As in years past, the International Narcotics Control Board (INCB) highlights the problem of HIV epidemics fuelled by injection drug use in its 2007 annual report. The phrase harm reduction is used in the report without scare quotes but the Board cannot refrain from sounding cautionary notes.

The 2007 report mentions HIV 54 times. On harm reduction measures to reduce such HIV infections, the 2007 report demonstrates some small positive changes. In contrast to the report on 2006 and 2005, where provision of sterile syringes went unmentioned, the Board notes provision of sterile syringes in its review of developments in countries including Viet Nam, Malaysia, and Australia, as well as 24 European Union member States (paras 510, 511, 706, 653 inter alia).

The Board cannot refrain from sounding cautionary notes - the INCB calls on Australia to ensure that sterile syringe programs in New South Wales, for example (para 706), are carried out in compliance with the provisions of the international drug control conventions, despite previous declarations from the Board and legal experts that such programs do not violate any convention. When calling for adequate services for drug offenders in prison (para 26), the Board does not mention needle exchange, despite clear guidance by WHO and other authorities about the benefits of such services in penal institutions. Instead, the Board calls on governments to ensure that access to illicit drugs in prisons is terminated (para 60 (d)). Nonetheless, compared with the silence in previous years, these mentions of needle exchange are important.

The phrase harm reduction is used in the report on 2007 without scare quotes. This should be unremarkable given the endorsement of increased availability of harm reduction by all member States in the 2001 Declaration of Commitment on HIV/AIDS and multiple other United Nations documents such as the 2008 United Nations Office on Drugs and Crime discussion paper (endorsed by the INCB) on reducing the adverse health and social consequences of drug use. However, it is a notable departure for the INCB.

The Board also matter-of-factly notes the implementation of addiction treatment with methadone or buprenorphine in countries including the United States, the Islamic Republic of Iran, Canada, Viet Nam, Malaysia, and all European Union member States (paras 99, 510, 511, 653 inter alia).

Those hoping that the Board would more actively pursue its mandate to ensure adequate availability of licit drugs for medical purposes, however, will find little cause for optimism in the report on 2007. As in years past, and despite the call of the UN drug conventions for treatment, rehabilitation, and aftercare for drug abuse, the Board does not congratulate or note with approval the implementation of new methadone programs to address what in Asian countries has been a growing problem of injecting drug use and associated HIV infection.

Indeed, the Board continues to see such expansion of treatment primarily in terms of risks of diversion of legal medicines to illegal markets, calling on countries to strengthen control measures on methadone and buprenorphine. The Board notes with concern the lack of adequate access to opioids for pain management (paras 97, 208-213), yet makes no comment on the shortage or illegality of methadone or buprenorphine treatment for addiction in countries across the former Soviet Union and Asia.

In fact, the comment that supply of such treatment has risen slightly or decreased in many developing/transitional countries (para 276) - a development that should provoke alarm from the body responsible for helping countries to accurately estimate need for methadone or buprenorphine-is not accompanied by any expression of concern. In a report that contains multiple paragraphs on the danger of celebrity drug use, this omission is striking.

As in years past, the 2007 report does express strong opposition to medically supervised safer injection facilities, (paras 161, 369), saying that such programs are in contravention to international drug control treaties. The INCB’s recommendations include a call for countries with safer injection sites to close those facilities and instead provide appropriate "evidence-based" programs (Recommendation 24, at para 734). This demand is itself in tension with the evidence, since the benefits of safer injection facilities have in fact been documented in peer-reviewed literature and include fewer deaths from overdose, more referrals to treatment services, and a reduced risk of HIV and hepatitis transmission through decreased syringe sharing.

The INCB does not mention the 2002 analysis of the Legal Affairs section of the UN International Drug Control Programme, which detailed arguments justifying safer injection facilities, as well as other harm reduction programs, implying that such programs do not contravene drug conventions. The Board’s call for the cessation of efforts to provide "safer crack" kits (para 369) was similarly undocumented.

Finally, the Board does extend welcome attention to the question of drug treatment, rehabilitation and reintegration, noting that programs need clearly articulated objectives and evaluation, that treatment should be comprehensive and evidence-based, and that treatment should be available in prisons (paras 56, 505). This, and the Board’s call for suitable facilities and close cooperation between criminal justice and health agencies (para 56), are important, though the 2007 report remains silent on the many known instances in which criminal justice authorities decided to place large numbers of drug users in compulsory treatment that does not meet minimum medical standards.

In China, for example, where UNODC estimates that as many as 340,0000 are interned in compulsory detoxification and re-education through labour centres, the Board restricted itself to observing that treatment should be “comprehensive and evidence based,” (para 505) but makes no mention of the compulsory labour, lack of access to medication-assisted treatment, or human rights abuses reported in such facilities.

The Board visited Viet Nam in 2007 and notes the country’s efforts to strengthen HIV prevention and treatment. While expressing concern about relapse and offering a general reminder of the importance of evaluating different modalities for drug abuse treatment (para 539), the Board omits mention of what UNODC estimates to be more than 50,000 drug users interned for as long as five years in facilities that offer no HIV treatment and little drug treatment besides “moral re-education” and labour at low wages.

The Board’s note that treatment does not need to be voluntary to be effective (para 57) is similarly notable for its failure to address the ethical or human rights issues involved in compulsory treatment at the country level. The Board, for example, notes that the Russian Federation is considering legislation on compulsory treatment and the establishment of special medical centres (para 664) without noting that Russian authorities have banned the best studied and most effective forms of medication-assisted treatment.

Taken as a whole, the 2007 Annual Report shows some signs of a more balanced approach by the INCB to the real policy dilemmas that governments face in designing and implementing their drug control policies. While this is welcome, the method of operation of the Board, and its approach to these issues, still fall a long way short of what is necessary for it to play a positive and objective role in helping governments to find the right balance between their drug control obligations, and wider policy objectives related to social development, public health, and human rights protections.

Adapted from: The International Narcotics Control Board: Current Tensions and Options for Reform, IDPC Briefing Paper 7, February 2008