Side event: A health-centred approach to drug dependence, a multi-factorial health disorder

Organized by the Governments of Italy, Norway and the United States of America, the United Nations Office on Drugs and Crime, UNAIDS, the International Narcotics Control Board, the World Health Organization, the Civil Society Task Force, and the International Federation of the Red Cross and Red Crescent Societies.

Yury Fedotov, UNODC: The UNGASS Outcome document recognises drug dependence as a complex, multifactorial health disorder with causes and consequences that can be prevented and treated. Challenges are important in this regard. 275million people use drugs at least once in the previous year. A percentage experience disorders. 10.6 million inject drugs. 1.7 million live with HIV. Over 5 million with HCV. Drug use implies a high burden of disease. Treatment isn’t reaching all people who need it, particularly in low and middle income countries. Inequalities in terms of access to healthcare affect women, young people and people incarcerated.Countries should be supported in turning to alternatives to incarceration, allowed by the Conventions. UNODC collaborates with WHO and other organisations to support public health responses to drugs. We are produ to be in the 10thanniversary of UNODC-WHO programme on treatment and care. Concrete example of interagency cooperation. Individuals with drug use disorders should receive nothing less than what is expected for other chronic health disorders. Our group on treatment of drug use disorders has just concluded successfully a series of tests. Our standards on the matter have made explicit the need to implement a comprehensive package of interventions for people who inject drugs. More than 80% of people in need for palliative care do not have access to these. The work on the INCB in improving this is worth remarking. I am pleased that our cooperation with WHO and INCB have been strengthened. On the latest 26 June, the Secretary General of the UN underlined the need to advance prevention, treatment, rehabilitation services. UNODC is committed to continue supporting public health response to the world drug problem based on human rights and science. UN Agencies, MS and civil society must continue cooperating to protect the new generation.

Bent Høie, Minister of Health and Care Services (Norway): Thank you Chairperson, The saying ‘Health is Wealth’ reminds us about the value of good health and what we should aim for: Good health for everybody – leaving no one behind. However – people who use drugs is often a forgotten and neglected group who do not receive the health care they need and are entitled too. This reminds us about the reality and existing inequality of health. Recognizing this, we have to consider the reasons why this group is suffering and discuss to what extent the reasons are connected to the drugs and the drug use itself or if they are consequences of drug policy and how we as society have treated these persons. We also have to discuss what we have to do better to change this unbearable situation, as health always should be at the centre whenever drug policy discussed. The overall goal for any drug policy should be to promote health while preventing and reversing the adverse and harmful consequences of substance use on individuals and the society. Norway pursues a knowledge-based drug policy, which aims to prevent substance abuse, advance harm reduction, save lives and ensure dignity. On my initiative, we are in Norway now in a process of formally changing the authorities’ response to personal use and possession of drugs from punishment to health, treatment and follow-up. Through a reform, we will transfer the responsibility for drug related issues from judicial authorities to the health and social sectors. The reasoning behind this drug reform is a recognition that substance use is essentially a health challenge. Criminal prosecution of use and possession of illicit drugs for personal use has contributed to stigmatization, to marginalization and social exclusion and may have excluded individual users from appropriate and customized health services and follow-up. We have to change this. The drug reform involves a significant shift in drugs policy. A shift in attitude towards the drug problem and people who use drugs – and how we as society face this problem. Norway will not legalize drugs. The ban of drugs is an important signal about the risks connected with drug use, and it does provide a gateway to provide assistance. Nevertheless, we should not chase and sanction people for being addicted. Such sanctions seem to limit the person’s opportunities and prospects, and be more harmful than helpful. Furthermore, Norway has had and will maintain a strong focus on prevention. We will prevent where we can and repair where we have to, with the idea that the more and better we prevent, the less we have to repair. Clearly, prevention is the first choice both from a human and from a financial perspective. Norway is proud to have supported the International Standards on Drug Use Prevention that has been recognized by all Member States on numerous occasions. We highly welcome the fact that this is now a joint publication with the World Health Organization. Norway is a strong supporter of the United Nations efforts to prevent a further spread of HIV and minimize or eliminate AIDS. Norway has joined as a member of the UNAIDS Prevention Coalition, where we underline the importance of strengthening the HIV prevention among persons who use drugs. The number of new HIV infections among people who inject drugs has decreased steadily over the last 10 years in Norway. These numbers clearly show that harm reduction efforts, such as needle syringe programmes, work. Norway has been a member of the Commission since 2016 and 2019 is our last year this time around. I am proud of how we have used our membership to increase the focus on health and public health, on human rights and on the involvement from civil society, and especially representatives for people who use drugs. I am also proud of the three health-related resolutions we have drafted. I believe that our efforts are very much in line with the sustainable development goals and the principle of “leaving no one behind”. In conclusion, Chairperson, you can trust on my continued contribution to ensure that health promotion beyond dispute will become the basis of any drugs policy. Thank you! .

WHO:More than ever, a health- centred approach to drug policy is needed. Drug use and disorders constitute a public health issues. Strategies based on public health and respectful of human rights, putting people at the centre of the response, ensuring no one is left behind is key. Drug dependence is a condition that can be treated within health systems. People with drug use disorders should have access to prevention, interventions reducing harms and risks associated to drug use. People with drug dependence have the same right to access to health as anyone else. Prevention and treatment is recognised not only as a major public health issue but also developmental. SDG 3.5. The 10thanniversary of WHO-UNODC collaboration on the matter, built on the understanding of drug use disorders as a multifactorial health disorder. This understanding should be acknowledged not only by health professionals but also drug control authorities. We help countries to address opioid overdoses and save lives. Drug dependence is incredibly complex. Addressing health needs of people experiencing drug disorders requires full involvement of treatment and care systems. The situation is not satisfactory currently. Effective treatment coverage must increase. Treatment based on science and evidence of effectiveness, grounded on principles of equity, social justice and human rights. Methadone, buprenorphine and naloxone must be available, accessible to all in need. We will continue working towards this goal.

UNAIDS:Drug treatment should be voluntary. Compulsory centres are still in use in Latin America, South East Asia and Eastern Europe; in violation of human rights. Treatment must be confidential; compulsory registration in some places violate this right. The violation of confidentiality of patient records is a significant barrier. Treatment fees are another barrier, which calls for States to reducing or eliminating them. GeNPUD reported 7x increase in coverage of OST after removal of fees. People who use drugs are more likely to experience complex and social needs. They’re often excluded from social protection services. Some countries have made welfare support conditional to abstinence; a practice that needs to be removed. All measures to encourage HIV care uptake must be taken. Concerning HIV, we strongly support harm reduction, including NSP and OST. There’s comprehensive and compelling evidence that harm reduction is safe, effective and cost-effective to prevent and reduce mortality related to HIV and HCV. Harm reduction principles are universal. Special attention of young people, women, sex workers, people who use psychoactive substances, with mental health care need, inter alia. The golden standard is the need to engage representatives of various groups of people who use drugs into planning and implementation of services.

Timothy Martineau, Acting Deputy Executive Director, INCB:The health and welfare of humankind is the lynchpin of the Conventions. Governments should take all practicable measures to prevent drug use, and availability of treatment, rehabilitation, social reintegration and aftercare of people with drug dependence. Only 1/6 people with drug use disorders have access to treatment. The thematic chapter of the INCB annual report in 2017 focuses on treatment, rehabilitation and social reintegration for drug use disorders as essential components of drug demand reduction. Treatment services for drug dependence tend to be available in larger cities. Women with drug problems have disproportionately less access to treatment and rehabilitation services and are affected by a lack of gender sensitive services. INCB has called on member states to apply a comprehensive approach to involve women, young people, people affected by mental health disorders, migrants, sex workers, inter alia. The Board has underscored the need for different treatment options. I used to work in an NGO supporting people with HIV and with drug use disorders. We found that there is one temple in Northern Bangkok. We talked to the head. They agreed to perform cremations for people with HIV. Temples would not perform cremations for people with HIV and drug use disorders. Through dialogue, we managed to create a treatment facility in the temple to treat HIV and drug use disorders, in cooperation with health authorities. This approach then spread. Authorities realised more had to be done and special wards were set up. Related to the quality and availability of treatment, access to medication to support drug dependence is a fundamental objective. The Conventions seek to ensure access for medical and scientific purposes. Treatment of drug dependence should be part of the right to health. The provision of drug consumption rooms, for INCB, can be consistent with the Conventions if the objective is reducing the adverse consequences of drug abuse through the provision of referrals to health services and not impinge on demand reduction response. SDG 3 on healthy lives and wellbeing necessitates access to treatment for drug use disorders. I would like to recognise the work of NGO in prevention and treatment of drug use disorders. We see this through our country missions. We hope the cooperation between health, drug control and social health authorities is enhanced. INCB, together with WHO and UNODC, will continue to support implementation of UNGASS. Respect for human rights and the rule of laws are central for the implementation of treatments. People with drug use disorders must have access to treatment that is accessible and on a non-discriminatory basis. Extrajudicial actions have no place in drug control.

Kirsten D. Madison, US Department of State: The US is suffering from an unprecedented overdose crisis. 71,000 thousand deaths. We are hopeful in the sense that substance use disorder is a disease and that people can recover. In the US, in addition to law enforcement, we are supporting prevention, treatment and recovery programmes. Raising awareness on the risks, reducing exposure to prescription opioids and preventing misuses, evidence based guidelines on safer prescribing, safe storage strategies, inter alia. Naloxone distribution. Training of first responders and community members. Financial resources to expand state and local capacity to provide MAT for opioid addiction and ancillary psychosocial support services. Increase treatment for low level drug offences. We collaborate with UNODC, INCB and WHO to advance these goals. The Standards mentioned before, for instance. Building on international standards, we support the development of programmes and guidance for countries on the matter. Evidence-based treatment curricula implemented in more than 60 countries around the world. Ensure quality treatment systems. Professionalise service systems to promote consistent outcomes. Accreditation of treatment facilities, for instance. We work with UNODC on a quality assurance mechanisms to support nations aligning their systems with international standards. We work to reduce demand and recognise the legitimate uses. We seek solutions to promote a balanced approach that includes reducing the availability of dangerous drugs, support for evidence based public health actions, enabling long-term recovery for those suffering substance use disorders.

Amb. Maria Assunta Accili Sabbatini, Italy: Many factors contribute to substance use disorder and condition individuals’ susceptibility and vulnerability to drug addiction. There’s also protective factors: healthy family setting, secure parental attachment and care from early age, education system that raises awareness on the consequences of drug use, social environment where drug use is risky. Our efforts focus on vulnerable people, particularly children and adolescents, and their families. Preventable and treatable condition. Using controlled drugs for nonmedical purposes is not a right: it risks individuals and has negative implications for society at large. Access to treatment must be considered a right. In Italy, it is guaranteed to all people in need. The treatment, rehabilitation, social reintegration services for people with disorders in Italy is based on scientific evidence and interdisciplinary approach. Our centres all over the country offer harm reduction, education services, social assistance and legal protection; alongside therapeutic communities. Free care for 140,000 drug users. This shows how the health-centred approach to drug dependence is at the core of our drug policies, in balance with other aspects of our response (law enforcement, etc.). We are fully aware that much, too much maybe, remains to be done. Coverage and quality are an issue, particularly in reference to vulnerable people (in prison settings, where alternatives to incarceration; particularly treatment, should be promoted). No escaping the need for sustained investment in drug prevention strategies and treatment, healthcare, social protection and rehabilitation services. We look forward to work together to promote a truly health centred approach ot the world drug problem.

Massimo Barra, International Federation of Red Cross and Red Crescent Societies: Illusion around the world that repression can prevent drug use disorders. Humanity has used drugs since Noah’s time and will always use them. No force will ever be able to prevent suffering humanity from seeking relief of pains by using substances that can make people happy and seemingly immortal. The act of taking drugs has roots in the irrational part of the brain and is therefore insensitive to “Just Say No” messages. This concept presupposes humanity always acts towards good, not evil; which is unrealistic. Public responses need to mitigate suffering for people and communities. A person who takes drugs is dangerous to them and society, but a person who is not known to authorities is twice as dangerous. It’s in everyone’s interest to invest in therapy, since violence always brings more violence. Therapy, therapy and therapy for everyone should be our watchword and slogan. A drug addict who asks for help should be always welcome. Shouldn’t wait its turn in line or a waiting list or arrested or tortured. By “therapy” we mean any action improving the condition and life for the person. No therapy is decisive in itself. The evidence suggests the longer the person stays in therapy the better the outcomes. We should seek alliances to propose person centred interventions to offer more care and treatment options. Single options are doomed to failure. People are different and conditions are different. Therapy must be adapted to the subject, and not vice-versa. Not enough to have institutions waiting for drug users to come to their doors. A drug user who comes to therapy is sick. But a person not able to make the request for help, is sicker. Instead of waiting, governments should assist people in the street where they live a daily tragedy. Importance of outreach work!

Morgana Daniele, International Coordinator, YouthRISE: Thank you all for this opportunity. My name is Morgana, I am Civil Society Task Force representative for youth and the director of Youth RISE, a global youth organisation. I would like to start with a question – DON’T you find it surprising we are still discussing a health-centred approach to an internationally recognised mental health disorder (addiction) today, in 2019? Because I do. But I also know why – the health-centred approach has not been implemented yet in so many countries. Here are 3 questions young people from across the globe would like to ask their governments: 1. When will evidence-based PREVENTION be implemented? 2. When will evidence-based HARM REDUCTION be implemented? 3. When will evidence-based TREATMENT be implemented? First of all, what is PREVENTION? I have seen sons of diplomats, just like your children, spend their entire childhoods in summer camps. I have also seen children wear the same sweater from age 6 to 16. I have also seen children beaten up with a cable for unmade bed in the morning. And I have seen those sons of diplomats use drugs from the age of 14, lose teeth, sleep rough and shoplift. I have seen children choose living on the streets instead of returning home. I have seen 16 year olds die of drug overdoses in abandoned building, where they lie in piles of rubbish. For decades, prevention in many countries was implemented through scare-tactics, with pictures of our peers who have suffered from addiction. Just as your generation did, we learnt to despise those in need of healthy relationship and emotional support, because they did drugs of course. We learnt to shy away from them. This pattern must change. Multi-factorial health disorder means best summer camps and football fields do not compensate for family ties. Multi-factorial health disorder means scary pictures of drug use consequences tomorrow are less scary than the real experience of domestic violence today. Multifactorial disorder means drugs responded to the needs of your children better than you did. There is robust research available, which illustrates what works and what does not work in prevention. There are guidelines and standards published by the United Nations. Take them. Go home. 1. End the era of a scare-tactic approach to prevention. It has been proven ineffective and the only scary thing about it, is how it teaches to despise and shy away from those suffering from mental illness. 2. Build your prevention on supporting families. 3. Develop mental health systems that would respond effectively to the needs of both, your youth and their caretakers. Their states of mental health are closely linked. Now let me turn to HARM REDUCTION. Across the world laws, policies and regulations limit access to harm reduction to young people. Youth RISE has been contacted by parents, claiming they need us to come and talk to entire classrooms at schools, because their children do use drugs and these parents are worried about their childrens’ health and lives. Youth RISE keeps receiving messages from drug using peers, with requests to consult about their drug use and health but refusing to address registered practitioners or other specialists. In many countries Youth RISE remains the only limited source of funding for local youth organisations to work and provide services which are desperately needed. In many countries the work is carried out voluntarily, with no financial support. Harm reduction for youth offers inclusion instead of exclusion. It helps us learn to take care of our health, grow proud of being informed. It connects us with peers, creates a community and thus assists us through our adolescence teaching to be aware of our emotional needs. And this is the key to better mental and physical health as we grow older. Harm reduction does not prevent drug use, but by embracing those who use, and providing inclusion, it increases the chances that these young people will not develop a disorder and will remain functional members of society. There more than likely are peer youth organisations in your countries. Go home and talk to them. 1. Decriminalise drug use to avoid further exclusion of your children from society. 2. Fund and support and peer organisations as a link among your youth and specialists in the field. 3. Work towards a health-centred approach to both, drug use and drug use disorders. And finally, evidence-based TREATMENT: why can’t we treat our young people now? I have seen young people try every option of treatment available in their country. I have advised young people to leave their countries and go to those where more options of support are available. To them, it was their life at stake. Their future, their happiness, their whole existence. I have seen my own friends denied of treatment, punished and excluded from society, despised and humiliated, and ending up dying of a drug overdose. There is no time to wait for more evidence. There is enough evidence. Read the research available. Go home. 1. Expand opioid substitution treatment with all medications available, including heroin-assisted treatment. Combine medication and psychosocial approach. Open various kinds of rehabs, abstinence and medication based, allow them to try as many variations as possible. 2. Employ all means of harm reduction available to help your drug using youth to remain as functional members of your society – open safe consumption rooms and establish community drop in centres. 3. Make sure they stay ALIVE and healthy to the day they are ready to heal – open and expand needle and syringe exchange programmes, distribute overdose prevention kits, provide drug checking services. An finally, be wise. Fight your own personal distaste for those ill with addiction, fight your anger, fight your fear of political opposition, fight your own indecisiveness. Be wise and work for lives and health of your children by providing them with as many means to overcome their illness as possible..

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