Human rights and people who use drugs in the Mediterranean region

By Council of Europe

Developing a better understanding of the meaning of human rights in drug policy.

When people have a history of dependence, they often experience stigmatisation and are frequently perceived as criminals. This stigma has a negative impact on their lives, therefore the issue of human rights for people who use drugs is crucial and needs to be taken seriously, and urgently, into consideration. This publication puts into perspective different country situations and practices. It helps countries to enlarge their view on how to integrate a human right approach into the daily life of people who use drugs, in a concrete manner.

This report provides an overview of the situation of human rights and drugs policy in the 18 participating countries of the Pompidou Group’s Mediterranean network for co-operation on drugs and addictions (MedNET). The research was conducted by collecting data in these countries, covering both the northern and southern rims of the Mediterranean, on specifics issues linked to human rights and people who use drugs. It is the second, and more exhaustive, effort to gather information on this important topic which underlies the Pompidou Group’s mission. In 2022, the research includes new topics such as the issue of children of parents who use drugs and children who use drugs themselves, the gender dimension in prevention and treatment, the treatment and care services available in prison and the impact of the Covid-19 pandemic on drug policy.

• Language: English
• Publisher: Council of Europe
• Release date: Dec 6, 2022
• ISBN: 9789287193285

Book preview

Preface

Substance use is a very complex phenomenon. It is perceived in so many different ways depending on whether you are the person using substances, a parent, relative, neighbour, community member, religious leader, health professional, scientist, public health official, policy maker, law maker or media professional – as well as the country and culture you live in.

Substance use, especially drug use, is very often seen as illicit behaviour involving an illicit substance. And because the behaviour of use is considered illicit, so is the person who uses. Thus, the person who uses becomes the person to punish for it. This is how stigma has built up over decades and become, in many countries, the only window through which persons who use are viewed. Not until recently has the world started to move towards an understanding of the mechanisms and factors behind substance use. Addiction as a chronic relapsing brain condition is now, more than ever, being treated as a medical condition rather than deviant behaviour. But because substance use tends to become recurrent and addiction takes its toll physically and mentally on the person, criminal offences are common under the influence of the drug or the addiction itself. At some point in their tumultuous lives, persons using drugs are likely to encounter arrest, prosecution, sentencing, incarceration and probation. Is there any alternative to imprisonment? Is there proportionality during sentencing? Is appropriate science-based care available, before, during and after imprisonment? Are the conditions of imprisonment decent with regard to the basic human needs of the person, their gender, health condition and other vulnerabilities? Do prisons provide the path to real recovery? Are in- and after-prison rehabilitation programmes effective? Are post-release rehabilitation programmes into the community accessible? This remains a grey area in many parts of the world. Beyond the issue of alternatives to imprisonment for people using or possessing drugs, there is a need for a broader approach encompassing the right to access and the availability of treatment programmes; the right to proper and evidence-based treatment and care; the right to rehabilitation and harm reduction programmes; the right to information; the right to be heard and listened to when it comes to policy making; and, first and foremost, the right to science-based prevention targeting youth.

Moreover, human behaviour is always complicated, for it involves internal and external factors. Most internal factors are not under one’s self-control and pose the philosophical issue of attributability. Many external factors, especially environmental ones, lie heavily on us, and often there is no way out. All these factors contribute to a balance of vulnerability versus resilience that cannot always be predicted or even influenced.

All these issues of human rights for people who use substances are crucial and need to be taken seriously, and urgently, into consideration. The main objective of the United Nations conventions, which all our countries are parties to, remains, after all, the well-being and welfare of humankind. Hopefully, this document will be an eye-opener for the many stakeholders working on both sides of the Mediterranean Sea, and will trigger a new dynamic to compare situations, share practices, and inspire each other for the good of all those who use drugs and suffer in our region.

Professor Jallal Toufiq

MedNET Representative for Morocco

People with a history of dependence often experience the stigma of the drug addict and social marginalisation. This stigma leads to feelings of fear and isolation, and often means substance-dependent people feel unwelcome at social engagements and in work environments, resulting in marginalisation, confinement and social exclusion in general. Stereotypical prejudices, discriminations and negative social traits are often attributed to substance-dependent individuals, who may be labelled dangerous, criminal, weak, and lacking skills or interests. The consequences of this unfair treatment are mainly social and professional, but are also psychological, both for substance users and for their families. The stigma experienced by substance-dependent people may have a negative impact on their mental health, as well as on their rehabilitation, leading to unemployment and housing problems.

Stigma may directly affect people’s self-confidence. People with a history of dependence may internalise stigma, feel devaluated and ashamed, and conceal their substance use. In addition, the fear of being confronted with stigma affects their interactions with other people. Fearing rejection, substance users may isolate themselves or hide their situation in order not to be judged. Consequently, people with a history of dependence find it difficult to seek help. And even when they do receive the appropriate help, they face the same difficulties all over again in their reintegration into society, in finding a home, in finding a job or in sustaining a normal social life.

It is for these reasons that the Pompidou Group, MedNET and its member countries promote drug policies and comprehensive actions based on human rights that aim to eliminate stigma. The development of comprehensive drug systems in prisons; the training of policy makers, health professionals, and professionals from the police and the legal sector; the exchange of knowledge and experiences among neighbouring countries; the establishment of a network to facilitate change and in effect ensure the availability of care, treatment and rehabilitation services in prison settings as well as in the community – these are fine examples of actions facilitated by MedNET. The aim is to ensure that the human rights of people facing drug-related problems are protected and that healthcare and support are available at all times, even if they are deprived of their liberty as a result of incarceration.

It is vital that we all continue to join forces to eliminate stigma and otherwise support substance-dependent individuals. MedNET and its members are committed to these goals through their continued co-operation to promote human rights in all policies, and the establishment of new actions, programmes and interventions, so we can gradually create a society of zero discrimination against substance users.

Leda Christodoulou,

National Addictions Authority of Cyprus and MedNET Chair since 2022

Introduction

In 2019, a discussion entitled Human rights and people who use drugs in MedNET countries: current situation, challenges and the future was carried out by the Pompidou Group Secretariat during the 25th MedNET meeting. It was chaired by Professor Nabil Ben Salah, MedNET Representative for Tunisia and chair of the MedNET network (2019-21).

In preparation for this discussion, research was conducted by the secretariat, resulting, in 2020, in the report P-PG/MedNET (2020) 4, Human rights and people who use drugs in the Mediterranean region: current situation in 17 MedNET countries. This was made possible by a response rate of 70 % from MedNET representatives following the secretariat’s request for information.

Professor Jallal Toufiq, MedNET Representative for Morocco, proposed the topic and facilitated the discussion, framing the multidimensional scope of a human rights approach for people who use drugs.

Drug use must be rightly considered a medical condition to be treated by qualified health professionals.

Treatment must be available, accessible, affordable and science-based, and should use best practices.

Prevention must be grounded in science, facts and best practices.

Data collection must be considered a part of the right to access information for the community of practice and professionals involved.

Rehabilitation and social reintegration must be provided.

Access to treatment and care must be available to specific populations, including people who use drugs in prison, sex workers, pregnant women, migrants, refugees and the elderly.

Combating stigma and raising social awareness is key.

A human rights approach, especially for minors and non-trafficking users, should be incorporated into law.

People who use drugs should have the right to form their own associations and self-help groups.

People who use drugs should have the right to access treatment for all the consequences of drug use.

All strategies aiming at reducing the health, economic, social and legal consequences of drug use should be promoted.

In the country research, the aim was to gather information on the above-mentioned topics. The results presented were not intended to be exhaustive but to provide an overview. The main objective of the discussion was to better understand the meaning of human rights in drug policy and to exchange best practices and ideas. This is consistent with the 2018 Stavanger Declaration of the Pompidou Group’s 17th Ministerial Conference, which reaffirms a focus on human rights as a fundamental cornerstone in drug policy, in line with the Council of Europe’s core mission.

Due to the importance of the topic, and the focus on human rights within the Pompidou Group work programme, it was decided to proceed in 2022 with a second round of data collection from the MedNET countries. The exercise requested MedNET country representatives to update their replies from 2020 by responding to the following questions.

How is the issue of children considered in drug policy? This topic could include two aspects: children whose parents use drugs and children who use drugs themselves.

How is the gender dimension addressed in drug policy? Are women considered to have special needs? Are specific services available?

An issue for both women and children is the question of pregnant women who use drugs. Are there services available to them? Is there a follow-up for newborns (and up to what age)?

Is the question of the LGBTQI community considered, in terms of the stigma they may face?

Keeping in mind that treatment should not stop at the prison gate, what drug treatment services are available in prison? Is there a rehabilitation programme? Is there continuity of treatment after prison?

From criminalisation to illness, does policy consider drug users to be criminals or people in need of help and treatment? Has the policy evolved, for example is there an increase in the number of treatment centres?

What is the involvement of people who use drugs in the process of decision making regarding drug policies?

What consequences did Covid-19 have for drug policy and what lessons can we learn with regard to the treatment offer and treatment modalities?

The following sections summarise the situation in each MedNET country.

Chapter 1

Algeria

1. Health approach at the policy level: drug use considered a medical condition to be treated by qualified health professionals

The Algerian Law 04-18 on the Prevention and Suppression of the Illicit Use and Trafficking of Narcotics and Psychotropic Substances of 25 December 2004 considers drug use to be a medical condition in its own right that requires therapeutic treatment. The therapeutic injunction as an alternative measure to imprisonment for cases of drug addiction provided for by the law is a step towards the recognition of drug addiction as an illness.

The law marks an essential step in changing the status of (drug) users: it no longer considers them to be criminals who must be punished, but as sick people who must be cared for. The law emphasises the therapeutic injunction, which it presents as a care and prevention measure and an alternative to a penal response. It thus constitutes a significant development in Algerian legislation.

Article 6 of the same law cited above stipulates that: Public action shall not be taken against persons who have complied with the medical detoxification treatment prescribed to them and followed it to its conclusion.

Similarly, public action is not taken against persons who have made unlawful use of narcotic drugs or psychotropic substances when it is established that they have undergone detoxification or medical supervision since the date of the offence committed.

2. Treatment to be available, accessible, affordable and science-based, using best practices

Following the promulgation of Law 04-18, the Algerian Government launched a multi-year programme in 2007 aimed at setting up a vast network of centres specialising in the therapeutic management of drug users.

The residential treatment programmes offer reception and counselling services, motivational interviewing, and assessment of the most problematic drug use habits (early onset, cumulative use, excess use and repetition) and risk factors (personality traits, risky behaviour, and school, family and environmental context, etc.).

Several Algerian doctors have taken part in training on substitution treatment, organised by the Pompidou Group in several countries in the region as part of the activities of MedNET. On 5 January 2021, Algeria introduced opiate substitution treatment (OST) with methadone. Two centres for the treatment of drug addiction were selected, and 100 patients benefited from methadone treatment that year. This number will increase to more than 320 patients by 2023, according to the Ministry of Health. Under the work programme established by the ministry in 2007, 44 intermediate care centres out of the 53 planned and 4 drug treatment centres out of the 15 planned are operational.

The health sector is making constant efforts in the following areas:

information provision and awareness raising on social problems, including drugs, as part of the activities carried out by screening and monitoring units in co-ordination with the Ministry of Education;

a continuing education programme for professionals specialising in the fight against addiction.

A certificate of specialised studies in addictology was launched in 2017 for two groups composed of more than 40 doctors from the intermediate care centres in the medical faculties of Algiers and Blida. Furthermore, 40 more doctors and psychologists were trained in 2021 in motivational interviewing with the support of the Pompidou Group. Thirty general practitioners working at the level of Centres Intermédiaires de Soins (CES) spread throughout the country, constitute a third group, and are currently undergoing training at the Faculty of Medicine in Badji Mokhtar Annaba University to obtain a diploma in addictology (specialised study certificate CES in addictology). Meanwhile, the provision of healthcare to drug users seeking care fell from 24 424 in 2018 to 23 416 in 2019 and 21 638 in 2020.

The national sexually transmitted infection (STI)/HIV/Aids strategic plan includes the following two objectives:

to include injecting drug users (IDU) in priority target groups classified as vulnerable or at high risk of exposure to HIV;

to develop measures to prevent and reduce the risk of STIs and/or HIV/Aids among this population group, with a view to encouraging the adoption of less risky behaviour.

3. Prevention grounded in science, facts and best practices

The ONLCDT has developed a new strategy for the period 2020-24. The National Strategy for the Fight against Drugs in Algeria emphasises prevention and asks all actors