two dozen specific policy prescriptions in the realms of addiction treatment, harm reduction, prevention, and criminal justice that have been proven to save lives and reduce dependency on opioids. These policy prescriptions are doable now -- and some are being implemented in some fashion in some places -- but require that political decisions be made, or that forces be mobilized to get those decisions made. Some would require a radical divergence from the orthodoxies of drug prohibition, but that's a small price to pay given the mounting death toll.

Here are 24 concrete policy proposals that can save lives and reduce addiction right now. All the facts and figures are fully documented in the heavily-annotated original. Consult it if you want to get down to the nitty-gritty. In the meantime:

Addiction Treatment

1. Create Expert Panel on Treatment Needs: States should establish an expert panel to address effective treatment needs and opportunities. The expert panel should evaluate barriers to existing treatment options and make recommendations to the state legislature on removing unnecessary impediments to accessing effective treatment on demand. Moreover, the panel should determine where gaps in treatment exist and make recommendations to provide additional types of effective treatment and increased access points to treatment (such as hospital-based on demand addiction treatment). The expert panel must also set evidence-based standards of care and identify the essential components of effective treatment and recovery services to be included in licensed facilities, especially with regards to medication-assisted treatment, admission requirements, discharge, continuity of care and/or after-care, pain management, treatment programming, integration of medical and mental health services, and provision of or referrals to harm reduction services. The expert panel should identify how to improve or create referral mechanisms and treatment linkages across various healthcare and other providers. The panel should establish clear outcome measures and a system for evaluating how well providers meet the scientific requirements the panel sets. And, finally, the expert panel should evaluate opportunities under the ACA to expand coverage for treatment.

2. Increase Insurance Coverage for Medication-Assited Treatment (MAT): Seventeen state medical plans under the Patient Protection and Affordable Care Act (ACA) do not provide coverage for methadone or buprenorphine for opioid dependence. Moreover, the Veterans Administration's (VA's) insurance system has explicitly prohibited coverage of methadone and buprenorphine treatment for active duty personnel or for veterans in the process of transitioning from Department of Defense care. As a result, veterans obtaining care through the VA are denied effective treatment for opioid dependence. Insurance coverage for these critical medications should be standard practice.

3. Establish and Implement Office-Based Opioid Treatment for Methadone: Currently, with a few exceptions, methadone for the treatment of opioid dependence is only available through a highly regulated and widely stigmatized system of Opioid Treatment Programs (OTPs). Moreover, several states have imposed moratoriums on establishing new OTPs that facilitate methadone treatment despite large, unmet treatment needs for a growing opioid-dependent population. Patients enrolled in methadone treatment in many communities are often limited to visiting a single OTP and face other inconveniences that make adherence to treatment more difficult. Initial trials have suggested that methadone can be effectively delivered in office-based settings and that, with training, physicians would be willing to prescribe methadone to their patients to treat their opioid dependence. Office-based methadone may help reduce the stigma associated with methadone delivered in OTPs as well as provide a critical window of intervention to address medical and psychiatric conditions. Office-based opioid treatment programs offering methadone have been implemented in California, Connecticut, and Vermont.

4. Provide MAT in Criminal Justice Settings, Including Jails/Prisons and Drug Courts: Individuals recently released from correctional settings are up to 130 times more likely to die of an overdose than the general population, particularly in the immediate two weeks after release. Given that approximately one quarter of people incarcerated in jails and prisons are opioid-dependent, initiating MAT behind bars should be a widespread, standard practice as a part of a comprehensive plan to reduce risk of opioid fatality. Jails should be mandated to continue MAT for those who received it in the community and to assess and initiate new patients in treatment. Prisons should initiate methadone or buprenorphine prior to release, with a referral to a community-based clinic or provider upon release. In addition, drug courts should be mandated to offer participants the option to participate in MAT if they are not already enrolled, make arrangements for their treatment, and should not be permitted to make discontinuation of MAT a criterion for successful completion of drug court programs. The Substance Abuse and Mental Health Services Administration will no longer provide federal funding to drug courts that deny the use of MAT when made available to the client under the care of a physician and pursuant to a valid prescription. The National Association of Drug Court Professionals agrees: "No drug court should prohibit the use of MAT for participants deemed appropriate and in need of an addiction medication."

5. Offer Hospital-Based MAT: Emergency departments should be mandated to inform patients about MAT and offer buprenorphine to those patients that visit emergency rooms and have an underlying opioid use disorder, with an appointment for continued treatment with physicians in the community. Hospitals should also offer MAT within the inpatient setting, and start MAT prior to discharge with community referrals for ongoing MAT.

6. Assess Barriers to Accessing MAT to Increase Access to Methadone and Buprenorphine: A number of known barriers prevent MAT from being as widely accessible as it should be. The federal government needs to reevaluate the need for and effectiveness of the OTP model and make necessary modifications to ensure improved and increased access to methadone. And, while federal law allows physicians to become eligible to prescribe buprenorphine for the treatment of opioid dependence, it arbitrarily caps the number of opioid patients a physician can treat with buprenorphine at any one time to 30 through the first year following certification, expandable to up to potentially 200 patients thereafter. Moreover, states need to evaluate additional barriers created by state law, including, among others, training and continuing education requirements, restrictions on nurse practitioners, insurance enrollment and reimbursement, and lack of provider incentives.

7. Establish and Implement a Heroin-Assisted Treatment Pilot Program: Heroin-assisted treatment (HAT) refers to the administering or dispensing of pharmaceutical-grade heroin to a small and previously unresponsive group of chronic heroin users under the supervision of a doctor in a specialized clinic. The heroin is required to be consumed on-site, under the watchful eye of trained professionals. This enables providers to ensure that the drug is not diverted, and allows staff to intervene in the event of overdose or other adverse reaction. Permanent HAT programs have been established in the United Kingdom, Switzerland, the Netherlands, Germany and Denmark, with additional trial programs having been completed or currently taking place in Spain, Belgium and Canada. Findings from randomized controlled studies in these countries have yielded unanimously positive results, including: 1) HAT reduces drug use; 2) retention rates in HAT surpass those of conventional treatment; 3) HAT can be a stepping stone to other treatments and even abstinence; 4) HAT improves health, social functioning, and quality of life; 5) HAT does not pose nuisance or other neighborhood concerns; 6) HAT reduces crime; 7) HAT can reduce the black market for heroin; and, 8) HAT is cost-effective (cost-savings from the benefits attributable to the program far outweigh the cost of program operation over the long-run). States should consider permitting the establishment and implementation of a HAT pilot program. Nevada and Maryland have introduced legislation of this nature and the New Mexico Legislature recently convened a joint committee hearing to query experts about this strategy.

8. Evaluate the Use of Cannabis to Decrease Reliance on Prescription Opioids and Reduce Opioid Overdose Deaths: Medical use of marijuana can be an effective adjunct to or substitute for opioids in the treatment of chronic pain. Research published last year found 80 percent of medical cannabis users reported substituting cannabis for prescribed medications, particularly among patients with pain-related conditions. Another important recent study reported that cannabis treatment "may allow for opioid treatment at lower doses with fewer [patient] side effects." The result of substituting marijuana, a drug with less side effects and potential for abuse, has had profound harm reduction impacts. The Journal of the American Medical Association, for instance, documents a relationship between medical marijuana laws and a significant reduction in opioid overdose fatalities: "[s]tates with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate compared with states without medical cannabis laws."Another working paper from the RAND BING Center for Health Economics notes that "states permitting medical cannabis dispensaries experienced a 15 to 35 percent decrease in substance abuse admissions and opiate overdose deaths." There is also some emerging evidence that marijuana has the potential to treat opioid addiction, but additional research is needed.

Harm Reduction

9. Establish and Implement Safe Drug Consumption Services: States and/or municipalities should permit the establishment and implementation of safe drug consumption services through local health departments and/or community-based organizations. California and Maryland have introduced legislation to establish safe drug consumption services, and the City of Ithaca, New York has included a proposal for a supervised injection site in their widely-publicized municipal drug strategy. In Washington State, the King County Heroin an Prescription Opiate Addiction Task Force has recommended the establishment of at least two pilot supervised consumption sites as part of a community health engagement program designed to reduce stigma and "decrease risks associated with substance use disorder and promote improved health outcomes" in the region that includes the cities of Seattle, Renton and Auburn.

10. Maximize Naloxone Access Points, Including Lay Distribution and Pharmacy Access, As Well As Immunities for Prescription, Distribution and Administration:Naloxone should be available directly from a physician to either a patient or to a family member, friend, or other person in a position to assist in an overdose, from community-based organizations through lay distribution or standing order laws, and from pharmacies behind-the-counter without a prescription through standing order, collaborative agreement, or standardized protocol laws or regulations. Though some states, including California, New York, Colorado and Vermont, among others, have access to naloxone at each of these critical intervention points, many others only provide naloxone through a standard prescription. Civil and criminal immunities should be provided to prescribers, dispensers and lay administrators at every access point. In addition, all first responders, firefighters and law enforcement should be trained on how to recognize an overdose and be permitted to carry and use naloxone. Naloxone should also be reclassified as an over-the-counter (OTC) medication. Having naloxone available over-the-counter would greatly increase the ability of parents, caregivers, and other bystanders to intervene and provide first aid to a person experiencing an opioid overdose. FDA approval of OTC naloxone is predicated on research that satisfies efficacy and safety data requirements. Pharmaceutical companies, however, have not sought to develop an over-the-counter product.88 Federal funding may be needed to meet FDA approval requirements.

11. Provide Dedicated Funding for Community-Based Naloxone Distribution and Overdose Prevention and Response Education: Few states provide dedicated budget lines to support the cost of naloxone or staffing for community-based opioid overdose prevention programs. The CDC, however, reports that, between 1996 and 2014, these programs trained and equipped more than 152,280 laypeople with naloxone, who have successfully reversed 26,463 opioid overdoses.89 Without additional and dedicated funding, community-based opioid overdose prevention programs will not be able to continue to provide naloxone to all those who need it, and the likelihood of new programs being implemented is slim. A major barrier to naloxone access is its affordability and chronic shortages in market supply, 90 which overdose prevention programs, operating on shoestring budgets, can have a difficult time navigating.

12. Improve Insurance Coverage for Naloxone: Individuals who use heroin and other opioids are often both uninsured and marginalized by the healthcare system.91 States should insure optimal reimbursement rates for naloxone to increase access to those who need it most – users themselves.

13. Provide Naloxone to Additional At-Risk Communities: People exiting detox and other treatment programs as well as periods of incarceration are at particularly high risk for overdose because their tolerance has been substantially decreased. After their period of abstinence, if they relapse and use the same amount, the result is often a deadly overdose. States should require overdose education and offer naloxone to people upon discharge from detox and other drug treatment programs and jails/prisons. The Substance Abuse and Mental Health Services Administration has declared that prescribing or dispensing naloxone is an essential complement to both detoxification services as well as medically supervised withdrawal. Vermont passed legislation making naloxone available to eligible pilot project participants who are transitioning from incarceration back to the community. In addition, there are other programs/studies that provide naloxone to recently released individuals on a limited basis, including in San Francisco, California, King County, Washington and Rhode Island.

14. Encourage Distribution of Naloxone to Patients Receiving Opioids: Physicians should be encouraged to prescribe naloxone to their patients and opioid treatment programs should inform their clients about naloxone, if prescribing or dispensing an opioid to them. Pharmacists should similarly be encouraged to offer naloxone along with all Schedule II opioid prescriptions being filled, for syringe purchases (without concurrent injectable medication), and for all co-prescriptions (within 30 days) of a benzodiazepine (such as Valium™, Xanax™ or Klonopin™) and any opioid medication. The Rhode Island Governor's Overdose Prevention and Intervention Task Force found that offering naloxone to those prescribed a Schedule II opioid or when co-prescribed a benzodiazepine and any opioid would have reached 86% of overdose victims who received a prescription from a pharmacy prior to their death, and could have prevented 58% of all overdose deaths from 2014 to 2015.

15. Expand Good Samaritan Protections: "Good Samaritan" laws provide limited immunity from prosecution for specified drug law violations for people who summon help at the scene of an overdose. But, protection from prosecution is not enough to ensure that people are not too frightened to seek medical help. Other consequences, like arrest, parole or probation violations, and immigration consequences, can be equal barriers to calling 911. States with Good Samaritan laws already on the books should evaluate the protections provided and determine whether expansion of those protections would increase the likelihood that people seek medical assistance.

16. End the Criminalization of Syringe Possession: Syringes should be exempt from state paraphernalia laws in order to provide optimal access to people who inject drugs. Twenty-two states criminalize syringe possession. Thus, even if there is a legal access point, such as pharmacy sales, paraphernalia laws still permit law enforcement to arrest and prosecute individuals in possession of a syringe. Public health and law enforcement authorities should not be working at cross-purposes.

17. Reduce Barriers to Over-The-Counter Syringe Sales and Permit Direct Prescriptions of Syringes: While the non-prescription, over-the-counter sale of syringes is now permitted in all but one U.S. state, access is still unduly restricted.States should evaluate the potential barriers to accessing syringes over-thecounter and implement measures to improve access. Moreover, doctors should be permitted to prescribe syringes directly to their patients, a practice few states currently permit.

18. Authorize and Fund Sterile Syringe Access and Exchange Programs; Increase Programs: States should explicitly authorize and fund sterile syringe access and exchange programs, and states that have already authorized them should evaluate how to increase the number or capacity of programs to ensure all state residents – whether in urban centers or rural communities -- have access to clean syringes, as well as evaluate any possible barriers to access such as unnecessary age restrictions.

19. Provide Free Public, Community-Level Access to Drug Checking Services: Technology exists to test heroin and opioid products for adulterants via GC/MS analysis, but it has so far been unavailable at a public level in the US (aside from a mail-in service run by Ecstasydata.org). Making these services available in the context of a community outreach service or academic study would lower the number of deaths and hospitalizations and also allow for real-time tracking of local drug trends.

Prevention

20. Establish Expert Panel on Opioid Prescribing: Though the CDC has issued guidelines for prescribing opioids for chronic pain, the guidelines are voluntary and are likely to exacerbate disparities in treatment that already exist. Research has shown, for example, that African Americans are less likely than whites to receive opioids for pain even when being treated for the same conditions. Moreover, the CDC guidelines only address prescribing practices for chronic pain, not prescribing practices more broadly. States should accordingly establish an expert panel to undertake an assessment as to whether prescribing practices, such as co-prescriptions for benzodiazepines and opioids or overprescribing of opioids, have contributed to increased rates of opioid dependence, and, if so, the expert panel should develop a plan to address any such linkages as well as any treatment disparities. The plan must account for the potential negative effects of curtailing prescribing practices or swiftly reducing prescription opioid prescribing volume. A task force in Rhode Island found that while changes in opioid supply can have the intended effect of reducing availability of abuse-able medications, they have also been linked to an increase in transition to illicit drug use and in more risky drug use behaviors (e.g., snorting and injecting pain medications). The plan must also account for chronic pain patients, particularly those already underserviced, and not unduly limit their access to necessary medications. Finally, to the extent prescribing guidelines are issued as part of the plan, they should be mandatory and applied across the board.

21. Mandate Medical Provider Education: States should mandate that all health professional degree-granting institutions include curricula on opioid dependence, overdose prevention, medication-assisted treatment, and harm reduction interventions, and that continuing education on these topics be readily available.

22. Develop Comprehensive, Evidence-Based Health, Wellness, and Harm Reduction Curriculum for Youth: State education departments, in conjunction with an expert panel consisting of various stakeholders that ascribe to scientific principles of treatment for youth, should develop a comprehensive, evidence-based health, wellness, and harm reduction curriculum for use in schools that incorporates scientific education on drugs, continuum of use, and contributors to problematic drug use (e.g., coping and resiliency, mental health issues, adverse childhood experiences, traumatic events and crisis), as well as how reduce harm (e.g., not mixing opioids with benzodiazepines). Education departments should also establish protocols and resources for early intervention, counseling, linkage to care, harm reduction resources, and other supports for students.

CRIMINAL JUSTICE

23. Establish Diversion Programs, Including Law Enforcement Assisted Diversion (LEAD): LEAD is a pre-booking diversion program that establishes protocols by which police divert people away from the typical criminal justice route of arrest, charge and conviction into a health-based, harm-reduction focused intensive case management process wherein the individual receives support services ranging from housing and healthcare to drug treatment and mental health services. Municipalities should create and implement LEAD programs and states and the federal government should provide dedicated funding for such programs. Various other forms of diversion programs exist and can be implemented should LEAD prove unsuitable to a particular population or municipality.

24. Decriminalize Drug Possession: Decriminalization is commonly defined as the elimination of criminal penalties for drug possession for personal use. In other words, it means that people who merely use or possess small amounts of drugs are no longer arrested, jailed, prosecuted, imprisoned, put on probation or parole, or saddled with a criminal record. Nearly two dozen countries have taken steps toward decriminalization. Empirical evidence from the international experiences demonstrate that decriminalization does not result in increased use or crime, reduces incidences of HIV/AIDs and overdose, increases the number of people in treatment, and reduces social costs of drug misuse. All criminal penalties for possession of small amounts of controlled substances for personal use should be removed.

The Philippines' bloody-handed president is facing harsh criticism as the UN Commission on Narcotic Drugs meets in Vienna, West Virginia gets a marijuana legalization bill, New York City Mayor Bill de Blasio rolls out a plan to fight opioid addiction and overdoses, and more.

Marijuana Policy

West Virginia Legalization Bill Filed. Delegate Sean Hornbuckle (D-Cabell County) introduced House Bill 3035 Tuesday. The bill would tax and regulate marijuana like alcohol. It has been sent to the House Health and Human Resource Committee. If it gets through there, it must then go to the House Judiciary Committee before heading for a House floor vote.

Medical Marijuana

Arkansas Bill to Ban Edibles, Public Smoking Wins Committee Vote. A bill that would bar medical marijuana patients from consuming edibles or from smoking their medicine in public was approved Wednesday by the House Rules Committee. But the measure, House Bill 1400, faces an uphill battle to win final approval because any changes to the voter-approved medical marijuana law require a two-thirds vote to pass.

Massachusetts Bills Would Protect Patients' Employment Rights. Even as the state Supreme Court Thursday heard a case on employment rights for medical marijuana patients, two bills alive in the state legislature would do just that. Rep. Frank Smizik (D-Brookline) has introduced House Bill 2385, which would explicitlyprotect the rights of a medical marijuana patient to use the drug without facing discrimination in hiring, firing or terms of employment. The bill would also protect medical marijuana patients from discrimination in education, housing and child welfare and custody cases. That bill is currently before the Committee on Marijuana Policy. A similar bill was filed last sessions, but didn't pass. A second bill, House Bill 113, is aimed mostly at updating state law to bring it in line with the Americans With Disabilities Act, but one provision clarifies that employers cannot take adverse employment action against someone for using medical marijuana. That bill is before the Joint Committee on Children, Families, and Persons with Disabilities.

Nebraska Medical Marijuana Bill Gets Charged Hearing. At a hearing in the Judiciary Committee Wednesday, law enforcement, the state attorney general's office, and the state's top doctor all came out in opposition to a medical marijuana bill, Legislative Bill 622, but legislators also heard emotional testimony in favor of the bill from Army veterans and others who said they would benefit from access to medical marijuana. Five of the bill's sponsors sit on the eight-member Judiciary Committee, so the bill is likely to make it to a House floor vote, where opposition has killed similar measures in past years.

Heroin and Prescription Opioids

New York City Mayor Reveals Plans to Fight Opioid Addiction. Mayor Bill de Blasio said Monday that the city planned to spend as much as $38 million a year on a broad array of measures aimed at reducing opioid addiction and overdoses. Among the measures mentioned were expanded methadone and buprenorphine treatment, the distribution of the overdose reversal drug naloxone to all 23,000 city patrol officers, a focus on city hospitals on dealing with addiction and overdoses, and increased prosecution of opioid dealers. De Blasio mentioned outreach, treatment, and law enforcement, but not harm reduction.

International

Bolivia Says It Does Not Need US or European Help to Fight Drug Trafficking. Bolivian Vice President Alvaro Garcia Lima said Wednesday that his country doesn't need help or advice from the US or Europe on its coca policies or its fight with drug traffickers. "We fight against drug trafficking with Bolivian money, we do not depend on the European Union (EU) to fight against drug trafficking. Before when we depended on the United States, Bolivia received about USD $100 million. We have set aside that aid," he said. Garcia Lima's remarks came in response to European Union criticism of a new Bolivian law nearly doubling legal coca cultivation. The EU suggested that perhaps its aid to Bolivia should be "refocused." Garcia Lima retorted that Bolivia is "not begging money" from the EU.

Philippines Vice-President Condemns Duterte's Drug War. In an interview with Time magazine ahead of a speech set for Thursday at the Commission on Narcotic Drugs in Vienna, Philippine Vice President Leni Robredo condemned President Rodrigo Duterte's bloody drug war and said she was "inspired" by growing opposition to it. She also said she was "encouraged" that the international community is speaking out. "We hope that in the next few months we, together with the international community, can convince the current administration to focus its efforts in ending human-rights violations and extrajudicial killings," she said. "In addition, let us work together to strengthen the existing accountability mechanisms in the Philippines in order for us to have those responsible brought to justice. We hope that we can persuade the administration to concentrate more on the bigger war we are facing -- the war on poverty."

Philippines Lawmaker Files Impeachment Complaint Against Duterte, Cites Drug War Killings. Philippines Rep. Gary Alejano has filed an impeachment complaint against President Rodrigo Duterte, calling for his removal for high crimes, abuses of power, and betrayal of public trust. The complaint lists drug-related murders, the operation of death squads while Duterte was mayor of Davao City, and conflicts of interest among the impeachable offenses. Pro-Duterte lawmakers said the complaint "will not fly," but Alejano was undaunted. "Our goal with this complaint is to be a vehicle for Filipinos to have a voice to oppose and fight against the abuses and crimes of President Duterte," Alejano told a televised news conference. "We know it's an uphill battle... but we believe that many will support this."