Thematic sessions – Follow up to the 2019 Ministerial Declaration, 18 October

Third round of thematic sessions on the implementation of all international drug policy commitments following up to the 2019 Ministerial Declaration

Theme addressed: ‘… synthetic opioids and the non-medical use of prescription drugs pose increasing risks to public health and safety, as well as scientific, legal and regulatory challenges, including with regard to the scheduling of substances’

Background Note by the Secretariat

Morning Session

CND Chair: Welcome to the third day of this session of the CND intersessional. Today, we will discuss synthetic opioids and non-medical use of prescription drugs pausing increasing risk to public health and safety, as well as challenges regarding the scheduling of substances. We also have videos from yesterday which we will show later on. I welcome our panellists from the Africa Group: National Drug Law Enforcement Agency (Nigeria); National Dangerous Drug Control Board (Sri Lanka); Public Health Department of Estonian Ministry of Social Affairs (Estonia); Permanent Mission of Australia to the UN in Geneva (Australia); International Association for Hospice and Palliative Care (VNGOC). I hope we can continue our discussion and remind you, including our panellists, to take focus on the issue and stick to 5-7 minutes for presentations so that we can hear everybody. I will leave enough time to ask questions to panellists, but keep your interventions to the point.

John Brandolino, UNODC: I would like to introduce the topic of the day. The non-medical use of prescription drugs is posing increasing challenges. We will start with a brief overview from Angela Me, then have a group of panellists representing regional groups, then go to other thematic experts, we have people representing the UNODC opioid strategy: WHO, INCB, Universal Postal Union, UNODC. There will also be short videos for people who could not make it today. Please stay within your time frame so that we have enough time for delegations to present their views.

Angela Me, UNODC: I apologise that you have to hear my voice again, my role here is to frame the discussion and bring some of the evidence to help the discussion of the day. We should understand what substances we are talking about. Describing what we are talking about is complex, let alone understanding what is happening and how to address challenges. Opiates are substances coming from the plant. Then synthetic opioids can be synthesised in labs, they don’t need plant-based compounds. Within this, you also have codeine, morphine. When we talk about pharmaceutical opioids, we include both opiates and synthetic opioids. If we start looking at this from a control perspective, you can see that some substances are under international control, some aren’t. Within synthetic opioids, there is fentanyl, which is an example of a synthetic opioid under control, and you also have Tramadol which is not under international control.

The discussion of opioids concerns 3 areas: the issue of accessibility for medical use; the harms they pose; the two crises we have: the fentanyl crisis in North America in Europe, and the tramadol crisis. What does this mean for the CND? What are the characteristics of this crisis and how can we respond?

Availability of opioids for medical use: some regions have very high availability, but others have very limited – Africa and Asia.

In terms of harms: the number of drug related deaths and the concept of years of healthy lives lost. If a person dies at 20, they on average lose 60 years of life. In terms of deaths, hepatitis C is the main cause of death globally. Opioids are the ones that produce most deaths as a type of drug. Opioids are the substances that pause most concerns from the health perspective.

Opioids have different characteristics, each country and region face different challenges. This is true for opioids and opiates. For some regions, the main issue is heroin. In other regions, synthetic opioids and non-medical use of opioids is the main cause of concern.

In terms of the two crises: you have heard many times the increasing number of synthetic opioids coming to the market. One issue is that of tramadol, with data from Egypt. The mostly used drug is cannabis, but right after is tramadol in Egypt. Statistics from Nigeria show that almost 5 million people use tramadol. One in five become dependent. The other crisis is the fentanyl crisis, including the concentration and the hotspot. I am showing here the number of deaths of heroin and fentanyl together. Fentanyl markets are mainly in the Eastern coast. There are two moments; 2014 and 2017. The number of deaths has expanded greatly, as has the concentration of fentanyl. This is not only limited to the USA. There is a market in Europe also, especially in Estonia. It is not a big surge of deaths there, but it is a market. The Swedish government has also seen an increase in its fentanyl market.

What can we learn in terms of how the new use of pharmaceuticals has emerged? Fentanyl has developed the market in a different way. In some countries it has replaced heroin (e.g. Estonia; in Finland it was replaced by Buprenorphine; in Latvia it’s increasingly replacing heroin; in the USA and Canada, fentanyl is replacing heroin). In other countries like Sweden and some US and Canadian states, fentanyl evolved together with heroin. This is all to do with how the market expands. In the USA and Canada, there are users who try to avoid substances with fentanyl. But it started to emerge that some users are looking for fentanyl. Fentanyl will stay together with other drugs in the market in most countries.

What can we say about the two crises? These will require a different type of intervention. On tramadol, the Nigerian Ambassador said that the substance is very cheap. So in a way this is expanding drug use, it’s much cheaper than heroin. It’s also very profitable to traffickers. And we saw a similar trend for fentanyl, it’s very cheap for traffickers. There has been an increase in the number of people with drug use problems related to tramadol; while fentanyl has not led to an increase in the number of users, but in the number of harms. Tramadol is a market of itself, while fentanyl is not a market of itself, it is found in combination with other substances. The fentanyl crisis is supply driven. It started from the supply merging it with other substances. It is not yet a demand-driven market with users asking for more. While tramadol has been supply induced, but it is also demand driven now. The issue of non-medical use of tramadol is that there is a blur between informal markets, legal markets, etc. There is an issue of pharmaceuticals sold in informal markets in Africa, something we don’t have in North America. Tramadol is a traditional epidemic. Typically, you see that the use goes up, the harms go up, then society realises how harmful it can be. This is what we have seen with heroin, cocaine and even cannabis. The fentanyl crisis is not a typical epidemic. It is still on the peak. Deaths are stabilising, but they are not going down. I want to show you the difference between tramadol, heroin and fentanyl. You can see how much users spend a day for heroin and for tramadol, there is a striking difference, and you can see how easy it is for the tramadol market to expand. For fentanyl, it’s about how cheap it is for traffickers to include fentanyl together with heroin or alone. Comparing the costs is different because they have different potencies between heroin and fentanyl. If we use the morphine equivalent per kilo, you can see the price before it enters the USA, as wholesale prices. You see that 50% pure heroin is 10,000 dollars, while it’s 100 dollars for fentanyl. The profit fentanyl can bring traffickers is striking.

The tramadol crisis, in terms of prevention, and supply control: working on the price, keeping the market through law enforcement may be efficient and effective for tramadol. But for fentanyl, it’s actually counterproductive because increasing the price of heroin would increase the incentives from traffickers to move more towards fentanyl. In terms of prevention policies, people should understand the harms in schools and others, that would work for tramadol. But we need to balance this with the issue of accessibility for medicinal purposes. Tramadol is a great substance for treating pain. For fentanyl, the typical prevention message doesn’t work. People are not looking for fentanyl, so how can we prevent users from accessing fentanyl? It’s much more challenging than for tramadol.

Afghanistan: When you say heroin has been replaced by fentanyl, what do you mean? Do users know they are buying fentanyl or are they trying to buy heroin but find themselves with fentanyl? The second question is price: do you say that if we increase heroin prices traffickers will turn to fentanyl, but then if we lower heroin prices, won’t we have more heroin users? If you can control heroin, and increase its price to a level impossible for users to use, then you wouldn’t have as many users. In terms of supply-driven markets, what do you see as the future? There is a different picture now that is very dangerous. What do you see happen in five years? Some countries like the USA, Canada and Europe are greatly affected, what would happen if the same happens in Africa and Asia? Should there be specific steps taken to manage the situation of the opioid crisis?

Finland: Since Finland was mentioned in the context of buprenorphine, I wanted to say something. In Finland, the national supervision authorities follow up on prescriptions and there are evidence-based guidelines and e-prescriptions. There are challenges too, prescription drugs sometimes end up in the illegal market. Those end up being smuggled from other countries. If you have any comments on this, it would be good to hear.

Mexico: Could you show us your first slide again, on the relationship between natural opioids and synthetic opioids? We know that there are increasing types of opioids coming to the market, which are generally adulterated. I want to know at which stage you consider a substance no longer being natural, when does it move from one category to the other one? Second question is on the next slide on lives lost, drug related deaths: are you only talking about drug users or do you also have numbers including drug-related violence?

Angela Me, UNODC: First question: it’s hard to understand when one substance replaces another on the market, and here I gave the examples of Estonia and Finland. When fentanyl reached the market in Finland, the users didn’t like it, so it never took hold. In Estonia the users did like it. If you have a group of users starting to like a substance, that’s when it takes hold and start replacing another substance. But there is also a supply-driven issue. In North America, fentanyl is replacing substances in some states, but not in others.

On the lower prices, what I think here is you’re right: if you don’t think about keeping the heroin price high, the response to the problem is different in different contexts. When heroin is the main market, we should do everything to keep the price high. But when you have a mix between fentanyl and heroin, you may unbalance the chain and it might be counter-productive.

On what to do: that’s the hard question. On cross-border cooperation, I hear the Nigerian colleague in terms of how important international cooperation is.

For substances, these are single compounds, that define plants. Synthetic is when you have no natural elements. There is no name yet for a substance that is half heroin and half fentanyl. People who know more chemistry than me can provide more information.

On number of deaths, it only focuses on deaths related to drug use.

United States: We think it’s useful to get data and compare experiences in areas where there are similarlities in the crisis. On the idea that fentanyl is supply-driven, what we have found that while demand remains, traffickers adapt their methods and there are now fentanyl analogues now to meet the demand. So demand reduction is a key part of our response. I want to ask: users are often unknowingly aware of the presence of fentanyl. So is prevention of typical drug use valuable in combatting this crisis?

Nigeria: Sometimes when I talk about the tramadol crisis, it is with mixed feelings. I am emotional because of our experience of watching the epidemic. Sometimes young men stop you to ask if you’re there to buy tramadol. This is an epidemic across Africa, across Asia. There seem to be a kind of understanding because of the importance of tramadol for people in Africa, the idea of introducing some kind of control is very important. We think that every drug policy should evidence-based. If the harmful effects of a drug are not reduced, they should be scheduled. 4.1 million people used tramadol in 2017 alone. The figure might now have tripled. Terrorists use tramadol too, as well as farmers using it to work for many hours at an end. The challenge is enormous and there should be a regime change in the way we view tramadol. We have focused more on seizures so far. Sometimes these seizures are tramadol tablets beyond the medical dose. People take those to commit crime and put the lives of citizens at risk. Data collection should not only focus on dependency syndromes. It should also focus on the impacts of tramadol use. Is there away, in collecting data, to increase the capacity of practitioners to focus on the harmful effects of tramadol, to convince people to schedule tramadol?

Slovenia: What we think that in some countries there is strong advertising of opioid medicines. This pushes doctors in a bad position faced with clients who want access to medical prescription. We may agree here that we should prohibit advertising of opioids around the world. It is the way physicians can better control prescription of medicines.

Canada: I want to emphasize my delegation’s gratefulness for the secretariat’s preparatory notes. On the number of deaths and lives lost: hepatitis and HIV are a big part of those. The CND has adopted a number of resolutions on this, giving it emphasis. In 2008 alone, there was 1 Canadian dying every hour. You also mention that traditional approaches are not working on fentanyl. In 2016, we amended our drug strategy to add a fourth pillar: enforcement, prevention and treatment, adding harm reduction. This was used to inform our drug strategy, especially faced with the fentanyl crisis. We are adjusting our approach using all evidence-based policies that currently exist.

Angela Me, UNODC: On the USA: preventing people from using drugs is a start, it helps reduce use, harms, death. But what I meant is that the spiking number of deaths focusing on fentanyl and analogues, reducing that higher component, is difficult. The user is not aware, so how can we prevent it? I cannot agree more with Nigeria on the need to increase and improve data on deaths. What I present here is death data in North American and Europe. But improving systems to have drug-related deaths in other regions is very important. On advertising opioids, I mentioned how difficult to keep a public health perspective if there is a powerful business sector, it is also the case for cannabis. You have two contradicting objectives.

National Drug Law Enforcement Agency, Nigeria: The issue of non-medical use of synthetic opioids is something that has continued to evolve. Most of the times, these are drugs sometimes allowed for medical use to cure certain diseases and illnesses. Experience revealed that those who use these drugs continue to experiment with other drugs. We need to increase our capacity to share what we have discovered on people who use drugs. In West Africa, especially in Nigeria, drugs that pose most problems are tramadol. We also have issues of consumption of cannabis, and codeine preparations. The abuse of these drugs is significant and delicate because of prevalence among youth. There is also a dangerous trend: married women are drawn into the use of these drugs. This is very dangerous because it is against the customary rules of our country. The use of these drugs by married women include people who are in seclusion. Patterns of use range from a single drug, or as a cocktail of drugs, with consequences for society at large. Some record the negative effects of tramadol on individual drug users: hyperactivity, erratic dispositions, sleepiness and death. As pointed out earlier, it induces a lot of dependency. We don’t have sufficient statistics to show this. Deaths have resulted from use of tramadol. We have also had situations where seizures have been concentrated in the north eastern part of the country. Boko Haram activities are concentrated there, as well as banditry. There is a link between these insurgencies and tramadol consumption. Tramadol is the second most used drug in Nigeria. Tramadol seizures have revealed many dangerous patterns. About 250mg per tablet of tramadol have been discovered. We have statistics on tramadol seizures for 2016, 2017 and 2018. The problem we have is the regulatory challenges that exist in Nigeria, because tramadol is not a scheduled drug. The law that criminalises drugs says that only drugs included in the UN drug conventions can be criminalised. So this is an issue for tramadol because we cannot criminalise it. We have done some reforms to circumvent these challenges. The agencies responsible for drug control (drugs and food/drug administration) have seen how they could cooperate to overcome these legal challenges. There is a threshold of 50-100 mg for legal tramadol. Any tramadol above 100 mg is treated as illicit trafficking that can be seized. This method has yielded dividends in terms of seizures and prosecutions. At the same time, we have two conflicting decisions on this case: in one decision, we took judicial consequences of tramadol and we will treat it as a narcotic drug. In another case, the court of appeal in another judicial division looked at it legalistically, and since it’s not covered by the law of the agency, the conviction was overturned. We are yet to hear back from the Supreme Court which will give a final decision on the matter. But we have a very dangerous drug and have a legal system where we don’t know whether tramadol is licit or illicit. We look to the UN to see if tramadol can be scheduled. We want to explore the possibility of amending Nigerian drug law to schedule tramadol. But we still ask the UN to consider the scheduling of tramadol as a narcotic drug. We noted that the WHO has recommended against the scheduling, but the problem is that tramadol, which has extensively been documented to be the most trafficked narcotic drug in Africa, is not recommended for scheduling. We want the authorities to look into scheduling.

India: Coming from India, I must draw the attention of the WDR of last year: most of the tramadol seized worldwide between 2012-2016 originated from India, and then China. About 87% of tramadol seized in Ghana in 2016-2017 originated from India. I don’t want to go into details, but India’s government has placed tramadol as a psychotropic substance under our drug law. In Nigeria you are constrained by the fact that you cannot do so. We did that in India. From 26 August 2018, tramadol was notified as a narcotic. Anybody exporting tramadol can only do so through an export authorisation and the narcotics commissioner will only do so if he gets a corresponding import certificate from the importing country. If not, there will be punishment of up to 20 years depending on the quantity. The challenge is that we are still not exporting tramadol: no export authorisations were issued this year. Half of countries control tramadol, half don’t. For those who control tramadol, they have import certificates so we can check. But for those who do not control tramadol, we still use due diligence despite the lack of import certificates. We work with INCB, but we cannot hold back on exports of tramadol indefinitely. I can’t agree with you more. To be really effective, some form of international control is necessary. It is up to the international community to stand up.

United States: We have had seen tramadol issues a number of times, but we are stuck. We get recommendations from WHO which has sided the utility of tramadol as a medicine, and scheduling would impact on availability. It’s important we ensure, as part of our convention responsibility, that drugs having medical utility are widely available. But we need to take steps to ensure they are not abused. Your presentation shows the importance of doing our upmost to schedule drugs nationally. We also need to shed light on what the real harms are. Having no access is one side of the story, but when you have terrible abuse, then we need to have visibility on this too. This shows the important tole of governments, of WHO and the INCB charged with making sure drugs are available. We thank the INCB on their work on availability but ask them to take a hard look on the argument that scheduling somehow reduces availability and ask them to get us to a place where we can schedule tramadol as we do in the USA.

Algeria: Scheduling is very important from a legal perspective as it has repercussions on international cooperation and organised crime. It requires such cooperation and actors should be incriminated in both countries. In Algeria, we witnessed legal problems for certain substances abused by many youth and are mixed with coca cola drinks. These substances were not controlled internationally or nationally. This also applies to tramadol. But in Algeria we don’t have large seizures of tramadol. We have tried to amend our drug laws and have already drafted a law. Some mechanisms included were to set up a national committee within the ministry of health to reschedule substances on the basis of research. Other laws include the regulation of psychotropics, to create an electronic centralised prescription from the ministry of health to control prescription and dispensation at national level as part of anti-narcotics efforts.

Ghana: Tramadol in Ghana is a prescription drug and the registered strength is 100mg or 50mg for the country. I am not hearing of demand reduction to the drug issue. Some of us believe strongly with a good demand reduction programme that will either delay or that people will abstain from using drugs will go along to help with the drug issue. Today, it is tramadol that we are finding a solution to, with suggestions that it should be scheduled. Tomorrow it could be another medicine in use, Tramadol us one of the opioids that you could gain easily with prescription. But strengths of 200mg have been sighted in some chemical outlets in the country. Doctors also do’t prescribe it as a pain reliever simply because of abuse and tramadol is the only one available. It is high time that harm reduction is taken up seriously. Sanctions will have to come in but it has to go in tandem with harm reduction which will help all of us.

Chair: Thank you. Now Nigeria for any response.

National Drug Law Enforcement Agency, Nigeria: I agree with the comments by India. I made the point very clearly. We are still engaged with international control of tramadol and we are in the process of amending our law, but it has to be standardised across the globe. With respect that the drug is also used to cure some diseases- that is agreed, but the INCB also try and place a balance between the use of this drug and the capacity of this drug to be misused with a serious consequences on individuals and society. Once the supply chain is created, the availability issue will be solved. We also have drug regulation- 100mg and 50mg. We have also seen 200mg of tramadol. This is why there is need for international control due to the harmful effect on health and society. I agree that there is drug reduction but it also has to get balanced with supply control.

Sri Lanka (Panellist): Drug market of synthetic opioids is constantly changing, they are not being picked up and are under-reported. The sale of prescription drugs over the dark net needs to be highlighted which presents a serious challenge. Encryption and concealment through money laundering etc cause more challenges. We need to identify the critical deficiencies. Areas need to be explored; develop more effective measurable indicators to measure the drug problem and measuring the appropriate actions of member states.  Examine the current policies and address the root cause. The government of Sri Lanka has recognised that it should be addressed through multilateral setting. We conducted an expert meeting on expert balance and scientific strategy in March this year. We tried to gather drug related agencies and expert scientists to identify challenges relating to drug prevention and control and ways to overcome them. We also engaged in the establishment of an STI platform- a multi stakeholder online channel to work together with INCB and NGOs. We have taken action to prepare guidelines on science advice on drug policy making. We would like to get technical advice from UNODC and other expert agencies. We have created a sub-committee under NDDCB to improve scientific advice. There is evidence that the practice of mindfulness is impactful in treating drug abuse, with many studies published showing the effectiveness. We are in the process of finding out how mindfulness will treat the root cause of the problem. For therapeutic applications, Mindfulness is being practised in schools and prison settings. We would like to share a video on the effectiveness of mindfulness in school settings.

Chair: Thank you. The floor is now open for any comments or questions. We will go ahead with the programme. We have a video presentation from the Eastern European Group.

Adviser of public health department, ministry of social affairs of Estonia (via video link): We are one of the few countries where the legal drug market is dominated by Fentanyl. Estonia was hit by waves of overdoses due to this. It was thought that this would stop once the supply of heroin was restored. But we have since learnt that the lack of action taken has led to a lot of lives lost. Fentanyl is 100 times more potent that heroin, and can have fatal consequences when mixed with other substances leading to overdose. Now fentanyl deaths are more frequent that traffic accidents. Fentanyl is found online and the illicit market. There is a concern when it is mixed with heroin and counterfeit medicines. There is a threat to those who use and those who manufacture. Users are at a huge risk through lack of tolerance, large doses etc. Skin contact, inhalation and injecting poses a risk which puts family, friends, law enforcement etc at risk. Several future actions need to be taken: more insight is needed of health consequences, more research into treatment of fentanyl addiction. Schemes might need to be reviewed due to the higher risk of users. Countries not yet affected should stay alert. Systems should be developed to provide more information. There should be international cooperation to use naloxone including non-medical professionals. The  identification of fentanyl should be more sophisticated to detect it more precisely. People who might be in contact should be trained to prevent accidental exposure. There is a need for holistic approach which includes; monitoring control, early detection, prevention, harm reduction and treatment.

Permanent mission of Australia (panellist): The Australian context is similar to what has been described previously and the strategy we have employed and some of key steps to implement the strategy are also similar. Australia has a population of 25 million people. We have seen an increase in opioid induced deaths. These are not historical peaks- The numbers were higher in the 90s, but we have seen a significant increase. In 2016 there were 1045 opioid deaths between the ages of 15 and 64. 2/3 of these deaths were linked to pharmaceutical opioids. ¼ were heroin related, 11% were a mixture. Rates of death have increased from 1 per 100,000 people in 2007 to 2.2 per 100,00 people in 2016. For synthetic opiods, fentanyl and tramadol has increased from 0.11 persons per 100,000 in 2007, to 1.34 persons per 100,000 in 2016. This is a 12 times increase in 9 years. Our national drug strategy looks at alcohol, tobacco, other drugs- and looks to bring threats together. The national commitment is harm minimisation- balance view of harm reduction supply strategies. Australia put AUD 780 million over 4 years towards implementation.  We have a drug alcohol programme that funds treatments services, education, research… Having the right information being collected. 2/3 of the money is being put towards investment to primary health networks- independent groups funded by the government.

Opioid dependence and deaths: We have taken a number of steps- real time prescription monitoring: Whilst the state bodies were monitoring themselves there was forum shopping across state borders. Rescheduling products like codeine which means regulating it. Australia response to pharmaceuticals: key steps to develop online real time monitoring system- electron recording which will monitor use and misuse of controlled pharmaceuticals. This will feed into real time assessment and other work we are looking to fund such as research institutions.

Synthetic drugs: The main issues is there is a wide range of substances available which change daily. In 2015 we introduced laws which banned importation of synthetic drugs on the basis of psychoactive effects. The means that we have not banned specific substances which makes prosecutions more challenging. But it also opens up laws to a broad range of drugs. It seeks to ensure that dangerous substances cannot be imported as alternatives to other illicit drugs. We are key contributors to UNODC- they are a chief partner. We have worked with them on the SMART programme since 2008. There are two takeaways from this talk: Our strategy is about targeting resources which need them and a collection of real time information. This cannot be underestimated. We cannot base decisions on old data. Collection and analysis of info is key to tackling this problem.

Chair: The floor is now open to questions. Thank you.

Miss Broggiato, International Association for Hospice and Palliative care Care (IAHPC): Access to essential medicines is governed by 3 drug control treaties, yet they are unavailable in more that 70% of the world’s countries. The lack of access in invisible to UN bodies as measures of human suffering have been absent until now. Countries are reduced to lines on a map used by INCB in 2018 annual report. It is fuelled by lack of trained prescribers and weak supply chains. This issue is overshadowed by the crisis of non medical use in North America where there is aggressive marketing by big pharma and poly drug use. Harm reduction is largely unavailable. Is there any improvement on distribution of opioids? INCB data shows that expensive opioids has not been matched by use of affordable morphine by low income countries. Access and available to opioids remains a challenge in many countries where patients suffer and die in agony. Policy makers respond to the US crisis by tightening legislation rather than improving training. Most current evidence show that there is no correlation between rates of medical prescription, illicit use and overdose. Germany has the second highest opioid prescription writing in the world. This mirrors that of US, but Germany’s overdose rate has been among the lowest in the developed world. Germany has a system of Universal health coverage. It Implements drug dependence treatment, harm reduction services, rehabilitation programmes. In Uganda, procured medicine and supplies are at no cost to the hospice for trained nurses to prescribe.  Seizures come from illicit sources. IAHBC welcomes UNODC strategy which addressed the complexity of both opioid crisis. Disappointed that prevention and control have been well funded by North America. Yet, the access pillar has hardly no funding. We encourage Member States to remedy this, and contribute to this.

Chair: The floor is open.

Mexico: Addressing the health and public safety risk-there is a myriad of recommendations throughout documents. For example para 29 2009. Action 32 plan of action para a,b,c. For the last 10 years have been undertaken by WHO, Member States etc. but we should question if some of these commitments they should have been implemented before. Many of them considered fully implemented eg sharing info with WHO and incb. Are we doing enough? We are clearly not, but are we having the right approach to the problem? CND are being alerted to the changing of synthetic drugs, increasing risks for users and mortality, health workers etc. What are we going to do about it for a better response to this challenge which is one of the biggest that we are facing within the world drug problem.

Russia: We have touched on an important matter relating to palliative care, which is a key priority for Russia. In March, Putin signed a law on using psychoactive substances for palliative care. Citizens are guaranteed palliative care and access to analgesics as an in-patient and out-patient. Civil society organisations are helping us and we hope to learn from their experiences. CND knows that a special resolution was adopted and we hope that this topic will continue to be a priority.

Belgium: Thank you. This has been an important topic for Belgium . We continue to support this discussion and the need for highlighting this issue about the difference between misuse and the need to use to tackle pain where there is no access to opioids. We are optimistic because UNODC, WHO, INCB have shown good results. We see that Member States from CND and UN have made commitments and is seen as more of an urgency. This is thanks to the latest report from INCB on access an availability. We believe can tackle this issue by allocating resources. We would like to thank other states which support the work of CND in this issue.

VNGOC: Thank you to the delegation for the support on the topic.

Chair: Thank you to the panellists. Now we give the floor to Mr Christian from OECD.

OECD: I will be presenting about a recent study for 1 year, commissioned by Canada. Is the first project where we tackle the topic of drug related issues. It is the first and we try to take the approach combined which has been the discussion of the legal and illegal side. What is the magnitude of the problem of OECD in 36 member countries? 25/36 of the member countries have collected data and we are doing a policy analysis of these. For 5 years, opioid related deaths have increased by 20%. This is not only the case in US, but Sweden, UK etc are experiencing substantial increases. There are 4 main factors fuelling the opioid crisis: The health system- various reasons in different counties. There has been a development of a culture where opioids were safe and not going to create dependence issues. Doctors wanted to help their patients and this was the tool available. Opiates were the main tool and were safe.  Over prescription was very strong- has been pushing the increase of prescription. Doctors and patients have a lack of alternatives to treat pain- very important. There are other tools but they are insufficient to manage pain.

In the illicit market of opioids there is a higher availability and higher purity. Polyuse of substances is the cause of the majority of opiate related deaths eg mixing with alcohol, cannabis. Opiate use is also linked with mental health- eg data from USA shows that people with mental illness received more dosages of opioids.

According to INCB data, the availability of analgesics increased by 110% in the 2000s. The USA have decreased its availability, but other countries have increased it and is growing. For example, the growth is larger in Israel and the UK than other countries. OECD countries such as Iceland and Luxembourg have higher numbers of prescription of opioids that other countries. Chronic opiate use is for more than 90 days. There might be clinical reasons for this, but sometimes this needs to be revised. In 1/16 of surgeries eg wisdom teeth extraction, knee surgery- if you give opioid medication then they will end up being a chronic user.

Patients with opiate use disorders: There is strong evidence that medicated assisted therapy help patients.

This has not yet been presented, but social conditions and the economy has an effect. For example, high unemployment rates are linked with more opioid use. More use of health system eg emergency services due to overdose and deaths. It is the same with housing- people with homelessness and housing related issues. These issues are all related to social exclusion and stigma which needs to change in society more broadly. We propose 4 policy action areas- health system- prescription monitoring programmes, clinical practice guidelines- health literacy increase to patients and society. social policies- You need to address employment support, housing support. Area of regulation and enforcement. Information and knowledge- need better data, invest in research and development.  Regulation and enforcement actions: registration of precursors, air security- eg Canada low weight mail. Medication diversion- inspection and regulation of parties. Criminal justice system- good Samaritan laws looking for assistance without facing criminal offence, legal status of drug use. Availability of alternatives- This has been decreased lately and more focused on the opioid side. This needs to be revised and we need more research.

Opioid disorders should be considered a chronic health condition. We need better prescribing and care, intersectoral coordination, knowledge and research that needs to be led by governments to steer to what is really needed not just for the private sector.

Chair: open the floor for questions and comments.

USA: Thank you…What we take from your research is that how we get to these crises is not a single path. We all have examples of people going to their doctor for valid reasons and they unknowingly prescribe opioids. Could not agree with you more regarding more research across the board. Governments needs to step up and focus on research and not allow the commercial market to dictate. The USA put money into treatment and prevention- 2 million individuals are addicted, and we provide treatment to 1.5 million of those. Number of deaths we experience- we are happy to report that for the first time in decades there are fewer deaths than an increase. If we provide the services then we can get control of this problem.

EU: Thank you… have you any plans to follow up the situation and make a report after a period of time? Do you think this will be manageable in the future?

Canada: Agreeing with US delegation and thanks.

Spain: Thank you…We clearly understand the concerns raised. It is similar to that of heroin which devastated Spain during 80s. This led to the creation of government delegation of national control plan. Those of us who were present and witnessed the situation in 80s are still here, and the situation has improved. Changes were made to the health care system and is a form of success in dealing with the situation. Coordination with NGOs and civil service has an impact on improving quality of life and had positive impacts on HIV and AIDS cases.

Netherlands: Thank you…. We noticed that the number of people who use opioids has tripled in The Netherlands. We are monitoring very closely and have initiated actions. One of them relates to cooperate to work together. We appointed a task force consulting medical professionals, to turn around the trend. We have developed materials for doctors and patients. We have received our first positive results- 2019 decrease in number of patients who use strong opioids. In 80s, we also had a heroin epidemic- learnt a lot and no one silver bullet to take the challenge. We need to tackle from all angles- needle exchange, assisted treatment.

OECD: The holistic approach needs to be addressed: the USA’s and Canada’s actions are pointing in this direction and can have an effect in the short term which is something other countries can learn from. On top of more research, need to think of future access- we are working towards this. In response to the EU- we will continue monitoring data coming from health systems and publish regularly. We see an area where would like to gather support- what is the most cost effective policy to approach this issue?

Substance abuse specialist, Russia:  It is the 110th anniversary of Shanghai Commission on opioids. The media didn’t cover that event much and I fear that despite what we have achieved, we may be moving towards legalisation of narcotic drugs. Previously it was difficult to find shops where marijuana was on sale, now we see such shops in the most central streets of Vienna with open sale. That is a somewhat sad situation. The main problem is to maintain a balance of control and accessibility for medicinal purposes. Some time ago, we were experiencing this problem. We had harsh narcotic drug control. But starting in 2015, measures were undertaken to improve availability for medicinal purposes. Narcotic drugs can be used for anaesthetic and analgesic purposes Many different types of substances used and the entire spectrum of drugs are used in Russia. The control of drugs are quite strict- need a license, accounting in quantities of substance- special prescription- ban of advertising of narcotic drugs for pain control. Pharmaceuticals are not allowed to promote their products in any way in the retail segment as they are not allowed give incentives to doctors to prescribe certain products in their practice. Russia participated in discussions on standards on drug use and disorder treatment and recommendations adopted but there is an issue- no medical speciality that is responsible for implementing these recommendations. Another problem is identifying new narcotic drugs. We need to exchange data and libraries. There is very little use of tramadol.  Patients in clinics-15% abuse alcohol but 60% are abusing prescription drugs without having prescription. This needs to be discussed and we need to train interns in early identification of these problems. We have legislative provision of annual drug testing ages 13 to the end of school. This is a urine based test. We carry out early identification in the workplace and in hospitals. This is a very comprehensive system. We don’t use methodone, but we use naltrexone broadly which is a US substance used in conjunction with psychotherapy and produces good outcomes. We launched an overdose prevention programme and the patients that attend our clinic receive 2 ampules of naloxone with instructions. We introduced medical genetic consultation. During meetings here, we have had presentations and coorporating with USA on genetic research and we like this collaboration. We test children and provide recommendations on how to bring up the children to personalise the upbringing and education of children. In terms of future outlook, we need to work on creating and training specialists, parents and people in related areas. Parents know almost nothing about drugs, youth and subcultures that encourage drug taking and we need to have international recommendations on that.

Chair: I open the floor for questions.

Iran: Interesting presentation. In reference to a genetic study, it is a public study or are the people subjects to this study. Could we receive some information on that,.

Russia: Yes this is a state research programme for the moment. And it has not been rolled across Russia in a mandatory way but it is a budget funded research centre carried out in Moscow narcotic centre.

Afternoon Session

 

Chair: We continue with a video message we didn’t have time for yesterday

UNODC: Laos is located at the center of the so called golden triangle with a number of isolated communities that survive by cultivation, they are poor with limited access to education, markets, and other tools for socioeconomic development. The community we work with consists of 281 families. Leaders learned from their parents how to make their livelihood. They are using opium and you will hear stories of how locals are affected by the devastating stories. We asked about AD and they told us coffee prices were set by the only trader that comes to the village and that was inconsistent. Women weave and some told us stories about beginning to experiment with coffee but they were left alone – 12 villages told us the same stories. A lot of factors led them to stick to what they knew best, growing opium. They needed more tools to take charge of their own path and not rely on outsiders. They were not able to make meaningful changes alone. Previously isolated villages started to come together and received trainings together. After a year, they sent representatives from each village to discuss a more formal collaboration and some hundred families signed an agreement. We helped them access tool to grow a high value product. The first 260 families joined the coffee program in 2016. 381 families are in the process of establishing a cooperative. The first harvest is approaching – 20 tons of green coffee beans. We helped them access technology – primary processing facilities were built and UNODC colleagues will guide the farmers through the harvest. While the community is in early days, but farmers are becoming experts. They have access to equipment and infrastructure. They are experiencing a strong community and will sell their first coffee soon that ensures an annual reliable cash income. We are working with local authorities so our lessons learned will be useful in making policies.

EU: Synthetic opioids and the non-medical use of prescription drugs pose different challenges all over the world. 63 new opioids have been detected on Europe’s drug market and are monitored by the EMCDDA. This only concerns a few states but we see an increase in drug related accidents. It is difficult to plan public health responses and schedule generically. Policy that is balanced and evidence based is needed plus it needs to be comprehensive. Sine 1997, the EU has the capacity to detect and respond to the emergence of NPS. Since 2018 our new legislation strengthens this effort. Reliable data is a base for our work – we support the ARQ update. The ECDDA will continue their work and we courage UNODC to continue to work on the integrated strategy and collaborate with INCB and WHO. Overdose deaths are an indicator of the danger of drugs though it doesn’t affect EU as other regions. These are preventable deaths. OST, overdose risk assessment, etc… harm reduction responses. 6 EU MS provide high level harm reduction services. It is important to protect citizens from health and societal dangers. The misuse of medicines: experience shows benefits of a combined action – awareness raising, professional training, quality insurance, monitoring. EMA has taken steps to provide sufficient information, authorize medical products. We are to make sure access to pain medication is ensured for those who need it.

China: prescription medicine and misuse of such is not a new problem. In China, we are not facing a severe problem, the misuse of Tramadol – some of the so-called smart drugs have posed a danger on our youth. They take it before examinations. Most of these drugs are from outside of China and they substitute mainly amphetamine. Many of the drugs are sold online and different tools are used to sell the drugs. Some foreign students and Chinese exchange students upon returning bring these into the country. Since 2018 we have more and more people dependent on these drugs. Other compound drugs which are usually used as a treatment for diarrhea are also often misused, this is not a mainstream problem but they do reflect the trends. With the development of technology, the problem is growing.

UNODC Opioids strategy and toolkit:

UNODC Laboratory and Scientific Section: We have a lot of existing resources inhouse, but in order to not just give a suitcase of hundreds of manuals, we divided it up strategically. Forensics Module: presumptive testing and lab analysis; eg. test kits for drugs and precursors, handheld devices and guidelines for use, quality assurance, reference standards.

SINCB: Precursors Module: information about the control system, licit trade and suspicious shipment monitoring. We have a public website and a secure part of it is only accessible to government officials. I will not go through all elements of the toolkit but you can see all relevant resolutions and schedules here. There also some encouragements relevant to the scope of controls, a red list and links to materials from the lab section (eg. a multilingual dictionary). Other chemicals used in illicit manufacturing is on the limited international surveillance list. There is also a directory of substances and how they are controlled on national levels. Quick guides to voluntary cooperation with industries is also on the secure webpage. Investigations and discovered points of diversions can be found here too. It is a living tool.

Universal Postal Union: (Mail Security Module)
The Universal Postal Union was established by the Treaty of Bern of 1874, is a specialized agency of the United Nations that coordinates postal policies among member nations, in addition to the worldwide postal system. The UPU contains four bodies consisting of the Congress, the Council of Administration, the Postal Operations Council and the International Bureau. It also oversees the Telematics and Express Mail Service cooperatives. Each member agrees to the same terms for conducting international postal duties. The UPU’s headquarters are located in Bern, Switzerland. On the website, you can check out our security strategies and a roadmap for countries involved. Cooperation is paramount especially when it comes to drug trade. Primary transport is via air, so we utilize partnerships – UNODC is a key component to this, as well as the INCB through which we deliver trainings. Our key priorities: prevention of injuries of people (due to carrying dangerous packages), prevention of loss or theft, preservation of confidence. 2017 in Ethiopia, we established minimum security standards to protect the postal system and the supply chains involved. Suspicious mail poster is a traditional educational tool to detect possibly hazardous packages and a process to notify authorities. We are building capacity for posts to collect more data and share them with the right parties to help business flow and customs.

USA: We encourage countries to use these toolkits and report back on their experience. Thank you for the work done so far.

Canada: Are there any specific guidelines developed by the UPU regarding handling of NPS that you found in the mail(s)?

UPU: It is continually improving… we are dealing with quantities and substances that are easier to spot. So, yes we do – we are trying to get more information so that we can analyze and generate knowledge. It is a key component to what we do.

UNODC: we have a continuous plan for the toolkit. Feedback helps us.

Belgium: A number of modules haven’t been completed yet so I would like to know what is the impact of the program as it is yet? We hope it will be finished as soon as possible but does the presentation apply to the completed modules?

Interpol: We have an agreement with USU since 1997 which shows mails were targeted for criminal matters for a long time. Information sharing is crucial so we really wish to compliment CND for inviting UPU.

UNODC: the toolkit was launched in March and so far with the available funds, we pulled together 4 active modules. We are preparing new modules and the training is independent from it – it is a standalone tool. We are hoping for more contributions so we can activate more modules.

UPU: Thank you Interpol, you hit the nail on the head.

UNODC Prevention, Treatment and Rehabilitation Section: SOS Initiative. Thank you, USA for funding the program. Opioids are the most harmful drugs – HIV, overdoses, etc. We saw a 53% increase in affected persons, a tragedy. We read about a story where people were smoking fentanyl with closed windows so the police had to rescue a baby. I also met a girl who had to administer Naloxone 4 times in one afternoon to her brother. The morbidity associated to non-fatal overdoses is tragic: respiratory complication, brain damage. People are shifting from heroin to fentanyl and other synthetics that affects the life-expectancy of the US population. Women are showing an increase in heroin and opioid overdose deaths. Who are at risk? Opioid dependent, especially people released from prison, rehabilitation, people who inject, who use alone, people with medical condition, people living with a person living with opioid dependence. When we talk about preventing overdose, we need to improve prescriptions, treat people who are affected, strengthen emergency responses. Stop-Overdose-Safely (SOS) program aims to raise awareness about the importance of access to naloxone. WHO already has their guidelines released already. Globally, access to treatment is limited, only one in seven who need it will receive care. Overdose is simple to identify; it will have the appearance of death – people tend to be alarmed even though a reversal procedure is very simple: we administer naloxone. It removes opioids from the receptors on the brain. It has been kept in ERs or ambulances, there seems to be a scare around it. It can be injected through the clothes; intramuscular or inhalation and even self-administering is also possible.
UNODC/WHO Discussion paper from 2013 based on CND resolution 55/7 to prevent overdoses and improving treatment of opioid overdose. Raise awareness about Naloxone: it is a harmless medication; it can be safely distributed. WHO guideline for the management of opioid overdose on the community level, 2014: promotes the training of laypeople, it enables anyone to save a life. We are called to act to work on the prevention of overdose, especially through the promotion of the use of Naloxone. 90% of people who are likely to witness an overdose are trained within the SOS initiative. 90% of Naloxone carriers are using it. This requires broad mobilization, peers and surroundings of people who use drugs. Anybody can be trained to respond. We are currently undertaking a feasibility study and assessing the impact. We implemented it in 4 countries in Eastern Europe. 6500 take home kits have been distributed. Response requires of involvement on all levels including policy support. Opioid use disorders, especially in prison settings need evidence-based prevention, treatment and care. Promotion of alternative of incarceration also can reduce the number of impacted people.

USA: Naloxone is a critical piece of our response; we are taking steps to remove barriers from accessing Naloxone. We are providing support to people who might witness and overdose, to first responders in states, tribes and communities. We are working to increase awareness and we promote the SOS initiative. Loss of life is a tragic element of the world drug problem. We look forward to hear more of the results of the pilot study.

UNODC: Our work is hand-in-hand, the components of the program reflect the responses in the US.

Slovenia: This program is typical harm reduction program. Harm reduction is often not a very welcome word in this room. Naloxone is not enough, we need safe injection rooms as those save a lot of lives, we have to know that even though people use drugs, they need help.

UNODC: Indeed, safe rooms are one of the nine key interventions in our guidelines. SOS consists of many other elements, we promote the treatment of drug use disorders. Effective and evidence-based treatments, of course.

Russia: Thanks for the detailed presentation. Within CND we do talk a lot about Naloxone, it is an important resource. At the same time, we feel this is just a step. We would like to have a professional, deep discussion on rehabilitation.

UNODC: I would like to refer to a previous intervention: there will be a comprehensive guide from the perspective of prevention and treatment. In the meantime, we developed a wide range of tools that offers comprehensive tools. Naloxone is an emergency antidote but reintegration and recovery are an essential measure. We need to save lives though, when someone is having an overdose, we have seconds to act.

WHO (via video): On the module online, you will see the description of the conventions and what it obliges signatories – schedules and the protection of pubic health. ECDD assesses risk of abuse and harms. ECDD also assess whether a substance is available for medical use. This mandate is reinforced by CND. Our standard operating procedures are endorsed by the WHA and operationalizes WHO’s mandate as well as options for countries to initiate a critical review. Data collection and scientific evidence is essential for ECDD procedures – it considers published and unpublished data across disciplines. ECDD relies on cooperation with CICAD, EMCDDA, UNODC, CND and its member states. You will be aware that collection of robust data is a challenge especially for NPS. ECDDA Is an independent scientific body with experts from a range of related fields, they are cleared from conflict of interest, are balanced regarding gender and regional representation. Once a critical review has been carried out, ECDDA makes a recommendation for scheduling by the CND. Last November, the committee reviewed several NPS and were voted by CND to be scheduled following the ECDD process. At the 42nd ECDD, the committee will carry out review of a number of fentanyl analogues. To enhance the ECDD’s capacity and speed, the WHO holds annual ECDD meetings and increase the number of substances monitored.  Thanks for your patience with the technical issues.

Chair: I see no flags raised, we move on with our program.

UNODC Drug Prevention and Health Section: Meeting the health needs of all patients – a balanced approach is not as simple as we often like to think, it is not just balancing two sides. We have the mandate and the tools. Promoting medical and scientific use of controlled drugs is not in collision with protecting humanity from the danger of drugs. You have expressed this many times in many forms, in 2008 and 2016 as well as 2019, plus there are the SDGs. We have many resources but capacity of the health-care workforces, overcoming fear and community awareness are crucial. Inconsistent policy interpretation, lack of data and poor supply chain management are a challenge. I am showing you graphs from Austria and Togo about available morphine equivalents because they have a similar population size. As you can see the data available is very inconsistent in Togo but the biggest difference is the number, they get with morphine access 0.125 which is 500 in Austria.
We have a complex structure that I will not go into details with respect to time. We help MS build health-care capacity, build better data systems and strengthen the control and supply chain. The “five rights” of medication administration: patent, drug, dose, route, time.
National experiences: Ghana: a palliative care approach has become important on the continent level, Timor-Leste: capacity building with the support of Australia, Congo: we work with NGOs for capacity building with the help of Belgium, Nigeria: we work with EU fund and on the national level guidance documents are working the best, Panama: research-focus funded by the US, Mexico: data approach and e-prescriptions. Strategic planning in Central Asia and Latin America, but the issue is that we don’t have the funds to follow-up.
Balance is possible. Cure sometimes, treat often, care always.

SINCB: We have been discussing the issue of overconsumption and availability for years. We were asked to think of public health approach that can address the overprescription of opioids. There is an issue of growing consumption of synthetic opioids. The little amount of morphine consumed for pain alleviation is mostly used in high income countries, only 13% is available for 80% of the Worlds population. Opioid analgesics are overused in the US, Canada and Australia while most other countries’ needs are not met. What is the actual need of the United States? They are consuming thousands more than what they need. Nigeria is covering 0.2% of their needs. There is clearly a problem. Going into health policy, there is a study from the US about risks and benefits – when opioids are used for chronic non-cancer pain, risks outweigh the benefits. WHO has a guide for good prescribing. There has to be instruction and warnings in place, not only on the packaging. Treatment has to be stopped as soon as complications occur. Safer and rational use, training and education – adequate, independent and evidence-based. Alternative medications and treatment options need to be in place. Country level instruments also include monitoring of prescriptions – thanks to the development of technology, this is not an expensive action. Take-back initiatives: unused opioids are often used without prescription. Stigma reduction: destigmatize language, improve the situation in the news media.

Mexico: Last year, we saw an extensive presentation on this matter and we extended an offer for cooperation, we still stand by it.

Canada: INCB representative mentioned stigma reduction and it is worth a mention that we championed a resolution this CND on the issue.  As a preparation of an expert meeting on the topic, I would like to remind everyone of the importance of a wide range of engagement.

Belgium: We think combatting the improper use of medicine and ensuring that the opioid crisis doesn’t grow is based on the controlled use of them. They must be used cautiously and rationally. They must be applied when necessary. When they are used unnecessarily, people can quickly turn to the illegal market. Opioids should be considered as medication and this is an important point when you think about the seizures – there is a need for awareness raising in here too. Thank you for this scientific and reliable information presented, as for the last few years. I encourage all states to make use of the available tools.

USA: Turning to the first report, it is important to get the numbers and get the truth to the availability question, so we appreciate your presentation where you showed the countries where people don’t get the medication they need. This is the explicit role of INCB so we look forward to more of this. We did want to raise one point: we are seeing a number of deaths result from respiratory failures, especially among vaping young people and we are not sure what they are vaping. We don’t have a single component factor that is common to the cases. We had 26 lethal cases of youth, a number of hospitalizations many of whom relapsed. It is a concern. One of the things we should do is alert other governments and make a plea, if any other state has information relevant to understanding this better, we are listening.

UNODC: To Canada, particularly in the African continent, the stigma and fear is so strong that even patients will refuse the medication, so it is not only health professionals. To Belgium, most countries acquired an essential medicines list and these are on it. IT doesn’t mean the listed medicines available in the country. To the United States, I have a 14 years old nephew who challenged us with his vaping so I really empathize.

SINCB: Yes, I didn’t want to refer to specific countries but we do praise Mexico’s e-prescription method. We will continue to gather information from individual MS.

Slovenia: From my professional and personal experience, I can say that it is necessary that doctors follow the needs and not the wished of clients. This is difficult to do in todays society when you have google – there is often times a negotiation between physicians and patients. This is especially true where you have pharmaceutical companies pushing and advertising. Maybe we can start on the level of local communities, that they understand that suffering is not acceptable and it is the state’s responsibility to assure there is medicine available.

Nigeria: I thank the first presenter to summarize the challenges we face in Nigeria. I want to ask the SINCB: have you done research on the disparity regarding morphine? It is not only an issue of accessibility to the medicine, there are cultural factors, social and economic, etc.

Morocco: The importance of preventive actions & need structures for rehabilitation and treatment. These need to be developed in a multidimensional strategy. In Morocco we put in place centers for prevention, needle exchange, methadone substitution. In the context of availability: having an import license before import, follow-up of imports, accounting for consumption and stocks, licensing precursors. Morocco is involved in international control activities and notable in the prisons operation with INCB. We monitor illicit substances online.

UNOD: We have done a significant amount of work in Nigeria across ministries. The health care system makes a big difference, if people don’t have access to that, then people wont access medications. Morocco – excellent!
Prescription medications are not the same in all countries so I urge you to be careful and consistent with your language.

SINCB: To Slovenia, indeed advertising plays a big role. The conventions call for restricting adverts of controlled substances, but it is for the countries to decide how they handle freedom of speech and the social costs of restricting that. To Nigeria, we have been looking into the imbalance I showed you on the map – one particular concern is that morphine should be available at a low cost and some MS have difficulties in acquiring it. One possibility would be to set up a regional hub to respond to the needs of the countries. Thank you, Morocco for mentioning these actions.

Kayoda Adedoye, Society for Development & Community Empowerment: My presentation will discuss the use and misuse of prescription opioids, identifies risk factors for opioid-related harms, describes the recent increase in use of tramadol, heroin and illicitly manufactured synthetic opioids and its relation to the prescription opioid epidemic, describes the impact of prescription opioids on illicit markets, reviews the current state of surveillance systems, regulatory challenges and summarizes recent trends in treatment of OUD and use of naloxone to prevent overdose deaths in Nigeria and Africa.
Using prescription drugs for the wrong reasons has serious risks for a person’s health. Opioids like tramadol, Oxycodone, morphine and codeine, heroin, fentanyl is highly addictive, can lead to vomiting, mood changes, decrease in ability to think (cognitive function), and even decreased respiratory function, overdoses, coma and death are common. The shift towards opioids for pain management led to a dramatic increase in prescription opioid production. What is drug use and misuse? Misuse occurs when someone uses a drug for something other than it’s intended reason. Abuse is when prescriptions are used for the purpose of getting high. Drug misuse refers to the use of a substance for a purpose that is not consistent with legal or medical guidelines, most often with prescription medications. This could mean taking more than what is prescribed, or taking a medication that was not prescribed to you. What is prescription misuse? Misuse of prescription drugs means taking a medication in a manner or dose other than prescribed; taking someone else’s prescription, even if for a legitimate medical complaint such as pain; or taking a medication to feel euphoria (i.e., to get high). In most cases of abuse or misuse, opioid painkillers like tramadol and codeine syrup were never prescribed. Characteristics of opioid medication and how they are prescribed can affect the risk of nonmedical use and other harms. Three key characteristics of opioid medications that have been found to influence the risk of harms include the chemical compound, the formulation, and the intended route of administration. Also salient are the number of pills prescribed and dosage, as well as other prescribing and non- prescribing patterns. Opioid painkillers are supposed to provide pain relief, but there is now a plethora of injuries and deaths because they have been heavily marketed and inappropriately prescribed. Long-term tramadol use is associated with liver and kidney damage. In particular, high doses of tramadol may cause liver failure. Tramadol addiction, like other forms of addiction, can produce significant behavioral changes due to compulsive drug seeking and preoccupation with using it. Opioid abuse can lead to vomiting, mood changes, decrease in ability to think (cognitive function), and even decreased respiratory function, coma, or death. Opioids can be highly addictive, and overdoses and death are common. Even though tramadol is primarily a pain relief drug, non-medical use can produce similar effects to the high caused by heroin. Like heroin, Tramadol binds to opioid receptors in the brain and spinal cord and produces euphoric effects when the drug is taken at higher doses than medically prescribed. Tramadol, legally and legitimately prescribed by doctors for pain relief, are also being taken in life-threatening doses by millions in search of a fix or a release from poverty, unemployment and lack of opportunity. The shift towards opioids for pain management led to a dramatic increase in prescription opioid production. A typical occurrence in Nigeria is that of Oluwole, he had gone out for the night at a local hotel and decided to indulge in the potent mix of codeine, tramadol, rohypnol, cannabis and water or juice. While the mixture enhances the enjoyable high of each drug ingredient, their side effects are also increased leading to a very risky outcome. Reports say after taking his gutter water mix he had a seizure, and was rushed to a local hospital, where he was declared dead a few hours later. Past-year users of opioids were more likely to report chronic health conditions and poorer health status as compared with other drug users or the general population. Access to services to reduce the adverse consequences of drug use was also limited. (DRUG USE IN NIGERIA 2018). Past-year users of OPIOIDS reported higher rates of heart disease, high blood pressure, diabetes and chronic pain. With expensive illicit drugs like cocaine and heroin out of reach for many unemployed young people, they’re turning to a range of cheap options—and concoctions—to get high. The spreading addiction among Africa youth to cheap synthetic opioids brought in from China and India has had much impact recently in Africa. Boko haram fighters in Nigeria heavily use tramadol, factory workers, taxi and long-distance drivers (truck and bus drivers) abuse tramadol to stay strong and active. Also, IDPs who fled attacks use drug imported illegally from India to cope with post-traumatic stress and challenges in camps. Cheap Synthetic opioid like tramadol and fentanyl use is on the increase. Synthetic opioid use is booming, the United Nations, in a drug report that shows rising deaths from overdoses and a “crisis” of Tramadol use emerging in parts of Africa. The use of opioids – an umbrella term for drugs ranging from opium and derivatives such as heroin to synthetics like Fentanyl and Tramadol – was up 56 percent from 2016 with 53 million users worldwide(UNODC). There is another opioid crisis unfolding in African countries like Egypt, Nigeria, Ghana, Libya and South Africa, where abuse of the pain medication Tramadol has emerged as a problem. Drug use and its adverse health consequences is worse in prison settings, where those jailed were “especially vulnerable to drug use and face higher risks of HIV and hepatitis C transmission”.(UNODC 2018) It is now abundantly clear that tramadol and codeine-based cough syrups, use and trends in illicit drug markets have a substantial influence on the public health impact of prescription opioid use. Unlike several other opioids, Tramadol is not internationally regulated and available for cheap (less than $1) at Nigerian pharmacies, which do not require prescriptions. The lack of international regulation also means Tramadol production and distribution has gone on unperturbed in countries like China and India, which have become leading global exporters. The pain relief drug is also flooding other African cities including Cairo and Accra. Indeed, the US State Department declared Benin the world’s second largest destination for Indian Tramadol in 2016.But Tramadol is not Nigeria’s only worrisome opioid. Codeine-based cough syrups, sold locally for as cheap as $3, are also being widely consumed and are available largely due to corruption at major pharmaceutical companies. Monitoring and evaluation of drug use patterns, emerging trends, and prescription opioids (mainly tramadol, and to lesser extent codeine is nonexistent. Nigerian authorities seized shipments of about 2 billion tablet of tramadol painkillers via the ports in 2018, showing the huge scale of the country’s opioid crisis. Recent evidence suggests that Nigeria’s drug abuse problem is not going away anytime soon. The high number of tablets suggests Nigeria has become a transit hub through which the tablets are smuggled into neighboring countries—and it also highlights the scale of Nigeria’s opioid abuse problem. Indeed, there’s a willing Nigerian market of young people increasingly experimenting with and getting hooked on opioids and unconventional mixtures to get high. Nigeria’s government took a public stand in May 2018 with a ban on importing and producing codeine-based cough syrups but search finds show that the ban has not been effective: thousands of packets of codeine are still being seized in random searches. These seizures aren’t likely to put a major dent in Nigeria’s supply of illegal opioids, but they do show up how enormous the market for such drugs has become. A five-point comprehensive strategy for treatment of OUD: includes (1) better data, (2) better pain treatment, (3) more addiction prevention, treatment, and recovery services, (4) more overdose reversers, and (5) better research. Treatment of OUD (use of naloxone to reverse opioid overdose) is almost non- existent in Nigeria and several countries in Africa. The care that people receive is often inadequate, and poor-quality care is common across conditions and countries, with the most vulnerable populations faring the worst. Characteristics of opioid medication and how they are prescribed can affect the risk of nonmedical use and other harms. Three key characteristics of opioid medications that have been found to influence the risk of harms include the chemical compound, the formulation, and the intended route of administration; also salient are the number of pills prescribed and dosage, as well as other prescribing patterns. Opioids like codeine, tramadol, rohypnol are generally cheap and widely available due to unregulated production: Tramadol pills cost less than a dollar and codeine syrups sell for $3 in Nigeria. As a result, young adults are increasingly reaching extreme measures in search of a cheap high. There is a thriving black-market trade involving insiders at some of the country’s biggest pharmaceutical companies. The drug combinations indulged in by youths may differ from country to country, but the symptoms are the same: a lack of opportunities for the so-called youth bulge. African governments are struggling to find a cure to both the cause and the epidemic. Few have adequately staffed and equipped public rehabilitation centers or a coordinated public health response, never mind how to create jobs for Africa’s youth. Gutter water (potent mix of codeine, tramadol, rohypnol, cannabis and water or juice) is a dangerous cocktail of drugs which a generation of young Africans use to get high or fix for relatively cheap; it is a sad tale for a generation of poor, disenfranchised young urban Africans who feel there are few options for a better life.

UNODC Data Development and Dissemination Unit: We will receive feedback from MS this month. We came up with a good product with the help of all participants. Those who are interested can read on the webpage.

Iran: Could we have this draft before the reconvened?

Russia: We agree with Iran, following the implementation of the 1st phase, UNODC shall examine the text and send it out to the MS before December. This way, our national authorities will be able to provide detailed comments.

Pakistan: We agree with Iran and Russia.

Angela Me: Our mandate is to present it a draft to CND based on technical consultations. We agreed with experts that after piloting, we will make changes and after that we will give an other week for the post-pilot draft. Please appreciate the enormous amount of work going into this. If we submit it to CND, we have to edit it and translate it – there is no time for this until December. Are you thinking of a discussion or an update?

Secretariat: CND agreed to receive an update – it is not clear whether the pilot phase will be brought to an end in time. It would be under ‘other business’ and it would be an update. The content of the update will depend on the progress to date.

Mexico: The issue is not on a conversation with the extended bureau, it is about mandates – one from the Ministerial Declaration, other from GA resolution.

Iran: The mandate is clear. The idea is to have a discussion before going into CND. If the report is planned to be ready by mid-December, we are only requesting a little more time.

Angela Me: We are not trying to hide anything; you will have the week when the experts are looking at the piloted draft. IF there are major issues to be raised, that would be the time.

Chair: We will continue with video messages. There is no translation starting now.

Lauren Deluca, Chronic Illness Advocacy & Awareness Group (NGO): Good Afternoon, chair, honored delegates, ladies and gentleman. It is an honor to be able to address you today. My name is Lauren Deluca. I am the founding president of CIAAG. Our organization has been working with the elected officials to help enact rational legislation that would ensure compassionate, patient centered care for those who suffer from chronic illnesses and incurable conditions. Despite efforts to combat the opioid crisis in the United States, we have seen a rise in the abuse of illicit opioids such as fentanyl. We at CIAAG feel the increase in overdose deaths can largely be attributed to policy makers and law enforcements one-sided approach, which primarily focuses on restricting access to legally prescribed opioid analgesics. In the year 2019 alone, more than 500 state laws have been proposed to combat the opioid crisis, largely focusing on restricting access to opioid medications. As a result, patients suffering from post-operative and chronic pain are finding themselves unable to access effective pain treatments. The failure to provide adequate pain control increases the changes the patient may engage in risky behavior; potentially jeopardizing their health and exposing themselves to illicit substances. Regulatory and policy changes are mandating healthcare providers to recommend nonpharmacological treatments and self-management techniques in lieu of analgesic medications. As a result, there has been an increase in the reported number of individuals suffering in the post-operative care setting as well as those living with chronic illnesses and conditions. The continual push to restrict access to legally prescribed medications as a means to lower the incidence of opioid exposure, has proven to be ineffective as the crisis continues. It is known that illicit fentanyl is driving the crisis. In order to contain the crisis, the illicit drug trade needs to be stopped. This should be our primary focus if we want to effect change. We need to refocus our efforts, implement a new strategy, and make it our top priority as a nation to stop the flow of illicit drugs and to restore balance in our medical practices. The regulatory changes focus on restricting access has harmed public health and individualized patient care. Our elected officials need to recognize the importance of patient centered care in order to achieve the dual goals of combatting the overdose crisis and the crisis of untreated pain. Until the United States adopts a more balanced approach toward combatting the overdose crisis, we will continue to see rises in overdose deaths as well as suicides in those living with chronic pain. We as a nation can do better.

Chamrid KPADONOU , West Africa Drug Policy Network. (NGO): Non-medical use of prescription drugs in Africa, especially Tramadol, is presented as a ‘drug issue’ that can be corrected with drug control measures: repression, arrests, seizures and bureaucratic controls. After all, there is a logical appeal to responding to the situation in a way that is familiar and for which a process is already in place. All we must do is to repeat what we have done for hundreds of other products in the past. But Has this approach worked over the yearsMillions of people in Africa still can’t access the clinical benefits of effective pain medication and enjoy the freedom from unnecessary suffering. Tramadol is currently the most effective alternative pain medication. Placing tramadol under the list of internationally controlled substances will equal to prioritizing restrictive control to the detriment of ensuring adequate availability of an access to effective pain medications. Thereby violating the rights of people who need them. In 2018 a team of researchers including myself conducted a research on the non-medical use of tramadol in West Africa. This research helped us identify key factors that are often overlooked when it come to this important issue. Africa health care systems are still struggling from decades of neglect and sharp spending cuts. Let me share a true story of the situation on the ground from the findings of our study in West Africa. In the village of Sor, in the north of Ghana, we interviewed Naabil (not his real name) a farmer who had been stung by a scorpion days before we met. Formal channels to obtain pain relief are inaccessible, or inexistent, to the rural poor. So, Naabil procured tramadol from a local chemist shop that does not require a doctor’s prescription. If prescription medications like tramadol are to be treated as an illicit narcotic drug, thousands like Naabil would be unable to satisfy their legitimate medical need or, worse, face criminal sanctions for doing so.

Tramadol that doctors prescribe in most parts of West Africa for treating post-operative pain is of a strength of 50 to 100 mg, or 150 mg with slow release formulations. From our work, it was found out that several test purchases were strengths as high as 455mg which clearly do not fall within the ministry of health approved dose. Scheduling tramadol will have a big toll on legitimate patients who need this drug to treat pain. It is currently the only available pain medication with good profile that the general population can access especially the rural poor.  If tramadol is to be treated as an illicit narcotic drug, thousands like Naabil would be unable to satisfy their legitimate medical need or, worse, face criminal sanctions for a legitimate pain they seek to treat. Patients are then more likely to buy these from informal providers and markets where medications may be falsified and adulterated. This will also go as far as penalizing the poor, and push people who are in pain onto the criminal market. It is critical to be more nuanced and factual while responding to the current situation because scheduling Tramadol will lead to significant damage to the already weak palliative care system in Africa.  We can learn from what other countries have done to bring the situation under control.  For instance, in Ghana there was a joint effort by the Food and Drugs Authority, Pharmacy Council, Pharmaceutical Association of Ghana and civil society organizations to sensitize the populace on the dangers of unprescribed tramadol use among the youth. Pharmaco-surveillance was increased by the regulatory bodies in the country and that successfully brought down consumption among recreational users.

Ghana’s approach is a clear example of how African countries can address non-medical use without increasing harms to patients – using quotas for local manufacturers and importers, designating one single point of entry for importation of tramadol, and increasing funding for demand reduction strategies such as education and sensitization. Repressive responses can succeed in creating temporary shortages without eliminating supply. They fall particularly hard on the poor who are often brutalized by law enforcement. They have also proved ineffective in eliminating availability of substances that are internationally controlled and easily detected, such as cannabis. Current policies have not worked, we cannot continue to do the same thing without better results. Thank you.

Gretchen Burns, A new PATH (NGO): Imagine you are a loving mother whose child struggles with a chronic relapsing illness – such as diabetes. Now imagine your child continues to eat cookies – against doctor’s advice – so he is chastised as being of weak moral character. And, your friends & neighbors’ shame and blame you for their disorder. Imagine that healthcare providers label you a co-dependent enabler, and encourage you to let them hit bottom…that they are arrested, criminalized and incarcerated for grabbing a forbidden candy bar…that police, health care professionals and the community at large shun you for “loving too much”… So, besides the real fear for your child’s health & happiness, mothers must also grapple with the concept that it is somehow their fault because they were too involved… while they watch…helplessly and hopelessly as their child’s health and futures diminish… I am Gretchen Burns Bergman, co-founder and executive director of A New PATH (Parents for Addiction Treatment & Healing) and lead organizer of our national Moms United to End the War on Drugs campaign, now in 35 states with partnerships in 6 countries. We work to end the stigmatization and criminalization of people who use drugs and people who have a substance use disorder. Mothers have been told by healthcare professionals for decades to use “tough love” paternalistic approaches in handling children who struggle with substance use disorders. This has added to the stigma, and too many lives are being lost. Both of my sons struggled with heroin addiction for decades, and our family experienced not only the nightmare of addiction and incarceration, but also the devastation of stigma and shame. Somehow, they both found their way to long- term recovery. I’m a mother who believes in true love, not tough love, and I’m leading a movement of moms who reject the whole premise of co-dependency. We propose a philosophy based on the power of parental guidance and love. Maternal love is empowering and everlasting.  I’m glad that I never gave up hope, that I never stopped offering them lifelines during their hellish journeys – that I rejected bad advice about “co-dependency.” The words “tough” and “love” don’t resonate together and are a jolting and contradictory concept. Parents of people who struggle with an addiction to opioids know that their child is in critical danger of losing their life. It is almost impossible to navigate these murky waters alone, especially when you add the challenges and roadblocks that are created by criminal justice involvement.  Adding shame and stigma with a system of punishment, abandonment and retribution is counter-productive at best and highly destructive in most cases. Instead of shunning and expecting the impossible of them, we need to try to help, without judging. It is important that they know they are loved and have something to return to when they find their way to recovery. We reject the non-scientific philosophy of co-dependency that has been pushed on us, making us believe that we are parenting wrong, when we simply refuse to stop trying to save the lives and futures of our adolescent & adult children. We encourage mothers to trust their basic maternal intuition when it comes to loving, protecting and caregiving, while creating those difficult boundaries that you truly believe are in the best interest of you, your child and your family. We demand an end to the war on drugs.  Prohibitionist drug policies have led to mass arrest and incarceration, and have devastated families worldwide. So, moms say: stop criminalizing our children who use drugs. We call for education around a compassionate, public health, family centered approach to substance use rather than a criminal justice approach. We advocate for drug policy reform including decriminalization of drugs for personal use. And we promote maternal values, reject tough love and the war on drugs, which is a war waged on our loved ones. One person dies every 7 minutes of an overdose in the United States today. We propose humanistic approaches to address the opioid overdose crisis. We need: Adequate funding to provide an array of treatment & recovery services; A healthcare system of treatment on demand; Therapeutic services – not criminalization and mass incarceration; Medication assisted treatment – in community and behind bars; Community-based harm reduction services: syringe exchanges, safe consumption spaces & naloxone. Through our Ask Mom How to Save a Life campaign, moms are conducting overdose prevention trainings and distributing naloxone, a safe drug that can quickly reverse an opioid overdose. Parents are often the first 1st responder, so they should have naloxone readily available – because every second counts; The Tough Love model is not based on fact or science…and it has created needless pain and suffering, without producing positive outcomes. We offer a new philosophy: True Love. It is based on nurturing, maternal instincts, compassion, tolerance, and the power of parental love.

Bernice Apondi, Voices of Community Action and Leadership (NGO): In recent years the volume of heroin shipped from Afghanistan along a network of maritime routes in East and southern Africa has reached record levels. Most of this heroin is destined for Western markets, but there is a spin-off trade for local market and consumption. East Africa is now experiencing the sharpest increase in heroin use and a spectrum of criminal networks, cross boarder traders and political elites in East and southern Africa are substantially enmeshed in the trade. The political governments are somehow facilitating this trade knowingly and unknowingly. Political systems across the region show signs of having been significantly captured for criminal ends. Heroin use is growing, while public-health systems are generally struggling to respond to it with the unavailable or limited resources. The side effects of this trade are damaging to democracy and the prospects for broad-based economic development. Furthermore, in communities where there is widespread use there is growing numbers of HIV infections, sexually transmitted diseases, opioid babies and hepatitis C infection, and these communities are wracked by violence and criminalization, denying Africa its workforce. According to current report pupils as young as 8 years old in standard four are already consuming hard drugs. And their trusted handlers are guilty of introducing them to the substances.  In some cases, children easily access drugs from shops or bars near their schools. In the absence of these, Matatu touts, taxi drivers, kiosk vendors and chemists have become the conduits in the drug business. Heroin overdose is now a local issue in east Africa are not reported nor recorded by the health authorities, because drug use is illegal. Current drug policies in East Africa are based on the criminal justice approach and are a serious obstacle to other social and economic objectives and has resulted in millions of people imprisoned jailed or murdered. The same policies have proved resistant to implementation of harm reduction principles as a method of treating opioid addiction because of the use of synthetic opioid for therapy. Culture and religious principles highly held by leaders have only helped to make the situation worse. This has contributed further to high level of stigma and discrimination creating barriers to access to healthcare. East Africa needs to move away from its euphoria of “drug free world” embrace alternative sentencing and harm reduction principles to support the youth and people already caught in the addiction web. If we cannot control the demand of drugs, then there will be little hope of preventing foreign drug producers from fulfilling that demand. We will not get anywhere if we place a heavier burden of action on families and people and schools than on the executive and the legislature, who hold the key to directing these countries to the right path. Decriminalizing drug possession appears to have impact on levels of drug use. However, its principal impacts are reducing arrests of drug users and de-congest the prisons, especially those who are young and/or members of minority groups or women; reducing opportunities for low level police corruption; allowing police to focus on more serious crimes; reducing criminal justice system costs; and better enabling individuals, families, communities and local governments to deal with addiction as a health related rather than criminal issue. An example of Portugal who complemented its policy of decriminalization by allocating greater resources across the drugs field, expanding and improving prevention, treatment, harm reduction and social reintegration programs. This is the Way East Africa should go. The abuse, illicit cultivation and production and manufacture of narcotic drugs as well as the illicit trafficking in those substances and its precursors, have reached record levels, and that the illicit demand for and domestic diversion of precursor chemicals are on the rise, it is time to end the drug war, it is time for east Africa to change its policies.

Sai Lone, Myanmar Opium Farmers Forum (NGO): Mingalarbar! My name is Sai Lone, one of the Eastern Shan State opium farmer representatives to the Myanmar Opium Farmers’ Forum (MOFF). [MOFF has been convening annual forum with the participation of opium farmer representatives from major opium growing regions in Myanmar – Shan, Kachin and Kayah – since 2013. MOFF is a platform for opium farmers to come together sharing our experiences, discussing our problems and making our voice heard.] In Eastern Shan, opium farming has become the main livelihood for farmers living in remote high mountain area since many generations. Income derived from opium farming is used to pay for costs of food, daily commodities, religious donation, social activities, health care and education for kids. There are very few crops that can survive the extreme weather and thin soil fertility of high elevation. In addition, poor road access and distance from market (trading center) make many cash crops not profitable enough to feed their families. Significance of opium poppy as cash crop are: short term – can harvest within 100 days, easy to grow, easy to get credit, resistance to extreme weather of high elevation, least depletion of soil nutrients, easy to store and transport, high value and ready market. Furthermore, indigenous people use opium to cure many common diseases in highland regions, such as diarrhea, dysentery, asthma, chronic cough, rheumatic pain and hypertension, etc. They also use opium in social ceremonies – house warming, wedding, funeral and other cultural rituals. Therefore, highland people often refer opium as the “gift from heaven”. To address opium production problem, Myanmar government adopts suppressive law enforcement: criminalize farmers and eradicate opium fields without any livelihood supports. Forced eradication makes us lose all our investment and labor, and the income that expected to get us throughout the whole year. It pushed us into vicious debt cycle, as most of us had borrowed money to invest in our opium field. Some farmers migrated and worked in Thailand in order to repay their debt, and some even had to sell out their land. One opium farmer in southern Shan suicided last 2 years ago when his opium field was eradicated, it is really a sad news. Myanmar government has been eradicating our opium fields since I was a kid, but there are still opium fields nowadays and even increased. I think government should review and change their ways of doing thing. Eradication doesn’t reduce the opium cultivation. It only destroys the livelihood of poor farmers. Government should not punish us by eradicate our opium fields, it only makes our lives from bad to worse. Instead, they should work with us by providing supports that are effective and efficient for us to change our livelihoods without rely on income derived from opium farming. Thank you very much for your attention!

Chair: Meeting adjourned.

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