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Informal dialogue with the WHO

Lucía Goberna (VNGOC): Welcome

Vladimir Pozniak (WHO): Thank you for being here, we hope this will become a tradition at CND.

Kenzi Riboulet (FAAAT): There are three departments of WHO concerned with matters related to controlled drugs: Health products (EMP), Substance abuse (MSA), and Traditional/Complementary medicine (T&CM). What collaboration, coordination or cooperation exists between these three departments? Are all 3 departments involved with regards to the collaboration of WHO with UNODC and INCB, and generally with regard to WHO’s mandate under the international drug control conventions?

Gilles Forte (WHO): We are working on that, in particular that when it comes to health issues that WHO has a place in the CND mechanism. We have three departments actively involved: mental health and substance use, HIV, access to medicine division. We work with a 4th unit dealing with traditional medicine.

Katherine Pettus (IAHPC): How is WHO working on implementing the recommendations of Chapter 2 of the UNGASS Outcome Document? We learned recently that patients in one large East African country that is a member of the WHO EB have had no access to morphine for the past year, but that issue was not even raised at the recent EB meeting in Geneva. How can we give this issue more visibility?

WHO: We are an organization that issues standards and support MS in a number of health related issues. As far as access to medicine is concern, an important achievement recently is the recognition of this item – the availability of oral morphine for treatment of pain and palliative care. The global program is a framework for WHO. We commit to work with MS and partners to achieve specific targets and one of them is exactly this. As far as normative work goes, we work on the recognition of neurological a mental health conditions, updated treatment of addiction – essential medicines list serves as a guide for good prescribing. We are revising the WHO international guidelines based on new evidence and WHO internal policies. We are also engaged with a few countries to improve access to their medicines. We support policy makers and working on capacity building. Two countries is not a lot, we know – we are restrained by financial capacities. Political will and positioning is an important factor in these topics.

Slum Child Foundation (George Ochieng Odalo): Slum Child Foundation is an African NGO working with young people in Kenya. In Kenya a lot of people, especially from rural areas, still believe mental health issues are a result of witchcraft and do not seek treatment, and if they do they are often stigmatized. This has affected a lot of young people and lead to avoidable deaths of many children. What is WHO doing to address this issue in countries where stigma and cultural beliefs still remain a big problem?

WHO (dept Mental Health and Substance Use): Cultural myths and beliefs block access and the other issue is stigma and discrimination. These are overlapping but different issues. We work on several levels – on the policy level, we developed the Global Mental Health Action Plan; it depends on funding how to be closer to people and influence community beliefs. It is paramount to engage communities and civil society organizations that work on the ground, in direct contact with people. Regarding policy guidance, we can do that but the main responsibility lies in country offices and regional offices.

WHRIN, United Kingdom (Ruth Birgin): With regard to the new WHO/UNODC Treatment Standards Guide, we note the use of what has been termed the ‘disease model’ for understanding drug use as the basis for the guide, where drug use is pitched as an illness from which people must recover. Given the projected application of the guide worldwide, what if any monitoring arrangements have been included to ensure (particularly in countries with punitive approaches to drug use) that there are no negative consequences resulting in stigmatizing attitudes?

WHO: Let me start with words of appreciation – we analyzed your comments very thoroughly on these standards. We also organized face to face discussions with some organizations regarding the standards. We need extensive testing – 9 countries took part. We don’t have a pure medical model, we have a bio-psycho-social model but its impossible to deny the biological component and many medical treatments are based on biological factors. Let us know if you know of instances where human rights are not protected, we will examine the underlying issues of this misinterpretation” so we can think of appropriate measures.

UTRIP, Slovenia (Matej Košir) and CADCA, United States of America (Irina Green): In most of the UN Member States, prevention systems are not well developed and sustainable. Very often substance use prevention depends on political will and motivation of individuals, especially at the local level. Such situation gives very little chance to develop long-term, sustainable and successful partnerships between authorities, public services and civil society organisations (CSOs). What are your future plans and proposed strategies to improve the situation in the field of prevention globally, so there would be stronger policy commitments and sustainable long-term investments in evidence-based prevention policies and practices, and development of prevention workforce (sustainable education and training)?

WHO: Prevention is definitely a dimension of the problem. We have several activities that are directly linked to prevention. We don’t pay much attention to the legal status of substances – all psychoactive substances have an impact on health and we are motivated to prevent harms.
We have a very strict list of internal norms for any intervention in the public health domain. At the same time, we have taken an approach hat prevention of substance use particularly among young people are tied to non-specific factors tied to mental health. Currently, a project on child and adolescent health is going under a systematic review that will be based on new evidence. We have several prevention programmes based on policy guides in the field of alcohol, drugs and misuse of prescription medicines. We are eager to work together with civil society groups to work effectively on the global level.

Penal Reform International, United Kingdom (Olivia Rope): What is the WHO planning on doing to address the lack of harm reduction measures for the high number of people in prison who use drugs, bearing in mind the impact of this on mental health and wellbeing of those in prison? We know most countries have not implemented measures according to international guidelines.

WHO: Prison settings often serve as epidemiological pumps – the most risky period for mortality and risky behavior is after discharge. We do significant work in the area of public health responses to infectious diseases. Several country offices are involved in implementing interventions in prisons including methadone programmes. One of our mottos is that when a person enters prison, they should be deprived of freedom but not of health. One of the main issues in drug demand reduction projects is managing prison settings and also we are promoting alternatives to imprisonment.

Turkish Green Crescent, Ergin Beceren: Considering the heated discussions regarding the recommendations of the Expert Committee on Drug Dependence (ECDD) in June 2018 on, among others, limits of CBD and THC in an epilepsy medicine, is there any possibility for WHO to amend the above mentioned recommendation or give the scientific community more time for in depth research and discussion on this issue? How does this recommendation relate to the growing CBD market?

WHO: The work of the ECDD started a few years ago and the first recommendations were issued in June 2018 and the later ones in November 2018. Cannabidiol has been reviewed and the commission determined that CBD with THC level below 0.02% should not be controlled. These should have been submitted to a vote but it has been postponed. Then it was supposed to take place this year but it seems from the informal discussions that the decision will be postponed again. We organized information sessions with 300+ questions that we responded to. There was a lot of exchange regarding this work. We continue to be available but we feel that most questions have been answered already. There are reports of low abuse potential of CBD; there are medicines produced and marketed including CBD. These medicines followed very stringent processes and there is enough scientific evidence to demonstrate its effectiveness in treating a few important conditions. ECDD is specifically focusing on health and medical issues so the recommendations were not related to the industrial and food purposes.

International Drug Policy Consortium, United Kingdom (Marie Nougier): Given the surge in opioid overdose deaths worldwide, would the WHO consider launching a global campaign on overdose prevention, including specific measures that should be adopted and scaled up to prevent further deaths?

WHO: The exponential increase in opioid overdose deaths in certain jurisdictions deserves a global response. We cover one aspect of overdose prevention and management – Naloxone without prescription for witnesses of overdoses. It has produced wonderful results. The problem has many layers and the global response should address all of them. Treatment programs for all stages of opioid use/dependence. Some governments had strong requests to provide certain things happen.

Network of People Who Use Drugs, Belarus & Kazakhstan (Olą Belyaeva): The quality of OST programs in the EECA region is often very low compared to EU countries. What is the WHO able to do on a regional and national level to help solve some of the problems with OST programs, such as low availability of methadone in hospitals or inadequate services in general?

WHO: We realize the problems of insufficient capacity or insufficiently developed programs which is one of the main pillars of health responses. To a large extent, it depends on how all levels focus on these issues. I took note of the countries you mentioned and will discuss with our regional offices. At the same time, all policy documents have clear messages about substitution availability, as this is a first line response, it is referred in every single guideline and is also a part of our policy dialogues. Our position is firm and unchanged. When it comes to particular countries, we have to understand it is up to the discretion of individual member states. We provide the scientific background, evidence and remain in dialogue with all partners and MS.

Proyecto Hombre, Spain (Elena Presencio): To what extent do Member States deploy evidence-based and integral drug policies and interventions to better counter the world drug problem, attempting to prevent strategies based on beliefs or perceptions which are not supported by scientific evidence? What role does WHO play to accelerate such process?

WHO: This is a broad and challenging questions. We do what is within our mandate and in our core functions. We identified 5 critical dimensions: prevention of use and vulnerably risks, treatment and care, harm reduction, access to medicines, …
Before 2007 we had procedures where it was enough for a group of experts to come together and come up with recommendations, we have since come up with processes and strict rules to consider various aspects of a given issue. So our recommendations are very specified and are screened for conflicts of interests as well as fully based on scientific evidence.

Instituto Ria (Zara Snapp): Does the WHO believe that cannabis causes greater harm than substances that are legal such as alcohol or tobacco?

WHO: I can speak about the work of the ECDD – the harms of Cannabis have been reviewed and it is important to acknowledge them specifically among particular populations. The ECDD doesn’t recommend Cannabis to be legalized but the level of control has to be adjusted to the latest scientific findings. The ECDD mandate doesn’t allow harms to be compared such as that. We received a number of similar messages from MS. Cannabis use results in 13 thousand deaths globally, tied to road traffic accidents – this is in the millions for alcohol and some other drugs. Cannabis is an intoxicating substance and can result in use disorders – it is much less as with alcohol. There is research associating cannabis to cancer development but we will make an update of health consequences once we finish the scientific review. Lastly, alcohol and cannabis are not comparable.

Eurasian Harm Reduction Association, Lithuania (Eliza Kurcevic): In the EECA region the significant increase in the use of new psychoactive substances (NPS) leads to serious consequences for mental health of people using drugs (see EHRA research in Moldova and Belarus https://harmreductioneurasia.org/harm-reduction/new-psychoactive-substances) Does WHO have any plans which could ensure access to specific and effective mental health care for NPS users in the EECA region?

WHO: We are aware of increasing trends, it is difficult to come up with recommendations because the evidence base is still weak. At the same time, we developed a best practices document and pla to conduct more research. Our deliberations focused on accountabilities in connection to mental health disorders. We have taken note of your comments, thank you.

Thank you. We count on your support and collaboration in the future.

VNGOC: We are out of time for this session, thank you for your collaboration. We will coordinate written responses to the questions that we didn’t have time to ask this time.

The following responses were kindly shared by the World Health Organization (WHO) in written form, via the Vienna NGO Committee, to ensure all questions by civil society were provided an answer:

Fundación Latinoamérica Reforma (Dr. Sergio Sánchez Bustos): How do you explain the differences between scientific advisors and groups saying that cannabis does or does not have medical utilities, e.g. the report of the National Academies of Sciences, Engineering and Medicine (2017) and other systematic reviews arguing the exact opposite?

WHO: Cannabis is a plant that contains hundreds of different compounds, which makes scientific investigation into its medical use a complex subject. There are currently hundreds of ongoing clinical trials to explore cannabis medical use in selected conditions including pain management. Different studies have used various methodologies to draw various conclusions about medical and research applications of cannabis and preparations derived from cannabis. Cannabis is also used for multiple different conditions and much of the variability in conclusions about medical use occurs because the effectiveness of cannabis varies across different medical conditions: it is effective for some but not others. In addition, there are varying levels of evidence for different medical conditions.

World Information Transfer, U.S. (Jessica Williamson): This question pertains to dual diagnosis: How does the WHO facilitate the availability of mental health resources for those in substance abuse treatment since often, substance abuse is either an attempt to escape or cope with trauma or self-medicate pre-existing, undiagnosed mental health issues?

WHO: Thank you for raising this important question. In fact, comorbidity was the main topic of this year deliberations of the Informal Scientific Network convened by UNODC and WHO during CND session which underlines importance of this issue for service delivery. There are several WHO products and activities focused on dual diagnoses or, in other words, comorbidities of substance use and mental disorders, also developed or implemented in collaboration with UNODC. But in this response it is important to highlight mhGAP Intervention Guide and large scale related training activities supported by WHO around the world. The Guide covers all major mental health conditions as well as substance use disorders, and serves as a very important resource to ensure competence in identification and management of mental and substance use disorder. Also the challenges and models of linking or integrating substance use and mental health services are addressed in the revised edition of WHO-UNODC International Standards on the Treatment of Drug Use Disorders.

Turkish Green Crescent, Ergin Beceren: WHO organises a forum on alcohol, drugs and addictive behaviours every two years. Considering the serious risks of these addictions, and the fact that the CND is focused on narcotic drugs, is there a possibility for WHO to organise dedicated sessions on these topics annually, by bringing together healthcare practitioners, medical experts, and civil society?

WHO: Thank you for the question and it is good to hear that WHO Forums on alcohol, drugs and addictive behaviours are considered as important platforms for discussion of a broad range of issues related to substance use and disorders due to substance use and addictive behaviors. Organization of these forums, which bring together around 200 people from around the world, is a significant and resource consuming activity of our relatively small unit in WHO Headquarters, and convening the annual meetings are beyond our capacity now. The next, 3rd Forum is planned to take place in Geneva in June 2021.

Instituto Ria (Zara Snapp): During the review of medicinal cannabis studies and literature, what was the greatest lesson learned?

WHO: Since the International Drug Control Conventions were originally drafted, our scientific understanding of cannabis as a plant has developed significantly. Cannabis was never reviewed by ECDD and CND and scheduling was done without having an accurate knowledge of the composition of cannabis and of the effect of its components on the central nervous system. Today there is much more scientific evidence on the composition of cannabis, on its potential for abuse, dependence and harm and on its therapeutic use. There are a number of countries that recognise the medical value of cannabis and that allow its use in medicine. It is therefore of critical importance that as much scientific evidence and knowledge on cannabis harm and on the scope of its medical use is gathered in order to assist countries in the development of regulations for a safe and effective cannabis medical use.

International Drug Policy Consortium, United Kingdom (Marie Nougier): Is the WHO planning to issue international guidance on issues such as drug consumption rooms and the decriminalisation of drug use and possession/cultivation of drugs for personal use?

WHO: There are no immediate plans to develop such guidelines as there are more pressing needs to update or develop the guidelines which can be used and implemented in many countries around the world, particularly in low- and middle-income countries. For example, we need to update the WHO guidelines on pharmacotherapy of opioid dependence and develop guidelines on identification and management of stimulant drug use disorders.

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