The Need for a Sensible Drug Policy
Una Meistere
An interview with Kasia Malinowska-Sempruch, director of Drug Policy at the Open Society Foundations
Kasia Malinowska is a director of Drug Policy at the Open Society Foundations, which promotes drug policies rooted in human rights, sustainable development, social justice, and public health. She previously led the Open Society’s International Harm Reduction Development programme, which supported the health and human rights of people who use drugs.
Before joining the Open Society Foundations, she worked for the United Nations Development Programme in New York and Warsaw, leading capacity building and drug and HIV policy reform in Central and Eastern Europe and the former Soviet Union. Malinowska publishes regularly on drug policy as it relates to women, social justice, public health, human rights, and civil society. Her academic publications include works in the Lancet, the British Medical Journal, and the International Journal on Drug Policy. She wrote her doctoral dissertation on “HIV among Drug Users in Poland: The Paradoxes of an Epidemic”.
Malinowska coauthored Poland’s first National AIDS programme, and helped formulate policy at: the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the World Health Organization; and the Millennium Project Task Force on HIV/AIDS, TB, and Malaria. Malinowska holds an MSW from the University of Pennsylvania and a DrPH from Columbia University.
The following conversation with Kasia Malinowska is the first in the Spiriterritory interview series “Path”. The series is one of the events in the lead-up to the May 17 international online conference “Psychedelics: the game-changer in mental health and medical science” in Riga, as initiated by the association “Veselīga Latvija” (Healthy Latvia) and the cultural portal Spiriterritory.com.
I would like to start our conversation with a more general question: How would you define the term “harm reduction”?
Well, I think our colleagues in Western Europe did this for us decades ago, right? It’s really about meeting the people who use drugs on their terms and where they are at. In the early days of harm reduction, these interventions were mostly focused on HIV prevention. They included needle and syringe exchange, and expanded to hepatitis and HIV testing. I’ve been a part of this world for close to 30 years – actually, by starting the support of harm reduction programmes in Poland. So it’s been amazing to watch how the packet of interventions expanded. Since it was a response to infectious disease, then obviously, injecting equipment became important. But then in Denmark, street lawyers started to provide legal services to drug users – we were very impressed by that intervention because many clients of harm reduction programmes were in trouble with the law. If the police are chasing you, it’s a lot more difficult to take care of your health and other needs. In some places, showers and laundry rooms have even become a part of harm reduction services. So it really is about where your client is at, and actually letting your clients tell you what they need. Because if you assume, I’m the professional and I know, then there’s a huge probability that you will fail to address the most urgent needs. Whether it’s providing transportation somewhere in winter when it’s cold outside...really, just anything that could support an improved quality of life for the people who have drug dependence problems.
My experience in the beginning was very much focused on needle and syringe exchanges at the centre, and then grew to include a variety of other services. When we started to notice people using stimulants in the United States, a smoking pipe became harm reduction equipment for people who smoke crack. I’ve seen in Barcelona, for example, little pipes in harm reduction programmes that were adopted to suit stimulant users. More recently they have become available in the United States as well. In Canada there are vending machines that provide a variety of supplies for free, including crack pipes. People can just come in, push a button and get what they need. The beauty of harm reduction – and actually, the honour of participating in it for over three decades – is how incredibly responsive the community is to the needs of people who use drugs, regardless of what drugs they may be using.
And now, with fentanyl widely available and poisoning from it becoming a global issue, testing strips and more sophisticated drug checking services have become a part of harm reduction. And of course, life saving naloxone. When, close to 20 years ago, Dan Bigg [harm reduction pioneer, activist and founder of the Chicago Recovery Alliance, USA – Ed.] described to me for the first time the scale of the harm reduction programme in Chicago, it sounded somewhat unbelievable to me. When visiting him, I’d see huge warehouses full of a variety of items that were distributed from his silver-coloured harm reduction van – it was consistently impressive. Dan was the one who started the conversation about the availability of naloxone at the level of community, among his clients. When he first told me about it – it was well over ten years ago – I was a little surprised. The idea was new to me, but he was clear: I don’t want to wait for a doctor’s prescription – by then, people are dead. We have Dan to thank for this harm reduction innovation based on reason and deep compassion for harm reduction clients. What started in his programme has now become a norm across the world among harm reduction services.
I know it’s a long answer to your short question, but yes, it’s about meeting people’s needs, and letting people articulate those needs and designing services accordingly.
You’ve spent 30 years in harm reduction – how did your own path begin? Was that in Poland?
When a college student at Rutgers University in New Jersey, in my final semester, I took a class called AIDS and Society, and honestly, it blew my mind. Four years of education was worth it for just that one class. The professor, Susan Calvin, argued that basically, social inequalities are at the core of what is driving the global AIDS epidemic. It’s no accident that the community most affected first were the gay men in the United States, drug users, and in Sub-Saharan Africa – women, who are very often powerless in sexual relationships. It was almost like God had spoken to me – it suddenly became very clear to me what determinants of health are, and what they mean for marginalized communities. That’s when HIV became very close to my heart. When I went on to graduate school, I wrote almost every paper I could on some dimension of AIDS. After completing my master’s programme, during which I also worked for the American Red Cross as an HIV educator, I started working at the UN in New York and was lucky to have a fantastic mentor – Elizabeth Reid. I really wanted to work in my part of the world, in the countries of Central Europe, and eventually, an opportunity presented itself for me to come home – I was hired by the UN in Warsaw to lead HIV programming there.
Harm reduction was a very new concept in Poland. For me as well. I worked with institutions on the ground to raise funds, to build capacity, and to articulate harm reduction philosophy with the government, which was fully committed to abstinence only. The HIV epidemic was already very present in Poland; we were one of the first ones (actually, together with Yugoslavia) where the injecting of drugs was the driver to the epidemic, whereas Romania had the issue of children in orphanages. Once I was at home [in Poland], it became clear to me that injecting-drug use was driving HIV, and that we should focus on a sensible response. And, you know, it’s also been fantastic because there were so many people who were willing and interested to help. That’s where I met Dan Bigg; I knew him for a quarter of a century before he passed away because he was willing to come from Chicago and work with Poland, the Slovak Republic, Bulgaria and Romania on setting up their first needle exchange programmes. There was an incredible willingness and energy from folks who understood the significance of the problem and who really wanted to be helpful. It was incredibly beautiful to be part of the movement that was starting right here, in my home country.
Harm reduction was a very new concept in Poland. For me as well. I worked with institutions on the ground to raise funds, to build capacity, and to articulate harm reduction philosophy with the government, which was fully committed to abstinence only.
How would you characterise the situation in Poland now? It’s also had many different periods – there were very progressive tendencies, and then it went downhill due to politics and the COVID situation.
It wouldn’t be fair for me to have an opinion about Poland right now, just because I now live full-time in the United States, and we don’t engage with Poland a lot. What I do know from colleagues and friends is that it’s been assumed for a while that HIV infection rates among drug users had gone down and the number of harm reduction programmes is relatively low – definitely lower than needed. The availability of methadone is also limited. There are still parts of Poland where people have to travel extensively in order to access methadone. I understand that now the discussion is about the availability of buprenorphine, which you can take home and does not require people to jump through as many hoops. It’s unclear whether the current political leadership would agree to such an intervention. The elections are coming, and there is some hope that if things shift politically, more will be possible in Poland.
If we look at European countries in general, which country would you name as a positive example in dealing with harm reduction and drug policy?
Since I’ve been in the drugs field for over three decades, people often ask for examples of a perfect drug policy. The reality is that there is no perfect example. There are countries which are moving closer and closer to the ideal, but they’re not there yet. Czechia has a very generous threshold table of allowed personal drug possession – I think the most generous in Europe – for which people do not get arrested; but they have not regulated cannabis in the way that Canada has. Portugal has a fantastic range of services for drug users – from safe consumption rooms to low-threshold methadone. Vans travel the cities and offer low-threshold services, and personal possession has been decriminalized. Instead, people stopped by the police have to engage with the Commission for the Dissuasion of Drug Addiction – for a conversation. But, again, no legal cannabis. So, while Portugal has made lots of progress over the last 20 years, it is hesitant about legalising cannabis. Furthermore, it is cannabis users that end up in front of the the Dissuasion Commissions – which were originally designed for heavily dependent individuals in need of referrals to social services or information on how to access methadone, get some help with housing, etc. For Portugal, regulation of cannabis is the necessary next step.
Since I’ve been in the drugs field for over three decades, people often ask for examples of a perfect drug policy. The reality is that there is no perfect example.
Switzerland is fantastic when it comes to heroin maintenance programmes and safe consumption rooms but, again, is very slow on the question of cannabis regulation. Holland was early to the table with coffee shops, but they’ve gotten stuck in that mode for decades and nothing is changing. The coffee shops are still buying cannabis from the illegal market. One would hope that after all these years they would have managed to sort this out. Spain is a good example but not for the entire country. In Catalonia, one can find fantastic harm reduction services, along with “cannabis clubs”. Since there is no national regulatory framework for cannabis, people get together in small groups and create cannabis clubs. Nothing is perfect, but many of those countries are providing successful examples of what is possible.
As the conversation progresses, one thing I would say about Europe (which is actually disappointing) is that since European drug policy is gentler and kinder than in the US, you’re less likely to be violently arrested or to have your door kicked down; the drug policy advocacy in Europe is also a bit subdued. The real problem with this way of thinking lies in the fact that the situation may not be terrible and it is “good enough” for the mainstream. But this is not the experience for people of colour, refugees – generally people perceived as “the other”. If one visits prisons in the UK, Italy, France, etc., the people detained for drug-related offences are mostly black and brown. This assessment that things are “good enough” is really just for the white and economically privileged citizens of those countries.
In Catalonia, one can find fantastic harm reduction services, along with “cannabis clubs”. Since there is no national regulatory framework for cannabis, people get together in small groups and create cannabis clubs.
I’m talking to you from a part of Warsaw called Saska Kepa, an affluent part of the city where I rarely see police. We are close to a neighbourhood known as Praga – and the police presence there is constant and very visible. If you grew up there, in a family with significant economic problems, possibly alcohol issues, and your brother already has had multiple run-ins with the law, you’re being constantly watched by the cops. Europeans who can grow cannabis on their balcony without fear of being prosecuted are somewhat blind to this privilege and do not speak up for others. A refugee would be immediately arrested, and also kicked out of the country. When compared to the US, we are missing in Europe a sense of solidarity with the people who still get punished by the even the relatively lenient drug laws in Europe.
I want you to elaborate more on the issue on cannabis and drug policy. What is your opinion – why is there still so much struggle and controversy around cannabis despite the huge amount of clinical research that supports its use? For example, according to clinicaltrials.gov, at the moment there are 1449 studies going on researching the use of cannabis for different medical purposes. In the meantime, cannabis is still somehow demonised, including here, in Latvia.
In Poland, this conversation was also difficult, but even now, under the current Conservative government, laws have been recalibrated. So, medical cannabis in Poland is no longer the big taboo it was 10 years ago. It’s still not easy to access it because doctors haven’t been trained and policy pathways are unclear. And there is tons of stigma, of course – something we always struggle with, one where drug users are portrayed as manipulative and not trustworthy. The world’s biggest funder of drug research is the United States – and that’s NIDA [the National Institute on Drug Abuse – Ed]. Over the last 40 years, NIDA has only given money to research that shows the negative impacts of cannabis use. If you put forward a study that will say that you want to study benefits, you wouldn’t get funded. That was the case in the United States and all over the world because NIDA funds globally. So, in the world of science, we’ve trained people to think that cannabis is bad. But now that NIDA is backing away a little bit, the infuriating thing about the United States is that it puts out a certain goal of its own out there in the world, funds the proof to show it’s the right way, but when it changes its mind, things change only in the United States. It doesn’t undo all that damage elsewhere. 20 states in the US now have recreational cannabis, yet NIDA is not sending money around the world encouraging others to do studies showing a positive impact.
Over the last 40 years, NIDA has only given money to research that shows the negative impacts of cannabis use. If you put forward a study that will say that you want to study benefits, you wouldn’t get funded. That was the case in the United States and all over the world because NIDA funds globally. So, in the world of science, we’ve trained people to think that cannabis is bad.
One always needs to understand the larger global context. It’s the US that set up those standards, and those things change really slowly. Just keep in mind that there was big machinery working in the United States that wanted things to be that way. Now that they’re backing out a little bit, they’re not bringing all of us together with them; these changes are being accepted just within the United States.
Our part of the region has an additional problem, which is Russia. Never mind the terrible war that’s happening – methadone is not available in Russia. I mean, people almost went to jail for advocating the use of methadone. There is just a lot of advocacy and a lot of work that needs to happen. Talking about the Baltics, Sweden is also a collaborator in the region, yet it is ultra-conservative on drugs. I think the strategy of how to do this in a sustained way is by involving your policymakers, your medical establishment, the parents of kids who need assistance...there just has to be very sustained advocacy. The global architect of prohibition definitely was the US, and then Russia took the flag and continued. For the Baltic countries, I think that the geopolitics are not working in your favour.
However, looking at the experience of countries who have “been there and done that”, I would think that if you have a sustained and really well-planned strategy for action, shifting a small country could be easier and quicker.
I think the strategy of how to do this in a sustained way is by involving your policymakers, your medical establishment, the parents of kids who need assistance...there just has to be very sustained advocacy.
The other issue is psychedelics. There are many already completed, as well as still ongoing, studies on the use of psychedelics (e.g. MDMA, psilocybin and ketamine) as safe and effective treatment for depression, post-traumatic stress disorder (PTSD), nicotine addiction, alcohol dependence, and end-of-life anxiety.
You know, this is actually a fantastic example of what I said about the US. The US was the primary architect of their prohibition, but then the US FDA gives the approval to study MDMA for post-traumatic stress disorder, and the results of those studies are fantastic. I have no doubt this is going to move forward in the US, but the US is not bringing everyone else along. Now the US is going to benefit from this, while we are still struggling with the US-styled scaffolding of the war on drugs in our own countries. So that’s one piece.
I think the data coming out from some European academic centres and from the US are fantastic. What I worry about a little, to be honest, is that we have to be able to weave access to psychedelics for medical purposes into the fabric of a country’s drug policy. Because my concern is that all these people who were advocating harm reduction – let’s fight for cannabis: medical, recreational, etc. – now someone’s told them about a little shiny toy which sounds great, so they’ve dropped everything [regarding access] and are looking at the shiny toy. I don’t think that’s going to change the whole picture because that shiny toy – which is still on its own – will continue to be out of reach for a very long time. I think the question for us is how do we integrate drug policy in a way that it speaks on behalf of refugees, the Roma, access to pain medicine, medical cannabis, recreational cannabis, and for a range of harm reduction services, including Naloxone, so people don’t die from overdosing – and also include psychedelics.
What I worry about a little, to be honest, is that we have to be able to weave access to psychedelics for medical purposes into the fabric of a country’s drug policy. Because my concern is that all these people who were advocating harm reduction – let’s fight for cannabis: medical, recreational, etc. – now someone’s told them about a little shiny toy which sounds great, so they’ve dropped everything [regarding access] and are looking at the shiny toy.
My warning is that the current excitement about psychedelics is sort of deprioritising other things. And I think that in the end, this will be to the detriment of psychedelics. Because if those issues have not been addressed, if those discussions have not properly happened at country level, then the implementation of psychedelics will be of out of context and will not be successful. I think the potential is fantastic, but it’s infuriating that we lost decades of research when we made the decision to just basically cut it all off. Yet I also think that we need to find a way to integrate all of those pieces together into one sensible Drug Policy.
Thank you!
P.S. More information about the conference program and registration can be found there: veseligalatvija.lv/newpathformentalhealth/
