 Good morning everyone. Okay, good morning everyone. I'm Neve Eastwood from Release in the UK. We are delighted to welcome you to this official HR 19 press conference, which we hope will give you a insight into some of the key findings from the conference this week. The press conference is being streamed live, so for those of you who are watching online, welcome. Before I introduce my colleagues sitting with me today, let me touch briefly on a few points. As my colleague Naomi Burke Shine reiterated last night at the opening ceremony, we are deeply privileged to be here in Portugal to learn about the health advances that have been achieved under the Portuguese decriminalization model. As Naomi remarked yesterday, there has been huge advances in this country, and the world still looks to Portugal for leadership on this issue, but more can be done. And I think we ought not underestimate what kind of impact these reforms have had on health. Portugal in the late 80s and 90s was experiencing skyrocketing rates of hepatitis C and HIV. Twenty years later, after decriminalization, it has one of the lowest rates of blood-borne viruses and of drug-related deaths in Europe. The same cannot be said for other European countries, where the criminalization of people who use drugs creates an environment of fear and stigma and contributes to record levels of drug-related deaths. The UK and Sweden are countries that continue to arrest and punish those who use drugs. The rates of drug-related deaths in the UK are 77 per million. In Sweden, it is 88 per million. Compare that to the Czech Republic and to Portugal, where we are today, which have both scaled up harm reduction and decriminalized personal possession of drugs, and where the rate of drug-related deaths is 4 per million. The evidence on decriminalization and harm reduction is in, and as we will hear from our speakers today, that evidence continues to grow and throw up new responses to the growing opioid overdose epidemic in Canada and the US. So, I am going to hand over to our esteemed panel, but first a bit of housekeeping. We will hear some brief remarks from our speakers, and then I will open to the floor for questions. Once the press conference has ended, you can approach a number of our speakers for one-on-one interviews or arrange to speak with them later on this week. I believe everybody is available at the end of the conference to meet with you. Our first speaker is Jane Buxton. Jane is an epidemiologist and the harm reduction lead at the British Columbia Centre for Disease Control in Vancouver, Canada. Jane will talk to a fascinating presentation she will give later this week on changing drug use behaviour around fentanyl. We think it's really exciting research, and we're really looking forward to hearing your comments. Thank you. So, for those of you that don't know, British Columbia is the most western province in Canada. It, like many of our regions in North America, has a high and increasing death rate from illicit drug deaths. So, in BC, we used to, before 2011, we had about 250 illicit drug deaths per year. Last year, 2018, we had 1,500, so six times that amount. And, of course, this, as many people will know in North America, has been attributed to fentanyl. Fentanyl is a very potent toxic opioid, and the discussion that has been in the media have been around fentanyl poisoning, people unknowingly taking fentanyl when they think they're taking something else like heroin. So, what I'm going to give you is a little bit of a description of how fentanyl and how the landscape changed, and what our most recent study showed. So, we first had this real wake-up call in October of 2014, when we were told there were 30 overdoses occurring at InSight at a weekend. Not deaths, there'd been no deaths at any of our supervised consumption sites, but there were 30 overdoses. The police came and took a substance that people thought they were using was heroin, and in fact, it was fentanyl. There was no heroin at all, it was pure fentanyl with caffeine. Following that, we thought we'd better find out where fentanyl's occurring. We did a study where we asked people throughout BC at harm reduction distribution sites, what drugs they'd used in the past three days, and would they give us a sample of their urine, and we used the fentanyl pest strips to identify if there was fentanyl there. Over time, we've seen fentanyl presence in deaths increasing. It was about 4% in 2012. It went up to 25% in 2014. In 2018, it was 87% of illicit drug overdoses had fentanyl. Because of the awareness, because of the alerting that goes out, and also having identified analogues such as car fentanyl, which is even more toxic, we thought we needed to assess again, and having done a survey for four years, we did another one in 2018. We again asked people what substances they'd used in the past three days, and then we sent the urine off for full analysis. What has happened over time with the analogues appearing, the fentanyl test strips don't always pick up things like car fentanyl, so we needed to have it properly done at a laboratory. So what did the results show? Well, in 2015, when we were first seeing fentanyl appearing, people weren't realizing they were using it, 13% of people said that they had used fentanyl. In fact, when we looked at the samples, 29% had, so that 73% were using substances and unaware that they were using fentanyl. In 2018, 39% said they were using fentanyl. When we looked at the urine analysis, 64% of people knew that they had taken fentanyl. It was only 36 that didn't. So what we've seen over time is that people are knowingly taking fentanyl. That's what the predominant down is. No longer it's really hard to find heroin and heroin alone, so people know what they're taking. But it's still so, so dangerous. But the actual dialogue has changed that it's not unintentional poisoning. It's people know what they're getting. And until we have decriminalization, until we have better regulated supply of opioids, it's going to continue to cause deaths. And our 1500 deaths that we saw last year looks as though it's going to be similar for 2019. Thank you. Thank you, Jane. I'll move straight on to our second speaker, Barrett Lambden. Barrett is a senior epidemiologist, an implementation scientist with the Community Health and Implementation Research Program at RTI International in the US. I know there's a lot of expectation around Barrett's presentation on the new data being released on an unsanctioned consumption room in the US. Barrett, what are you about? Good morning, everybody. So I'm going to be presenting this week a proof-of-concept evaluation of the first four and a half years of operation of an unsanctioned supervised injection facility in the United States. In September of 2014, an unnamed organization in an unnamed location in the United States opened a supervised injection site to address the overdose crisis that was occurring in the surrounding community. What this looked like was that there were two large rooms dedicated solely to injection and then hanging out post-drug use. Six stainless steel stations with mirrors and a table for assisted injections were within the site. Access to clean needles and syringes. Naloxone was on site. To be able to use a site, people had to be invited to use it. As you can imagine, the illegal nature of the site requires controls on making sure that other participants and the staff of the site are protected. And there's a staff person stationed in the injection room at all times. So to date, the site has observed over 9,000 different injections, events. This has effectively resulted in the prevention of nearly 8,400 public injection events. These are injection events that would have occurred in the surrounding communities. That includes parks, sidewalks, bathrooms of local businesses. Over 85% of people from the site report that when they're not using at the site, they're having to rush their injections. That has big implications as we all know for overdose, for infectious disease transmission, abscesses, wounds, etc. During the period of the study, we observed over a 540% increase in the overdose rate occurring at the site. So in 2015, 2016, what that looked like was just under one overdose per 1,000 injections. And in the first part of 2019, what that looks like is about 6 overdoses per 1,000 injections. So when you translate that, that effectively means that for every 167 injections that occur at the site, there's an overdose event. And if that, what we see at the site was reflective of what's occurring in the community, you can imagine the level of response that's needed to respond to that, those overdose events in the community. But despite this rapidly increasing overdose rate, all overdoses at the site have been reversed with naloxone, so the overdose death rate has remained zero at the site, even in spite of a rapidly increasing overdose rate. Our preliminary findings suggest that we need to consider this tool to address the overdose crisis in the United States. It is not too difficult to imagine that if we could take a substantial portion of the injections that are occurring in unsafe locations and move them into safer locations as this site has done, then we could expect to see community level impacts in overdose death rates. Thank you. Thank you, Barrett. That's such important work in the context of the US at the moment. Our third speaker is Lindsay McKay. Lindsay is a family physician from Canada. She will be speaking on her presentation on the use of hydromorph as a fentanyl substitute in British Columbia in Canada. This research really does demonstrate where we've arrived with the opioid overdose epidemic. So, it's important work again. Lindsay. Thank you for the invitation to the conference and for this audience today. I'd like to take this opportunity to discuss a solution to the opioid overdose crisis that we at PHS Community Services Society, a non-profit based in Vancouver, Canada that provides housing service and advocacy in the downtown East Side, have adopted to compassionately combat opioid poisoning. Many of you might be aware that the Public Health Agency of Canada issued a report that revealed that over 10,300 Canadians died of opioid-related deaths between 2016 and 2018. The opioid crisis stems from many converging issues, from policy issues including housing, poverty and health care, to matters of social justice, such as colonization, the denial of indigenous sovereignty, gender-based violence and social isolation. This number, 10,300, is an absolutely harrowing figure and can never serve to quantify the loss experienced by family members, friends, neighbors, coworkers and community members. But within the story, there's hope. There's a different way to address opioid use. Last year, across our three PHS supervised consumption sites, we saw over 331,000 visits and reversed almost 3,500 overdoses. And within the 15 years of insight, the first of these consumption sites being available to the drug-using community, there has never been an overdose-related death. Not there and not at the peer-led overdose prevention sites either. And so, we learned that this intervention has been an oasis of ingenuity and hope in the crisis. Community-based health centers like this were keeping people connected, and they were sparing folks from the stigma that killed others who were using a loan and dying. There are countless literature, reports and news coverage talking about fentanyl and how it has compromised the street drug market. But outside of medical care, the street market has been the only supplier of accessible opiates to people in the downtown East Side community for decades. So, how do we go about disrupting the system in a manner where drug users retain their agency are not stigmatized and can work with their physician towards a goal of safety? There is robust evidentiary base for providing opioid users with observed injectable opioids in order to address their substance use. Our clinical team at PHS decided we needed to supply the opioids to those who needed them. We worked with Vancouver's drug-using community to start our tablet and injectable opiate agonist therapy programs, or IOT. We knew how this program was situated in the community would determine its success, so we went to where the community was best supported and had established resilience and harm reduction practices, the supervised consumption sites and overdose prevention sites. Here, we seamlessly integrated into the continuum of services that community members were already accessing, and we were able to engage with and enlist opioid users who would most benefit from the program. A nurse, a community health worker, and a peer worker staff our overdose prevention site injectable program. The program is open every day. The injectable or tablet hydromorphone is paired with flexible doses of oral opiate agonist therapy. Patients have the option to come twice daily for the injectable and up to five times daily for the tablet program. Transitions within the program are patient-led and patients have the option to transition between programs based on what works best for them. Since the program was made available in 2016, we have been operating a 50-person capacity for the injectable program with an additional 50 people in the tablet program since early 2019. We also have three housing-based programs that can have up to eight people at a time. More than 300 different clients have engaged with our various programs over the past two years. Our IOD and tablet programs have allowed us to connect participants to primary care services and has led to some incredible outcomes that are synonymous with patient-centered care. People report less anxiety around managing their substance use and engage in less criminal activity to finance access to illicit substances. To this date, there have been no overdoses inside of our program. In closing, I want to share with you the words of Paul Skiback, who was one of our first clients after IOD's initial launch. He says, On the fourth day of the program, I stopped feeling anxiety. Then I think it was the seventh day I started to think, what am I going to do with my time? I had all the spare time because I wasn't hunting dope, so I got a job. Three weeks ago, I was trying to figure out what I was going to do every morning for my fix, and now I'm working, and I haven't worked in 10 years. Thank you for your time. Thank you, Lindsay, and thank you for sharing Paul's story. Our fourth speaker is Kirsten Horsper. Kirsten is the strategy coordinator with the Scottish Drugs Forum. She will give us today a European perspective on some of the groundbreaking work being carried out by law enforcement agencies in Scotland. Kirsten. That's quite a statement to start with. Scotland has the unenviable position of having the highest rates of accidental and preventable overdose deaths in the whole of Europe. So in 2017, we lost 934 people, and in 2018, it's expected that there will be well over 1,000 people having lost their lives. So it's incredible rates. Scotland is absolutely in the midst of a public health crisis, and at times of crisis, we need to rely on other people who might not be our instant assumptions of those who would help in such crisis. The majority of overdose deaths involve opioids such as heroin and methadone, normally in combination with other drugs such as benzodiazepines and alcohol, and certainly over the last few years, Tizolam has been one of the main benzodiazepines involved in our drug deaths. But the majority of cases involve opioids. Naluxone is a medication that reverses the effects of an opioid-related overdose, and we have had a national Naluxone programme in Scotland since 2011. It was introduced by the Scottish Government and it was fully funded for five years, and then it has just continued to be funded by the Health Service and by local authority areas since then. Since the start of the programme, we've provided over 50,000 Naluxone kits to people who use drugs, staff working in drug services and others who are likely to witness an overdose. The priority of the national programme is absolutely to make sure that Naluxone is in the hands of those who are most likely to witness an overdose, which is people who use drugs, and it can be an absolute lifesaver if it is in the right place at the right time. However, we do also accept that other people are quite often in the presence of those who might overdose. There are other first responders. One group of first responders is prison officers. So in the Scottish Prison Service, overnight in the prisons, there is no nursing cover, so if there's a medical emergency, the prison officers are required to phone an ambulance, and obviously that can take some time. So in partnership with the Scottish Prison Service headquarters, Scottish Drugs Forum worked with the staff to provide training to around 300 night staff prison officers over the course of a few months. It's quite challenging training, but the ultimate outcome of that was that now in prison service across Scotland, Naluxone is available overnight to be used in an emergency by prison officers. The chances of an overdose occurring overnight in the prison service is fairly low. It's not something that they experience frequently, however it is the principle of having Naluxone available, which is a safe and effective medication that can be used by anyone for the purpose of saving a life. The other group who are more likely to be first responders are police officers, and we find that police officers in Scotland are quite often first on the scene at an overdose. They have been partners in the Naluxone programme in the eight years since it has been running, and we have worked with them throughout those eight years to try and enhance their role so that they are then in a position to actually administer Naluxone in an emergency and to carry it. I had hoped that by the time that this conference came around that we would be in the position where frontline police were piloting the carriage of Naluxone among officers, however just when you think you're getting to the next level, the final level, another level appears, so we are still working with them to achieve that. At the minute though the safer communities department within Police Scotland has a rolling programme to train new recruits, so we deliver training to probationers, and the outcome of that eventually will be that Naluxone training will be part of the annual officer safety training programme. So it's definitely something that we're nearer to than we ever have been before. It's likely that when we do pilot police carrying Naluxone it will be an intranasal version rather than an injectable one, but ultimately we do not envisage or desire a situation where police are leading in the efforts to prevent drug deaths, but we have to acknowledge that they are very often first on the scene and could potentially be saving lives with Naluxone. So just to finish, to be honest we don't care who you are, you could be a police officer, a prison officer, a person who uses drugs, a family member, friend, a member of the general public. If you are somebody who is likely to witness an overdose you should absolutely be carrying Naluxone just in case. Final speaker for today is Jasmine Tyler. Jasmine is the advocacy director for the US programme at Human Rights Watch, and she will reflect briefly on the human rights aspects of the opioid crisis. Good morning, thank you. Every 25 seconds in the United States someone is arrested for drug possession, and you could time in the amount of time this panel has even been going on how many people have been arrested. I haven't done that right now, I probably should have, but it's a crisis. Criminalization of drug use in the United States is a crisis, it's a crisis around the world as well, but the other crisis is that we have a lack of healthcare infrastructure and access to community-based services for individuals who are in need. The panel that I'll be on here at the harm reduction conference is called drug courts, hard lessons from implementing countries. And my colleagues on this panel will be examining and exploring research that has proven that drug courts are not actually the answer to those two problems, the problems of public health infrastructure and criminalization. In fact, drug courts challenge and violate international standards with respect to the right to health, the right to self-determination and proportionality in sentencing. There are a number of specific challenges that have been uncovered when it comes to the drug court model. Namely, the largest issue is that these courts tend to practice medicine without any medical practitioners involved. For instance, it seems to me and in the research to be a completely crazy idea to determine someone has a health condition, substance use disorder, but then instead of providing them services within a medical context, continuing to send them through a court process that again doesn't have medical staff involved and has a number of legal consequences because it is within the legal, criminal legal system. Some of those consequences around the criminal legal system also undermine the goal of not using or the purported goal of not using the criminal justice system as a lever for drug addiction, but the reality is that's the only lever the court has for individuals who may not be able to comply with the terms like sobriety and going to appointments on time, things like that, and what we've seen as many times individuals end up serving more time because of violations that they've experienced in drug courts than they would have maybe if they had just taken their original case to trial or to plead. It's important to also understand that the resources that drug courts are using actually take resources from community opportunities for individuals, so many times you'll have someone in a community call for drug treatment for themselves or for a loved one and they will be put on a wait list for access to services that could be anywhere from days to months because those drug courts have priority over the slots of treatment in those community-based treatment programs. So it's counterintuitive that a person who needs help and wants to get it, right, they're self-determining their desire to get help, gets stalled because people have to be criminalized in order to access that care. And so we see here that because of the use of incarceration as punishment and coupled with the lack of its own resources and taking from community resources that these programs really don't demonstrate the cost-effective solution that is also purported to be gained by implementing them. In fact, the government accountability office in the United States, Congress's research body, has determined that the cost-effectiveness in U.S. drug courts is just unfounded. And then finally I'll just say what we know is these challenges that people face who have been criminalized continue for a lifetime. And so while drug court seems like an option for individuals, it really continues to perpetuate the criminalization because many times you have to enter a guilty plea in order to participate. And so you forfeit not only your rights as a criminal defendant to work with your lawyer in privacy, but you also then adopt those sort of scarlet letter challenges of being a convicted felon for a drug offense. So you can't access public housing, you can't access public benefits for accessing food, you cannot vote. And there are a host of ways in which communities have been disempowered and obviously or maybe not obviously, but in the United States the war on drugs is largely a war on people of color. And so there are extreme disparities in what we see between the ways white people and black and brown people sort of play out in the criminal justice system. So drug courts also is another area in which there are preferences for people who are whiter, who are more affluent, who are likely to be successful anyway using these resources that could be perhaps seen as real cost savings opportunities and impactful interventions if used on a different risk population. Right now they're used on sort of lowest risk, lowest need, including marijuana offenses, possession for marijuana. But if we thought about using a drug court like intervention for more violent offenses, people who pose public safety threats, then we might actually see that cost benefit because we would see programming impact people's lives and we wouldn't have to pay for them to be incarcerated for years and years and years. So really looking forward to being a part of this panel, I hope you'll come, but also very excited to be here in Portugal to learn from the lessons of nonpartisan decriminalization and to of course be here with the international harm reduction crew for the conference. Okay, time for questions. When I call on you, could you please state your name and what media outlet you are associated with? Please keep your questions brief and indicate who you are directing the question to. So opening to you guys. Yes. No, I'm not. Yeah, so we asked a question, basically, if you were not using this site today, where would you be using your drugs? And people could choose different public environments or residences or locations, other locations that they could be using in. That's right. As far as I understand, yes. Question to the panel then. Could you tell us, Jean, the research that you did obviously shows that people are looking to use fentanyl, choosing to use fentanyl. Did you look behind what the drivers were, what their experiences were? Could you share some of that with us? Sure. I mean, this was very much a quantitative, what did you use, what do you think you used and then analyzing what exactly people used. I think what we see is that if somebody wants to use down or an opioid, fentanyl is what you get. The alternative pure heroin is not available as it had been in the past. So it's not necessarily a choice. That was what people would prefer. But we found that that is what people are using and knowingly using as well. And for the others on the panel, I mean, Kirsten and I are from the UK and drug related deaths are at a record high in both England and even more so in Scotland. Is there any lessons that we can maybe learn from your jurisdictions, your countries? Probably Canada more than the US at the minute. But if there's anything that you could suggest in terms of innovation around harm reduction. This isn't a suggestion. It's an observation. And I think one of the ways we were able to get police in BC all carry intranasal naloxone was because people were concerned about their own and their colleagues health and exposure to fentanyl. And that was a reason for implementing it so that people carry it for occupational reasons, but also very willing to use it on members of the public that they do come across who have overdosed. So it's a bit of a sad reflection on the state that we have in Canada. And just on that Jane, I guess we did some training with the Scottish police authority who are all the in the toxicology department. And we have equipped them with naloxone and it was for those exact reasons that, you know, they were concerned about if they were to get any fentanyl packages in that there would be potential exposure to their staff. And I guess whilst we recognised that the risk of that was slim to absolute none. Again, the principle of having the naloxone available was important, but I think what was noted throughout the training that we've done with prison officers and with police officers, and it's what you're hinting at there as well, is that there is a much broader need and an essential need to really challenge the stigma that exists within these groups and training is essential to do that whilst it's quite difficult and it is challenging. We can't not erase those issues and those need to be challenged for sure. Talk about innovation in terms of us working towards solving this crisis. It's really important to involve the community advocates and the people with lived experience because at the end of the day those are the people who know what they need and they're often best situated to be able to come up with those solutions. And we've seen some incredible innovation come out of the downtown Eastside in Vancouver and most of that is thanks to the people with lived experience. Just one more thing to add. I think what we see certainly in NBC is that it's not just the urban centres and that's why our survey was throughout the province and it was the same rate of fentanyl use because fentanyl was everywhere. And I totally agree in talking with people with lived experience and with substance use what their needs are and what's acceptable. There's no point us going in and saying hey we've got this good idea if it's not going to be acceptable. So having overdose prevention services which has had hundreds of thousands of injections throughout the province so that people can use close to where they are. Yeah and we heard from the plenary this morning about how important it is because we're saying how important it is to make sure that people who use drugs are part of the policy development law reform engaged at every aspect. Any more questions from? Yes. So could you say where you're from and who you are? Columbia. I have to admit to not knowing a lot about injection in Latin America but I do know that there's a lot of harm reduction efforts underway to build out harm reduction opportunities. One thing that I do know though is that much of our drug policy in the U.S. but also around the world tends to focus on what's happening right at the moment as opposed to thinking more comprehensively about how to deal with drugs in our societies. And I think the fact that you know every decade or set of years you can see like the focus of particularly U.S. drug policy sort of shifting on to a drug and trying to figure out how to deal with that drug. Then we've missed sort of how to deal with drugs in general and keep people as healthy as possible. On an array of treatment options so for instance you hear all of us talking or many people on this panel talking about naloxone and responding to opioid overdose. But we don't really hear anybody talking about response to stimulant overdose which is also a problem maybe not at the crisis level but still a problem in which people need to have a way to address it. My own brother died of a cocaine induced heart attack on his 37th birthday. I was 27 at the time. So this is a real challenge that people have so I'm not sure it's an answer directly to your question but it is an answer sort of about what we need to be doing better. I think on that note we'll wrap up. Thank you very much to all of the speakers. They will be available to talk to you after we've concluded so do come up and ask them any questions if you have some. All right thanks.