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Background: Muslim majority countries (MMCs) typically have limited alcohol policy development due to Islamic prohibition of alcohol consumption. In response to recent increases in alcohol consumption and related harms, MMCs have introduced civil alcohol policies, ranging from total prohibition to European-style regulations. Using Iran as a case study, we describe how alcohol prohibition is translated into policy in the face of influences from globalisation.Methods: We collected information from publicly available literature and policy documents, because of the sensitivity of the topic of alcohol in Iran. The search was conducted in English and Persian. We verified information through consultations with policy actors. We also reviewed newspapers over periods just before the 1979 Islamic revolution, and before and after the 2011 alcohol policy (2008-2010; 2014-2016) was introduced. We analysed policy content based on WHO policy recommendations and used the Walt & Gilson health framework to identify policy content, context, actors and process.Results: Despite its broad approach of civil prohibition with concessions for the non-Muslim population, Iran has developed approaches to reduce the harmful impacts of alcohol and adopted nine of ten policy interventions recommended by WHO. Pricing policy was the only intervention not used. We identified contextual challenges, such as resources, stigma and cultural offence that influence policy development.Conclusion: MMCs face challenges in creating civil alcohol policies. Iran has taken steps, including a national alcohol strategy, to reduce alcohol-related harms. The socio-cultural, governance and historical context have shaped Iran's adaptation of policy interventions recommended by WHO. [ABSTRACT FROM AUTHOR]

• UK law changed in 2018 to permit cannabis prescribing. Cannabis remains otherwise criminalised. Participants experienced benefits from cannabis across a broad range of conditions. • Most people who need a cannabis prescription in the UK still cannot access one. • Poor implementation of cannabis prescribing policy creates heath inequalities. • Intractable prohibition policy context continues to create social harms. This paper reports on the first qualitative study to interview people prescribed cannabis in the UK. Cannabis is a class B controlled substance under the 1971 Misuse of Drugs (MoD) Act, but a 2018 change to UK regulations provided for the prescription of cannabis for medical purposes. Relatively few people have been able to access a prescription, despite this policy change. This paper examines their experiences. Qualitative, semi-structured interviews were conducted with 24 people with a prescription for cannabis, or their carers. Data was analysed using a reflextive thematic analysis approach. The findings are discussed using a zemiology (social harms) perspective which provides a language for critical reflection on the current cannabis policy context. All participants reported that cannabis had significantly improved their mental and/or physical health, across a broad range of conditions. Many had been able to reduce their use of conventional medicines and reported that cannabis had relatively few side effects. Despite the potentially life-enhancing benefits of cannabis medicine, patients in the UK face multiple barriers to access. These include a lack of funding streams, bureaucratic supply problems, and a lack of training for doctors and police. Even for the few people able to obtain a prescription, the ongoing criminalisation of cannabis in the UK contributed to their experiences of stigmatisation. This often made it difficult and anxiety-inducing to take their medicine in public spaces. The UK government's lack of implementation of medical cannabis legalisation, combined with their ongoing prohibition position, is producing multiple harms to people who need cannabis medicine. The policy context is perpetuating stigmatising attitudes to cannabis which, as we demonstrate, contribute to social harms. We make recommendations on equality of patient access, and highlight the importance of education and policy change as means of combatting stigma. [ABSTRACT FROM AUTHOR]

On a Northern Plains reservation where alcohol was prohibited, we investigated community members' views on the impacts of alcohol availability. Our methods combined elements of Tribal community participatory research with qualitative inquiry to elicit these perspectives. We used rapid appraisal techniques to conduct confidential interviews with 31 key leaders representing 7 relevant major community systems, and representing a variety of perspectives. Topics included respondents' understandings of the current systems of alcohol availability and use on the reservation, the impacts of these systems on reservation residents, and possible ways to measure these impacts. Respondents reported impacts on individuals, families, and the tribe overall. Alcohol-related problems shaped and were shaped by a constellation of social-ecological conditions: kinship, housing, employment, public/social service capacity, and the supply of alcohol in nearby off-reservation areas, as well as inter-governmental relationships and the spiritual life of reservation residents. A variety of social-structural determinants magnified alcohol impacts, so that the problem drinking of a small number of individuals could have broad effects on their families and the entire community. Our participatory qualitative methods enabled us to directly include the voices as well as the personal experiences and expertise of community members in this presentation. These methods may be broadly applied within policy analysis to identify ways to reduce harms related to alcohol and other drugs for Indigenous communities. [ABSTRACT FROM AUTHOR]

Background: Recent decades have seen substantial changes in the UK cannabis landscape, including increased domestic production, the ascendancy of stronger strains (namely 'skunk') and the drug's reclassification under the 1971 Misuse of Drugs Act. Resultantly, cannabis retains significance in the consciousness, priorities and policy agendas of communities, drug services and criminal justice agencies.Methods: This paper presents an empirical study, which examined both perceptions and impacts of cannabis cultivation and its control within a North-West English borough. It draws on qualitative research with samples of professionals, practitioners, resident groups, cannabis users, cannabis users' families and cannabis cultivators themselves.Findings: The findings suggest that cannabis cultivation was not a uniformly familiar concept to respondents, who had limited knowledge and experience of its production. Across all participant groups, the transmission of accurate information was lacking, with individuals instead drawing on the reductionist drug discourse (Taylor, 2016) to fill knowledge deficits. Consequently, some participants conflated cannabis cultivation with wider prohibitionist constructions of drug markets, resulting in the diffusion of misinformation and an amplification of anxieties. In contrast, other participants construed cultivation as making economic sense during austerity, justifying such tolerance through inverse adherence to the same narrow socio-cultural construction of drugs i.e. that cultivation carried comparatively less harms than real drug markets. Enforcement mechanisms also drew on generic prohibitionist conceptions, assuming cultivators to be unconstrained, autonomous actors in need of punishment; a belief which lacked nuanced understanding of the local terrain where vulnerable individuals cultivating under duress played a key role in the supply chain.Conclusion: The paper concludes with a call for the provision of accessible information/education; the need to challenge and reconceptualise the assumed autonomy and resultant punity directed at all cannabis cultivators; and a subsequent need to reassess established forms of legal (and increasingly social) enforcement. [ABSTRACT FROM AUTHOR]

More than a decade in the making, America's opioid crisis has morphed from being driven by prescription drugs to one fuelled by heroin and, increasingly, fentanyl. Drawing on historical lessons of the era of National Alcohol Prohibition highlights the unintended, but predictable impact of supply-side interventions on the dynamics of illicit drug markets. Under the Iron Law of Prohibition, efforts to interrupt and suppress the illicit drug supply produce economic and logistical pressures favouring ever-more compact substitutes. This iatrogenic progression towards increasingly potent illicit drugs can be curtailed only through evidence-based harm reduction and demand reduction policies that acknowledge the structural determinants of health. [ABSTRACT FROM AUTHOR]

Advances in chemistry, technology, and globalization have contributed to the rapid development and diffusion of NPS (new psychoactive substances), creating perhaps the most serious challenge to the century-old international drug control system and to national systems. Very little is known about the effects of these substances which fall outside of national and international controls. The predominant response to the flood of NPS has been the development of more expeditious methods of prohibiting a new chemical entity. This article explores alternative mechanisms that have been considered: foodstuffs, alcohol and tobacco and medicines. None seems promising in terms of avoiding the problems of prohibition without permitting unsafe substances on the market. The article then considers whether there is a bias in the existing system toward excessive prohibition. In public discussion, no attention is given to the pleasures that users obtain from any NPS, to the possibility of substitution for a more dangerous legal or illegal drug or to the consequences of illegal markets for prohibited NPS. On the other hand, it may well be impossible to obtain meaningful assessments on any of these matters at the time when decisions are made. These complexities have led a number of countries, most recently Australia and the UK, to impose total bans, the effects of which are impossible to predict. [ABSTRACT FROM AUTHOR]

Contrary to popular belief, policies on drug use are not always based on scientific evidence or composed in a rational manner. Rather, decisions concerning drug policies reflect the negotiation of actors' ambitions, values, and facts as they organize in different ways around the perceived problems associated with illicit drug use. Drug policy is thus best represented as a complex adaptive system (CAS) that is dynamic, self-organizing, and coevolving. In this analysis, we use a CAS framework to examine how harm reduction emerged around heroin trafficking and use in Tanzania over the past thirty years (1985-present). This account is an organizational ethnography based on of the observant participation of the authors as actors within this system. We review the dynamic history and self-organizing nature of harm reduction, noting how interactions among system actors and components have coevolved with patterns of heroin us, policing, and treatment activities over time. Using a CAS framework, we describe harm reduction as a complex process where ambitions, values, facts, and technologies interact in the Tanzanian sociopolitical environment. We review the dynamic history and self-organizing nature of heroin policies, noting how the interactions within and between competing prohibitionist and harm reduction policies have changed with patterns of heroin use, policing, and treatment activities over time. Actors learn from their experiences to organize with other actors, align their values and facts, and implement new policies. Using a CAS approach provides researchers and policy actors a better understanding of patterns and intricacies in drug policy. This knowledge of how the system works can help improve the policy process through adaptive action to introduce new actors, different ideas, and avenues for communication into the system. [ABSTRACT FROM AUTHOR]

Abstract: Background: The last decade has seen the emergence of a new phenomenon in recreational substance use with the availability of herbal and synthetic, unregulated, psychoactive drugs in the market place; alongside this, international concern has developed in relation to their use and associated harms. New Zealand (NZ) was one of the first countries to experience this new phenomenon, with products containing chemicals of the piperazine group – mainly benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP). In 2008, the NZ Government prohibited these substances, but allowed a 6-month amnesty period for possession. Our study aimed to obtain a measure of change in BZP use over time. Methods: This study used a longitudinal, web-based survey, with data collected at two time points from the same participants. The first survey was carried out 3 months after BZP prohibition, and included retrospective questions for the 6 months preceding the survey. The second survey was conducted 9 months after prohibition and also included retrospective questions for the 6 months preceding the survey. Results: 273 sets of paired data were identified. The use of BZP party pills (p <0.0001) and legally available smokeable products (p =0.002) reduced over time. A majority of users of party pills obtained them from friends or from their own stockpiled supplies. The misuse of prescription drugs (p =0.02) increased over time, whereas statistically significant increases in stimulant or alcohol use were not noted. Conclusion: Following prohibition of piperazine-based party pills, we noted a significant reduction in the proportions of participants using them. The observed increase in the misuse of prescription medicines may relate to their perceived ‘quality’, or as being less ‘illegal’ than illicit drugs. [Copyright &y& Elsevier]

Abstract: Background: Recently, cigarette neo-prohibitionists have argued that a cigarette ban can be obtained from a de-facto phase-out of cigarettes based on a combination of effective anti-tobacco regulations and high taxes in conjunction with aggressive application of nicotine replacement therapies. The purpose of this study was to ascertain whether these claims were valid in Bhutan, which enacted a national cigarette sales prohibition law in 2004. Did Bhutan from 2004 to 2009 eliminate or nearly eliminate cigarette consumption and avoid a significant cigarette black market and smuggling? Methods: This study is a historical, qualitative, descriptive statistical, and archival content overview from 2004 to 2009 of smoking prevalence rates and smuggling and black market trends subsequent to the enactment of the Bhutan Penal Code Act of 2004. Results: For adults in Bhutan, tobacco prevalence rates are fairly low compared with other nations but in 2008 remained a serious health issue for those who consumed cigarettes. For minors, tobacco consumption and second hand smoke exposure in 2008 was a significant health issue. In addition, the best available evidence indicates that illegal tobacco smuggling including black market sales due to the sales ban in Bhutan remains robust. Conclusions: So far, in Bhutan, cigarette neo-prohibitionist arguments that stringent anti-tobacco tax and regulatory approaches including a sales prohibition will induce tobacco consumption to cease or nearly cease has not occurred. In addition, the best scientific evidence indicates that a harm reduction-oriented nicotine replacement therapy approach will not be entirely effective. The results of this study provide an important lesson learned for health practitioners and advocates considering or advocating, albeit a gradual, but total cigarette ban as public policy. [Copyright &y& Elsevier]

Abstract: In recent times there has been a concerted effort from some researchers, reformers and practitioners in the alcohol and other drug field to convince policy-makers, politicians and others that heroin use is, above all, a health problem. This push has occurred in a discursive framework pitting progressive and compassionate harm minimisation strategies against more punitive programs of prohibition. Within this framework, harm minimisation strategies are frequently cast as a response to heroin use as a health problem, while prohibition and punishment are characterised as responses to drug dependence as criminal. We argue that this polarisation of crime/prohibition against health/harm minimisation is a political red herring. Using deconstructive tools from contemporary social-political theory, we show how competing understandings of heroin use may mask a different kind of political contest. Exploring the discursive intertwining of people, practices and substances, we challenge the appropriateness of figuring different proposals to govern heroin use as a contest between science and politics, or of health-centred versus crime-centred strategies. We ask after the consequences of figuring criminal and medical arenas as rival frameworks for governing heroin use, and point to the perils associated with the apportionment of blame and victimhood therein. The broader aim underpinning our work is to locate and unpick political resistance to progressive harm minimisation strategies. [Copyright &y& Elsevier]

This essay considers U.S. Christian attitudes toward psychoactive substances. It presents classical Christian thought and the opinions of major historical church figures about pleasure drugs (especially alcohol) for comparison with contemporary attitudes about licit and especially illicit pleasure drugs (cannabis, cocaine, etc.). The Four Cardinal Virtues of Thomas Aquinas are the primary analytic rubric but selected Protestant denominational leaders are also cited. U.S. drug policies are critiqued in light of each virtue. The active moral character of the virtues is contrasted with the authoritarian and conformist aspects of abstinence ideology. The rhetoric and diverse viewpoints of the so-called Temperance Era are also considered. [Copyright &y& Elsevier]

Background: Globally, non-medical heroin use is generating significant public health and social harms, and drug policy about heroin is a controversial field that encompasses many complex issues. Policy responses to illegal heroin markets have varied from militarized eradication of the opium poppy and harsh punishment of users, to more tolerant harm reduction approaches with decriminalized possession and use.Methods: This paper reports the outcomes of a multi-criteria decision analysis (MCDA) on four generic regulatory regimes of heroin: prohibition, decriminalisation, state control and free market. Invited experts on drug harms, addiction, criminology and drug policy developed a comprehensive set of 27 policy outcome criteria against which these drug policy regimes were assessed.Results: State control of heroin was identified as the preferred policy option although other policy regimes scored better on specific outcome criteria. The free market model scored better than decriminalisation, with absolute prohibition scoring worst on every criterium. The ranking of the regimes was robust to variations in the criterion-specific weights.Conclusion: The implications of these findings for the development of future policy responses to heroin and opioids generally are discussed in detail. Despite increasing overdose deaths and an opioid epidemic in North America, prohibition remains the predominant policy approach to heroin regulation at present. It is hoped that the current paper adds to the discussion of finding a valid regulatory alternative. [ABSTRACT FROM AUTHOR]

Historically, the poppy plant has had multiple uses including as a food product and with medical uses in pain relief; today it is most commonly known as the plant from which heroin is derived. The United Nations international drug control regime currently only allows legal poppy production for medical use in 19 countries. Although Mexico is the third largest illegal poppy producer in the world, no Latin American country is currently allowed to legally produce poppies. Meanwhile, the United States and Canada are experiencing an overdose crisis due in large part to the adulteration and substitution of heroin with fentanyl and its analogues, while the price of opium gum has dropped 80% in the last two years in poppy producing areas of Mexico. The prohibition of opium has wide ranging health and development impacts that bring up a moral imperative regarding the safe supply of diverse opium-based products -including opium gum and heroin- that urgently need to be explored and addressed. Opium gum can be used orally or smoked, reducing riskier modes of administration and possible fatal overdoses. This article discusses the political and legal possibilities of safely supplying opium gum and manually extracted heroin from Mexico to Canada as a public health, harm reduction and development policy. [ABSTRACT FROM AUTHOR]

This article examines the recent trends in international, in particular multilateral, drug policy and the implications of these changes for shifting alignments and coalitions of actors and stakeholders. It places these changes in the context of the system's historical developments and applies previously unutilised analyses of other international governance structures. It suggests that the the international drug control system is undergoing a long-term process of fragmentation and evolution towards a 'regime complex'. In the short to medium term it suggests that exogenous challenges to the system remain somewhat limited. This is due to institutional battles over issue suzerainty and a limited funding incentive for other agencies to become involved. Instead, endogenous challenges and changes within the system represent the main avenues of adaptation. It continues on to suggest that in the longer term these endogenous changes will encourage and accelerate exogenous interactions with the system from other regimes and issue areas and thereby expand the terrain for cross-issue and cross-sectoral engagements. Thus, the short to medium term trends within drug control, while in some cases appearing to be in stasis or moving backwards, continue the overarching trend of regime fragmentation and shifting into an archetypal regime complex. [ABSTRACT FROM AUTHOR]

Objectives: Since 25th March 2020 India went into a complete and extended lockdown. Alcohol production, sales, and purchase were barred with this overnight prohibition order. We conducted a qualitative analysis of the media reports published within the first month of the nationwide lockdown with the objectives (a) using the media reports as indications of possible public health impact and population response of a sudden alcohol prohibition in India, (b) suggesting areas for future research.Methods: We performed thematic and content analysis of 350 articles published online in national newspapers between the 26th March, 2020 and 25th April, 2020. Initial inductive, followed by deductive coding was done in this exploratory thematic analysis.Results: The thematic analysis revealed four main themes: the beneficial aspects of the policy, the harmful aspects of the policy, non-compliance and attempts to change and / or subvert the policy, popularity and level of public buy-in of the policy. We generated relevant sub-themes under main themes. Two additional themes, not directly related to the sudden prohibition, were use of stigmatizing language and ethical concerns. The content analysis showed the frequency of the appearance of the main themes and proportions of sub-themes and codes under those main themes.Conclusion: The harms, perceived from the media reports, should be balanced against the potential benefits. Absence of a national-level alcohol policy was made apparent by the reflexive, disconnected, and conflictual measures. Future research could systematically examine the potential ramifications of alcohol prohibition on public health, social, and economic aspects. [ABSTRACT FROM AUTHOR]

Background: Brazilian drugs law and policy used to focus on prohibition of drug use. In 2006, inspired by the Dutch harm reduction approach, Brazil adopted Law 11.343/06, a new drugs law focused at harm reduction. Dutch harm reduction is characterized by a distinction between users and traffickers of drugs, and by a distinction between drug markets (soft drugs and hard drugs). Notwithstanding the new drugs law, some Brazilian scholars claim that Brazil still favors prohibitionism towards drug use. The current study investigates the extent to which the Dutch harm reduction approach is reflected in Brazilian law and practice.Methods: First, a documentary analysis of the Brazilian law and policy documents is performed to see whether they incorporate the distinctions between actors and markets. Second, a case law analysis of 102 judicial decisions delivered by the Rio de Janeiro courts of appeal was conducted to investigate to what extent judges refer to aspects of the harm reduction approach.Results: Findings of this study indicate that law and policy documents now indeed separate users from traffickers, but soft drugs are not separated from hard drugs. Moreover, where the distinction between users and traffickers in the Dutch law is solely based on the quantity of seized drugs, the Brazilian judge has large discretionary powers to decide whether the suspect is a user or a trafficker.Conclusion: The Brazilian legal system has partially incorporated the Dutch harm reduction approach. The law distinguishes users from traffickers, but does not prescribe criteria to make the distinction. The lack of objective criteria by Brazilian law and policy reflects in subjective and inconsistent decisions delivered by the courts, which impairs an approach of harm reduction towards drug users. [ABSTRACT FROM AUTHOR]

Background: Alcohol is a leading risk factor for death and disability globally. Due to the Islamic prohibition of alcohol consumption, alcohol policy is an under-studied and sensitive topic in Muslim majority countries (MMCs). In addition, drinkers in these countries may face barriers to treatment access due to stigma or the legal status of alcohol. Using Iran as a case study this paper explores how alcohol treatment is planned and delivered in the complex environment of an MMC.Method: We searched academic and grey literature, clinical manuals, guidelines and policy documents for information on the development and implementation of alcohol treatment policy in Iran. The search was conducted in English, Persian and Arabic. We conducted 6 consultations to verify information obtained. We analysed information based on the Walt & Gilson health policy analysis triangle, which identifies context, process, actors and content as key factors for understanding policy.Results: Iran initiated an alcohol-specific national strategy in 2011-2012 that aims to prevent, reduce and treat alcohol use disorders. This strategy has been designed to be implemented on a multi-sectoral level. Screening and prevention are mainly initiated in primary health care and cases are referred accordingly. Alcohol treatment is provided in specialised outpatient and inpatient settings. Due to contextual factors such as stigma, feasibility and affordability, alcohol outpatient units are planned to be integrated into existing public/ private drug addiction treatment facilities. However, the Ministry of Health has faced many challenges in implementing this pilot project. To date only small numbers of outpatient and inpatient units have formally commenced offering alcohol treatment.Conclusion: Implementing alcohol treatment has been challenging for Iran. Approval of new treatment programs may not be seen as a priority because of the low prevalence of alcohol use disorders in the country. Also, policy makers are implementing treatment services with caution due to the existing alcohol prohibition for the country's Muslim majority population. Barriers to treatment seeking need to be addressed at the micro and macro levels. Support from international agencies such as the WHO could assist MMCs to develop appropriate services that are feasible for their unique alcohol policy environment. [ABSTRACT FROM AUTHOR]