Special event: International Standards for the Treatment of Drug Use Disorders – Each person counts, leaving no one behind

Organized by the Governments of Italy, Norway, Sweden and the United States, the UNODC Prevention, Treatment and Rehabilitation Section, the World Health Organization and the Vienna and New York NGO Committees.

Yury Fedotov, Executive Director, UNODC: Looking forward to dialogue around further guidelines for treatment.

Pedro Luis Moitinho de Almeida, CND Facilitator for Post-UNGASS Matters, Ambassador and Permanent Representative, Permanent Mission of Portugal to the United Nations (Vienna): 100 operational recommendations in the UNGASS Outcome Document. This event is another important contribution to the UNGASS recommendations. In the subsection on treatment, member states recognized that effective and evidence-based drug treatment can address drug dependence. At core of UNGASS follow up is sharing of lessons learned, and what it means to implement a multidisciplinary, balanced, and evidence-based treatment. Disseminate good practices informed by science. UNGASS Outcome Document underlined importance of non-discriminatory access to treatment and related services, including in prison and after prison.

Aldo Lale-Demoz, Director of the Division for Operations and Deputy Executive Director, UNODC: Welcome increasing attention on drug use disorders and effective treatment and management strategies. Guaranteeing same quality standards as is provided for other diseases. Collaborating in this regard. UNODC and WHO signed a MOU for further cooperation on addressing the world drug problem. Unique opportunity to hear from member states on how they translate standards and norms into national policies and services. Member states need to work towards full recognition of drug use disorder as a health condition. Latest medical and social science research needs to guide our discussion. Must recognize and accept people who use drugs as fellow human beings, and make sure they have easy access to treatment and related services. Confident that international standards will contribute to this important goal.

Vladimir Poznyak, WHO: In the process of a testing exercise for the standards to ensure that they are sufficiently comprehensive, have high utility, and are feasible for implementation in diverse settings. In line with operational recommendations from UNGASS. Treatment for substance dependence continues to be low in even well resourced settings. Need to improve both coverage and quality, in other words, effective treatment coverage. This is based on science and evidence of effectiveness, and ground in social justice and human rights. Not every treatment service contributes to effective treatment coverage. With partners at UNODC, look forward to further collaboration on testing and implementation of international standards.

Ghada Waly, Minister, Egyptian Ministry of Social Solidarity, Egypt: We are working on decreasing the demand. Today we have 22 treatment centers. No compulsory treatment in Egypt. We use a call centre where people call in anonymously for support and for referrals to hospitals. We have a center for women, children, and other target groups. Decentralized, as we are not just working in Cairo. Plan is to have access to treatment across Egypt. Service is free, but we have a law that provides us with continuous flow of financing. This is not a one-time treatment, it is a continuous process. Funding based on fines from criminals bringing drugs into the country. Able to treat 150,000 patients in two years. We use drama, songs, films, and art. Aware that different target groups need different messages. Main challenge is building capacity of medical team. Have a plan for capacity building. Reintegration system is one of main successes. Once you start treatment, have fully recovered, and been in the program for a year, can get a low interest loan to start a small and medium-sized enterprise (SME). Have been able to place 150 people in industry. We use sports and competitions and have found that this helps in reintegration. Important partnership with civil society. Working with 10 Egyptian NGOs. Help in spreading the word and bringing together volunteers. 26,000 university students made people aware of treatment availability and address stigma. Data is still a challenge. Collecting survey in school, including smoking, different drugs, patterns, peer pressure, etc. This is a problem that has to be faced with a number of ministries together. Working with 11 ministries.

Stefan Brené, Programme Officer, Swedish National Board of Health and Welfare, Sweden: National guidelines in Sweden are for severe, chronic illnesses affecting a large number of people, with high costs to society and for care, and with large regional differences. Prioritize recommendations based on effectiveness, including cost-effectiveness. Swedish National Guidelines on Substance Abuse and Addiction was finalized in 2015 and includes alcohol, cannabis, stimulants, opioids, and prescription drugs (benzodiazepines and opioids). Includes 153 recommendations and 24 indicators for assessment of compliance to National Guidelines. Developed in close collaboration with experts and specialists.

Maria Skirk, Foreign Affairs Officer, Bureau of International Narcotics and Law Enforcement Affairs (INL), U.S. Department of State, USA: We hope standards can continue to enhance the support from WHO and UNODC to member states. Give us a common understanding of several options for types of treatment. Not one treatment works for everyone. Standards provide many options. In USA, we support treatment for special populations, such as women, children, and rural populations. Universal treatment curricula is peer-reviewed and disseminated to countries around the world. Not just training the treatment staff. By training the trainers, we can reach more professionals and expand the workforce. International organization for medical doctors working in this field and now there is an organization that recognizes prevention and treatment professionals, known as ISSUP.

Torbjørn Brekke, Norway: Enjoyment of highest health is a human right for everyone. All individuals need access to diversified services. Law does not guarantee that these rights are met. Need capacity as well. Focus on quality and competence must be expanded to include number of personnel. Range of different interventions makes it difficult to assess their quality, and for users to receive an overview. We also have national guidelines. Norway is one of first countries to have created a full medical specialty in addiction. When knowledge and competence is on the agenda, we often hear that we need more. Research suggests that health and care services make little use of available knowledge. Matter of taking stock of existing knowledge, just as much as generating more knowledge. In favour of research and searching for better methods, but this must not hinder us from using existing methods that are proven to work. Right to health is a universal right. Have to accept that there are differences in resources, but standards are universal. Welcome standards prepared by WHO and UNODC.

Alireza Noroozi, Vienna NGO Committee on Drugs (VNGOC) / New York NGO Committee on Drugs (NYNGOC): First medical model for treatment of women and pregnant women that use drugs in Tehran. OST programs established in 2002 in the community and in prison due to high burden of opioid use. Used methadone in 2002, buprenorphine introduced in 2006, and tincture of opium introduced in 2011. Large network of treatment, but 90% are private sector. In 2001, first residential program for male clients was established. Established first residential program for women in 2002. In 2006, started to integrate harm reduction into residential programs. Information on how to avoid premature death due to overdose in the case that they relapse. Education also on safe sex and safer injection. In 2016, established first pilot medical model residential program for female and pregnant clients. Developed a multi-dimensional risk model to determine if clients should be in inpatient, medical model residential, or outpatient programs. Treatment of pregnant women is helpful for mother and can prevent newborn from becoming addicted after they grow up. Breaking intergenerational transmission of addiction.

John Strang, Head of Addictions Department, King’s College London, UK: Value in scientific evaluation to check which advances deliver the most benefit. Poorly delivered treatments produce poor results. Danger that looking for cost-effectiveness comes at the expense of effectiveness. Not all people with addiction problems are the same. Need to realize their different healthcare needs. Even for the same individual, healthcare needs will change over time. Naloxone used for many years to reverse overdose. Recently realized this could be delivered intranasally.

Adam Bisaga, Professor of Psychiatry, Columbia University Medical Centre: International treatment standards development because most people with this disorder are not in treatment, and most that are in treatment are not in effective treatment, but are in treatment that could even be harmful. Such a document can be used as a call to action. Standards based on existing publications and contains a list of minimum standards that can be applied to all member states, as well as optimal standards for those that have more resources. First got together in December 2014 where we presented exiting standards, agreed on format, and created workgroups. Workgroups generated drafts in 2015 that were revised and sent back to workgroups by UNODC. In December 2015, discussed outstanding and controversial issues. Approved final draft in February 2016. Published and distributed at last CND. Resolution that called upon member states to initiate a systematic process for adopting these standards. Document is very simple. Talks about key principles, treatment modalities, special populations, and characteristics of effective treatment system. Effort undergoing to conduct field testing. Next step is to develop implementation package. Then will conduct a pilot trail and then a large implementation trial. Looking for member states to be active participants in this process.

Gaetano Di Chiara, Director, Department of Toxicology, University of Cagliari, Italy: Best treatment is prevention. Cannabis is the most used illicit drug today. Shares some basic mechanisms with all drugs of abuse. This drug has been increasing its potency because percent of active principal has gone up tenfold in most preparations. The more the science shows problematic nature of cannabis, the more the perception of risk decreases. Disassociation between scientific evidence and popular belief. Legalization for medical purpose in states within USA, and now eight states have approved legalization for recreational use. Legalization only applies to adults. For adolescents, cannabis remains prohibited. In spite of legalization, adolescents will continue to get cannabis illegally. Legalizing cannabis sends a message that cannabis is not as harmful as once thought, thus decreasing perceived harm, facilitating consumption. This is a contradictory message. The real reason for legalization is not that it is a benign drug, but to protect adolescents from criminal prosecution related to possession. Calls for campaign on the dangers of cannabis use.

Rita Notarandrea, Chief Executive Officer, Canadian Centre on Substance Abuse (CCSA), Canada: Development of quality standards on drug dependence treatment are to evaluate good practices informed by science and ethical principles. Established a scientific expert panel. Held face-to-face meeting with experts. Recruited a lead consultant to finalize the technical tool. So far we have reviewed three versions. This summer, there will be a training system to pilot the quality assurance mechanism. Goal is to bridge the gap between what we know and what we do, and guarantee for drug dependent people the same quality that is provided for any other chronic disease by health services.

Gabriele Fischer, Professor, Department for Psychiatry and Psychotherapy, Medical University of Vienna, Austria: Should not be surprised if someone that has a drug use disorder is relapsing. This is the course of the disorder and should not be penalized. WHO already stated that all prisoners have the right to receive health care measures available in the community. Still working to implement this. High mortality rates of released prisoners, even higher in women. Huge necessity to implement treatment, especially for female drug addicts in prison. Massive stigma for pregnant women, lack of services, fear of losing custody, fear of prosecution, etc. What is the human rights approach to serving these women? A pregnant women and the fetus should be thought of as a unit. Intervention strategies must benefit both. In terms of prison, Nelson Mandela rules provide guidance.

Marta Torrens Melich, Professor of Psychiatry, Autonomous University of Barcelona, Spain: Those with psychiatric co-morbidity have more emergency admissions, higher prevalence of suicide, higher unemployment, more violence and criminal behaviours, medical co-morbidities, etc. High prevalence among those with substance use disorders at between 40% and 70%. Be aware of this is most patients. Should screen for psychiatric co-morbidity in places where substance use dependence is treated. Have to avoid expelling from treatment. Have to be aware of gender relevance. Women with substance use disorders also have more problems than men. Come more from families with other problems, experienced more disruption in their families, have relationships with drug use partners, support habits through prostitution, have more co-morbidity, etc. Facilitate admission of women into treatment. Make sure treatment is adequate for their needs. Avoid continuing as present.

Rakesh Lal, Professor, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, India: We have guidelines in India to make treatment more affordable, available, and acceptable. There is enough evidence that OST works. Started with contemplation phase, then preparation phase, in which we expanded the program and introduced buprenorphine-naloxone combination. Then also started slow release morphine preparation. Then we had harm reduction. Now in the action phase. Opposition for OST outside establishment and within. NACO initiated OST program. No expansion because of lack of faith in NGO system in India. NGOs and government began a collaborative model to deliver OST services. Program of capacity building. In 2007, started methadone. Retention rates were less than buprenorphine. People prefer buprenorphine because of fewer withdrawal symptoms. Started drug treatment clinics in 2014. Low threshold program that is outpatient, has no waiting times, no compulsory urine analysis, etc. Wanted to attract more people without penalizing them.

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