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With digital spaces an increasing feature of our everyday lives, and the internet now a primary means of sourcing IPEDs and information regarding their use, this chapter seeks to understand how digital fitness forum communities shape the dissemination of culturally embedded harm reduction advice. Findings are drawn from two netnographic studies of fitness forums, which identify several key areas in which community norms and structures served to inform harm reduction behaviours. This included embedded forum reputation systems and the ways in which these shaped IPED access, including through elevating ‘expert’ users and encouraging informed discussion regarding product quality, to the emergence of steroid testing services from forums as a community harm reduction tool. Second, forums were observed to often encourage users to conduct research and inform themselves regarding safe use, though limitations to this norm were also documented in relation to poor-quality medical advice, highlighting the issues with IPED users' reliance on anecdotal advice in the contexts of prohibition. Finally, the role of digital fitness forums as ‘digital backstage’ is considered, examining both how this can be harmful to IPED users from excluded or ‘otherised’ groups, but simultaneously offers cultural participants the opportunity for airing vulnerabilities in a space where their masculine identity is not threatened in doing so, thus facilitating harm reduction among cultural ‘insiders’.

This chapter reviews the history of civil society engagement on drug policy at the UN. Despite the challenging beginnings characterised by small numbers of civil society attendees at the Commission on Narcotic Drugs, coupled with government mistrust, in the last two decades, civil society representatives have made visible progress in advocating for policy reform and changing the terms of the debate.

Efforts by non-governmental organisations (NGOs) in the lead up to, as well as during the 2016 United Nations General Assembly Special Session on Drugs (UNGASS), best illustrate this increase in impact and engagement. Reform-orientated civil society strategised heavily on how to bring ‘comprehensive, diverse, balanced, and inclusive’ representation to the UNGASS and achieved this through the Civil Society Task Force, which was carefully balanced in terms of geographic, gender and ideological diversity, and included nine representatives from affected populations, including people who use drugs, people in recovery from drug use disorders, families, youth, farmers of crops deemed illicit, harm reduction, prevention, access to controlled medicines and criminal justice.

The 2016 UNGASS saw the fruition of greater civil society engagement. Eleven speakers were chosen to speak in the forum showcasing the calibre and diversity of civil society representatives. They made powerful, at times poignant statements and pleas for better, more compassionate treatment of people who use drugs, farmers of crops deemed illicit, as well as respect for human rights, sustainable livelihoods and the need to approach the issue through a public health and human rights lens.

The chapter concludes with the finding that reform-orientated civil society had a significant impact on the UNGASS – both on the gains in the Outcome Document and at the actual event, while noting that the most impactful ways to influence has nonetheless been through reform advocacy efforts outside of the official civil society mechanisms. Civil society engagement remains a serious challenge. International solidarity and global networking remain a central part of the drug policy reform movement’s strategy to advocate for change at the national, regional and global levels.

The Swiss drug policy once was very progressive in the 1990s when the harm related to drug use was most visible to the public. Failure of repression opened the room for more innovative harm reduction approaches. In 2008, the four-pillar model including the legal basis for substitution and heroin-assisted treatment of opioid use disorders as well as for other harm reduction facilities was approved by the population that had learned about the success of these measures. Less violence, better health outcomes among people who use drugs and less stigma supported the change of attitudes in the population towards a public health-based approach when dealing with drug use. Switzerland first received heavy criticism for the autonomous policy change at the international level while it is nowadays often cited as best practice example for dealing with people with an opioid use disorder. Otherwise, the country has usually been quiet in drug policy discussions at the UN level. Nevertheless, Switzerland’s reappointment to the Commission on Narcotic Drugs, the central drug policy-making body within the United Nations for a period of four years starting in 2018 is promising, given their unblemished recommendation for human rights-based drug policies including the abolition of the death penalty for drug offences, among other things. Alongside cannabis policy changes at the international level, Switzerland witnessed an unexpected development in cannabis availability and sales. However, the country is still rather conservative with regard to current cannabis policies, although cannabis with less than 1% of THC can be sold legally and the possession of up to 10 g will be followed by a fine only, if at all. Switzerland is open to experiment with new regulations but only if the law allows for that. To conclude, the strong sense of connectedness with the international community may support Switzerland’s next steps towards public health and evidence-based harm reduction.

States in the Middle East and North Africa (MENA) have historically leaned towards conservative, reactionary models of drugs policy. The combination of authoritarian forms of government, whether dynastic monarchies (Morocco, Jordan and Persian Gulf countries), semi-military republics (Syria, Egypt and Algeria) or religiously sanctioned republics (Iran), with the strong influence of Islamic law and norms, has signified that the region has enforced strict forms of drug prohibitions. For that matter, the region is home to cultural and social norms that are less permissive than in other regions of the world: for instance, with regard to premarital sex, homosexuality, clothing, alcoholic drinks and freedom of expression. This image of the MENA region is often overplayed by media commentators and Western scholars, especially in the field of drugs policy. The almost total absence of studies of drugs policy or drugs history in the MENA, excluding works in epidemiology, speaks well about the oblivion to which the region has been relegated over the last decades. The chapter provides first a background on the main questions regarding MENA drugs policy, looking at the historical developments in drug regulations and drug trends. Then, it discusses the current policies that operate across the region and, if pertinent, the prospects of policy development. When necessary, the argument refers to contextual elements that have influenced the direction in national and transitional drugs policy. Conscious of the fact that the MENA is as vast and diverse as a continent, I have opted to focus on three paradigmatic cases (Iran, Lebanon and Saudi Arabia), which provide an adequate geographical and thematic coverage of the MENA drugs policy. The three cases cover different aspects of today’s MENA drugs policy spectrum, from draconian repressive measures to progressive harm reduction programmes. Taken in their geographical dimension one can appreciate the variety and difference that exists within the MENA region, therefore supporting one of the key objectives of this chapter, which is to provide a nuanced analysis of drugs policy against the grain of homogenising and culturally reductive approaches.

Much progress has been made in public opinion regarding drug prohibition. The policy has been an utter failure, very expensive, and increasingly disliked by people around the world. As a result, several states have passed drug reform legislation that reduces penalties for the production, distribution, and consumption of previously prohibited substances such as narcotics and marijuana. Other states have placed more resources in drug treatment programs (demand reduction) instead of drug interdiction efforts (supply reduction). In North America, several states in the US and Canada have passed medical marijuana legislation to take advantage of the well-known medical benefits of marijuana (Piper, Matthew, Katherine, & Rebecca, 2003).

This chapter provides a critical exploration of the European Union’s impact on the 2016 United Nations General Assembly Special Session (UNGASS) proceedings and Outcome document. It demonstrates that the ability to produce a European ‘common position’ ahead of the UNGASS debates represents a significant step forward in the ability to ‘speak with one voice’ in the global illicit drug policy arena, and has played an important role in ensuring key issues such as human rights and public health remain on the agenda. In highlights, however, a European failure to engage with issues such as the continuing suitability of the international drug conventions to preside over the current climate of drug policy innovation and experimentation, and the unintended consequences of a ‘war on drugs’ approach. Ultimately, therefore, it argues that these failures will hamper the development of a more progressive and effective global drug policy.

In recent years there have been increasing calls for the use of anabolic androgenic steroids (AAS) and associated drugs to be recognized as a public health issue. In the domain of the competitive athlete and professional bodybuilder, recent decades have seen the diffusion of AAS from the hardcore gyms of the 1980s and 1990s to the mainstream exercise and fitness environments of the twenty-first century. Alongside the apparent increases in the use of these drugs, there is a growing evidence base in relation to harms – physical, psychological and (to some extent) social. But is this form of drug use a public health issue? What criteria should we use to make this judgement? What is the available evidence and has our understanding of the issue improved? By drawing on the authors' research in the United Kingdom and the wider international literature this chapter will explore these issues and attempt to answer the fundamental question – is the use of anabolic steroids a public health issue?

In the years leading up to United Nations General Assembly Special Session (UNGASS), Southeast Asia drew the attention of the drug policy world because of its refusal to drop the goal of becoming a drug-free region and for the extreme methods used in striving to achieve it. This chapter presents an analysis of the official positions taken by governments in the regional body known as the Association of Southeast Asian Nations from before until after the UNGASS in the context of one of the most punitive drug policy environments in the world and offers a perspective on what we could expect from them in 2019.

This case study examines unique overdose risks and prevention strategies for women who have used heroin during pregnancy in New York City. The overdose crisis has resulted in increased efforts to implement drug user health services; yet, pregnant and parenting women who use drugs continue to be left behind. Three women who currently use heroin and had experienced at least one pregnancy during their heroin use history were interviewed using semi-structured qualitative interviews. Their experiences documented in this case study illustrate several gender-specific considerations when responding to the overdose crisis in New York City. Overwhelmingly, barriers to healthcare and overdose prevention were correlated with perceived stigma and the fear of or actual loss of child custody. Compassionate, gender-responsive interventions remain largely absent in policy and practice, especially for pregnant women. The shared experiences highlighted in this case study should be used to develop improved drug user health policies and practices as well as increase overall advocacy efforts for women of reproductive age who use drugs.