Special Section: Health, Rights, and the Future of Global Drug Control

Daniel Wolfe

Introduction

Focused on reducing negative consequences of drug use without requiring abstinence, harm reduction advocates have long worked at the intersection of health, human rights, and public policy. The HIV epidemic was a turning point, catalyzing a sustained engagement between harm reduction advocacy and international law, and narrowing the gap between drug policy and human rights discourse. The focus on bloodborne illness, however, is insufficiently responsive to current drug-related challenges and opportunities. Using three examples—overdose prevention, the therapeutic and spiritual use of psychedelics, and the deployment of artificial intelligence in drugs services—this essay calls for extending the harm reduction and human rights framework beyond HIV and the right to health. Such an expansion will require harm reduction to turn to new sources of authority within the multilateral system, including human rights actors, and to free itself from the evidentiary standards imported from the health sciences that have both enabled and impeded progress.

HIV as catalyst: Achievements and limits

For decades, the Vienna-based bodies charged with implementing and interpreting international drug control treaties—including the Commission on Narcotic Drugs (CND) and the International Narcotics Control Board (INCB)—considered people who use drugs primarily as abusers and participants in illegal exchange.[1] Special Rapporteur on the right to health Paul Hunt, noting drug control’s “scant regard” for international human rights, described Vienna-based actors as operating in a “parallel universe” in 2008.[2] Other analysts, noting attention to harm reduction, health care, and human rights by United Nations (UN) actors in Geneva and the marked rejection of the same in Vienna, characterized the disjunction as an example of UN “double vision” and a “disunited Nations.”[3]

The HIV epidemic—or, more particularly, HIV infections driven by injecting drug use—disrupted this compartmentalization. Five countries (China, Russia, Malaysia, Ukraine, and Vietnam) accounted for nearly 47% of cases in low- and middle-income countries by the mid-2000s, with the majority of those infections linked to the sharing of contaminated injecting equipment.[4] Advocates noted that the mechanisms linking drug injection to HIV incidence were structural rather than merely behavioral, including police seizure of syringes, state bans on the provision of sterile injecting equipment, the systematic denial of HIV medicines to people using illicit drugs, and incarceration or detention in settings where infection risk continued and where cruel, inhuman, and degrading treatment was prevalent.[5] Documenting the efficacy of needle and syringe programs and opioid substitution therapy in reducing HIV infections, advocates and UN norm-setters also highlighted the human rights violations that made such programs politically impracticable where they were needed most.[6]

This alliance overturned an approach that deemed people who use drugs as outside the law and thus unentitled to legal protections. Building on Paul Hunt’s lead, other Special Rapporteurs noted the importance of decriminalization and ending mandatory drug detention and denial of harm reduction services, presenting their findings at the CND.[7] The Office of the High Commissioner for Human Rights issued recommendations to remove bans on opioid substitution therapy and close compulsory treatment centers.[8] While stopping short of language on harm reduction, the CND from 2006 adopted a series of resolutions that, through language on HIV prevention, implicitly endorsed interventions such as needle and syringe programs.[9]

These achievements, however, were also bounded by the frame that produced them. Rights violations experienced by the person with chronic pain denied opioids, the Indigenous participant in psychedelic ceremonial practice prosecuted under a federal drug prohibition, or the user of stimulants subjected to compulsory internment in the name of treatment had no natural home in a framework oriented around HIV. Abuses in drug interdiction, including extrajudicial executions of alleged traffickers, were also unaddressed through the HIV frame, leading some scholars to call out the insufficiency of harm reduction and to argue for a more expansive human rights analysis.[10]

The case for expansion: Institutional contraction and new challenges

A complementary approach—and one favored in this essay—is to argue that an HIV lens is not enough and that expansion of the harm reduction and human rights frame is both warranted and urgent. A coalition of UN agencies, member states, and policy experts pointed the way in 2020, creating a set of International Guidelines on Human Rights and Drug Policy articulating rights obligations that include environmental protection, sustainable development, Indigenous religious practice, and proportional penalties for small-scale drug sellers.[11] A resolution at the fall 2025 session of the Human Rights Council, advanced by Colombia and 35 co-sponsors, also affirmed an approach to drug policy and harm reduction that extends well beyond the right to health. Highlighting links between drug enforcement and discrimination on the basis of race and gender, the resolution also challenged the analysis of Vienna-based actors, urging greater attention by the CND and the United Nations Office on Drugs and Crime (UNODC) to human rights generally and the drug policy findings of the UN High Commissioner for Human Rights in particular.[12]

The argument for “harm reduction 2.0” gains pragmatic strength in light of the institutional contraction of HIV advocacy funding and infrastructure. The Trump administration’s withdrawal of approximately US$4 billion from the global HIV response has included significant reductions to programming for people who use drugs.[13] Many of the donors that historically supported harm reduction have also withdrawn.[14] While these trends in no way eliminate the case for harm reduction focused on HIV or hepatitis C, they do signal that the advocacy infrastructure cannot be rebuilt on the old foundation.

Most importantly, multiple areas of drug policy and human rights concern are simply unrelated to HIV. The overdose crisis—particularly acute in North America but spreading to Europe—has killed more people in the United States since 1999 than HIV, gun violence, and homicides combined.[15] Curbs on religious use or research on the therapeutic potential of controlled substances—from cannabis to coca to psilocybin to MDMA—have exposed the inadequacy of the drug scheduling system. And the deployment of artificial intelligence to govern access to controlled substances in health care settings has created new questions about rights protection and possible positive uses for which HIV advocates have had limited response.

Safer consumption and supply: Drug checking and the rights to life, health, and consumer protection

Convention compatibility and the overdose crisis

The legal question of whether facilities offering spaces to use drugs under medical supervision are compatible with the international drug conventions was substantially answered in 2002. UNODC’s legal division concluded that harm reduction policies—including drug consumption rooms—were consistent with the convention’s call for measures to reduce human suffering when clearly intended to promote health rather than to incite illicit drug use.[16] The finding was ignored by the INCB, whose members condemned supervised consumption facilities as “opium dens” incompatible with international law. While the INCB’s stance later softened to recognize that such sites might not contravene the drug conventions if they lead people toward treatment and demand reduction, the CND has yet to adopt a single resolution endorsing the facilities.[17] This is despite reports of successful overdose prevention from all member states where drug consumption rooms operate, including Australia, Austria, Canada, Germany, Mexico, the Netherlands, Norway, and Spain, as well as in the few facilities permitted to operate in the United States.[18]

The potency of expanding harm reduction beyond HIV was demonstrated at the CND in 2024, when US advocacy for overdose prevention helped secure adoption, by vote, of the first-ever resolution explicitly supporting harm reduction.[19] That resolution, however, did not mention safer consumption facilities and mentioned human rights only in connection with protecting children from drugs. As the Special Rapporteur on health and the International Guidelines on Human Rights and Drug policy have affirmed, safer consumption facilities—which provide hygienic sites for use and have had a demonstrable impact on overdose and other harms—are clearly part of states’ positive obligations to protect life and health and to ensure nondiscriminatory access to health services under the International Covenant on Economic, Social and Cultural Rights.[20] More broadly, as Joanne Csete and Richard Elliott have noted, measures to increase safer supply—whether via drug consumption facilities or the prescription of heroin to those who are dependent—are consistent with other state obligations for consumer protection.[21]

Mobile drug checking—including the use of mobile spectrometry, infrared spectroscopy, and immunoassays such as test strips to help identify potentially dangerous drugs or contaminants—also remained unmentioned and unendorsed by the CND. UNODC’s legal analysis that drug possession need not be criminalized when clearly linked to advancing health protection is applicable here given the demonstrated efficacy of the approach in detecting health threats.[22]

Drug control, the evidentiary double standard, and the human rights corrective

While silent on human rights, the 2024 CND resolution mentions the importance of evidence-based approaches no fewer than 14 times.[23] This focus on evidence reflects what might be termed the paradox of evidentiary double standards in the global response to illicit drugs. Approaches to reduce drug-related harm without requiring abstinence are routinely held to the rigorous standards of evidence used in public health, including randomized controlled trials, tests of statistical significance, and the systematic review of published claims. In contrast, punitive drug policy measures—such as mass detention, forced drug testing, and police seizure of harm reduction supplies—face virtually no evidentiary threshold for implementation, even absent any demonstrable impact on drug use, harm, or any other policy objective.

Adding the human rights frame dissolves this paradox by shifting the analytical terrain. The question a harm reduction and human rights framework asks is not whether supervised consumption sites or drug checking reduce overdose deaths by a statistically significant margin, but whether the denial of such services is consistent with a state’s binding legal and moral obligations under the rights to health and life. It is not. 

Psychedelics and the rights to science and freedom of religion

Demands for evidence also fail to recognize how evidence generation itself has been constrained by drug control. Cannabis, psilocybin, and MDMA are classified by the UN drug conventions as having high abuse potential and no accepted medical use. The classification has produced a tautological logic, making research to demonstrate possible therapeutic benefit slow, costly, and impracticable.[24] UN authorities have repeatedly affirmed that the right to enjoy the benefits of scientific progress guaranteed by the International Covenant on Economic, Social and Cultural Rights encompasses freedom of inquiry in research and requires state action to ensure that “the scientific enterprise remains free of political and other interference.”[25] These are obligations that drug control has clearly violated.

Scheduling drugs solely on grounds of medical benefit also places drug control treaties in conflict with the right to religious freedom. Naturally occurring psychedelics and the scheduled substances that they contain—including peyote (mescaline), ayahuasca (DMT), and psilocybin mushrooms—all have been used for hundreds of years in spiritual and ceremonial practices. While states had the option of entering a reservation upon accession to the 1971 drug control treaty to permit the “religious or magical” use of psychotropic substances, communities—including Indigenous communities in Latin America—were rarely consulted about this option, and only four member states entered such a reservation.[26] The UN Permanent Forum on Indigenous Issues, citing the UN Declaration on the Rights of Indigenous Peoples, has repeatedly recommended repealing prohibitions against coca leaf that conflict with traditional health and cultural practices.[27] More recently, churches in the United States have used psychedelics such as LSD, psilocybin, and MDMA as sacraments integral to their sincere religious practice.[28] Challenges from US law enforcement have followed despite the centrality of freedom of worship to the country’s Constitution and national narrative about its founding.

Artificial intelligence, algorithmic governance, and rights

NarxCare and the governance of pain

New challenges are being raised by the use of artificial intelligence (AI) in the dispensing of controlled substances and in policing to control non-medical use. NarxCare, for example, is an algorithm currently deployed in 46 US states that generates an “overdose risk score” based on a patient’s prescription history and the location of prescribers that is displayed to clinicians and pharmacists prescribing opioids, stimulants, or benzodiazepines (though not to patients).[29] Used in an estimated one billion clinical encounters annually, the tool has never been adequately evaluated.[30] Health systems use these scores as a pretext for tapering or discontinuing opioid medication, leaving many previously stable chronic pain patients searching for doctors to continue their care or turning to street drugs, which carry a substantially higher overdose risk.[31] NarxCare’s proprietary black-box structure makes its reasoning impossible for patients or clinicians to challenge, and again underscores the evidentiary double standard whereby an unvalidated instrument of restriction is deployed uncritically while authorities demand that drug checking and supervised consumption sites provide high-threshold proofs of efficacy.[32] Similarly, algorithms trained on historical crime records and demographic information are now being used to forecast where crimes are likely to occur and who is likely to commit them. Using historically biased enforcement patterns to train algorithms reproduces discriminatory over-policing on the basis of race and place.[33]

Artificial intelligence, human rights, and drug policy

The right to health requires that health services be accessible without discrimination to the most marginalized.[34] Algorithms that reproduce or amplify existing disparities—through features correlated with race or socioeconomic status, or through the exclusion of relevant populations from training and validation datasets—violate these nondiscrimination obligations. The opacity of proprietary algorithmic systems also creates a structural barrier to the meaningful appeal or redress that international human rights law requires.[35] The allocation of medical care based on a system or score that cannot explain its reasoning is itself a dignitary harm.[36] Building on a long tradition of distrust by health systems toward people using controlled substances, NarxCare purports that its algorithm is more reliable than a patient’s self-account in identifying risk, and it denies care as a consequence.

The potential benefits of artificial intelligence for harm reduction

The same technological landscape that enables algorithmic harm has potential beneficial applications. Spectrometry used in drug-checking services generates images for each drug sample that require training and human resources to read. Deep learning techniques similar to those now applied with great effect to radiology, for example, could increase the speed and accuracy of image analysis, identify novel adulterants, and generate rapid public health alerts.[37] AI-assisted pattern recognition now used for predictive policing could be retooled to systematically document police violence or rights violations in crackdowns against people who use drugs, where systematic evidence collection has been difficult. Large language models can provide accurate harm reduction information to people in rural settings, in countries where services are legally restricted, across multiple languages, and during periods of acute need outside regular service hours.[38] States have the obligation not only to refrain from deploying discriminatory algorithmic tools but also to consider how available technologies could assist in their positive obligations to reduce preventable suffering.

Conclusion

The joining of human rights and harm reduction that emerged with the HIV epidemic must not end there. Building on the International Guidelines on Human Rights and Drug Policy and the 2025 resolution on drug policy, the fall 2026 session of the Human Rights Council featured multiple panels and side events on issues such as racism, gender discrimination in drug enforcement, excesses in the use of the death penalty, and new approaches to the coca leaf and protection of Indigenous and peasant rights.[39] The needed transformation, however, will be incomplete until the CND and INCB open themselves to a shift in the evidentiary frame. The double standard that seeks scientific proof of efficacy for harm reduction while demanding nothing of drug control measures was never fit for purpose. It should be replaced with attention to the moral and legal imperatives to respect, protect, and fulfill the rights of every person, including those engaged in both drug supply and demand, and a turn beyond the World Health Organization, UNODC, and the CND to the full range of relevant UN actors as states review and improve the global response to drugs.

Acknowledgments

I am indebted to the International Guidelines on Human Rights and Drug Policy, the Office of the High Commissioner for Human Rights, and the work of Joanne Csete and Richard Elliott for foundational thinking on the extension of human rights standards to the full range of issues in drug supply and demand.

Daniel Wolfe is former director of the International Harm Reduction Program at the Open Society Foundations and a health care advocate in New York City, United States.

Please address correspondence to the author. Email: danielmartinwolfe@gmail.com.

Competing interests: None declared.

Copyright © 2026 Wolfe. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

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[27] UN Permanent Forum on Indigenous Issues, Report on the Eighth Session, UN Doc. E/2009/43-E/C.19/2009/14 (2009), para. 89; UN Permanent Forum on Indigenous Issues, Report on the Ninth Session, UN Doc. E/2010/43-E/C.19/2010/15 (2010), para. 35; UN Permanent Forum on Indigenous Issues, Report on the Twenty-Fourth Session, UN Doc. E/2025/43-E/C.19/2025/8 (2025).

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[31] M. Szalavitz, “The Pain Was Unbearable: So Why Did Doctors Turn Her Away?,” Wired (2021).

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[33] K. Lum and W. Isaac, “To Predict and Serve?,” Significance 13/5 (2016).

[34] Committee on Economic, Social and Cultural Rights (2000, see note 20).

[35] Universal Declaration of Human Rights, G.A. Res. 217A (III) (1948), art. 8; International Covenant on Civil and Political Rights, G.A. Res. 2200A (XXI) (1966), art. 2(3).

[36] G. Pozzi, “Automated Opioid Risk Scores: A Case for Machine Learning–Induced Epistemic Injustice in Healthcare,” Ethics and Information Technology 25/1 (2023).

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[39] Human Rights Council, “63rd Regular Session of the Human Rights Council: Schedule and Directory” (2026), https://hrc63.sched.com.