CND Third Intersessional Meeting: Thematic Session 2- 20/10

Thematic session 2: The adverse health consequences of and risks associated with new psychoactive substances have reached alarming levels

Secretariat: Guidelines for meetings in the Vienna International Centre were shared ahead of the meeting. And that also available in hardcopy at the back of the room for those joining us online today. So first, I was addressing the colleagues that are with us here in the conference room. But now for those joining online, I would like to briefly recall the rules of engagement for participation in virtual meetings. So first, all microphones have been muted. Please only unmute if you have been given the floor to speak. And after you have finished, please mute your mic again. Secondly, please turn off your video because it enhances the overall performance. And you can turn on your video if you are invited to speak directly. Please speak clearly slowly and with adequate volume forth if you wish to speak kindly indicate so in the meetings chat, and then you will be given the floor. The chat will be used to establish the list of speakers. Please indicate the name of your delegation in the request. Please share any kind of substantive comments you have after you have been given the floor and not in the chat. As such, the chat is only to ask for the floor, as well as to if there are any technical difficulties. So also, there the Secretariat is at your disposal to helping you if you indicate in the chat that you have any technical issues. Thank you, Mr. Chair for providing me with this opportunity.

Chair: Let me reiterate a few points to ensure that we get the most out of our meeting in the spirit of yesterday. Panelists are kindly requested to limit their presentations to five, delegations make statements from the floor are requested to make the intervention short three minutes and are strongly encouraged to ask questions and make comments on the panel presentations. There will be no list of speakers’ delegations wishing to make intervention. As mentioned yesterday, I have Swiss clock and I will remind you if you go over the limited time to give everyone the possibility to speak. Now onto Miss Angela Me.

UNODC Research and Trend Analysis Branch: As yesterday, I’ll try to present the evidence that we have and talk about where you will find also more analysis. We know that there are few NPS that really taken the global stage and they have established a global market. I’m talking about Tramadol and Ketamine, but the policy around this substance is much more complicated. The Commission has discussed the issue of substances and how to balance between the prevention of abuse and the issue of accessibility – because these two substances are pharmaceuticals and are also in use for medical purposes. What I would like to focus here is what about the others that pop up, what the evidence is telling us is that in some countries, the countries where the NPS really started to emerge as an issue much earlier and they were the first countries confronting these challenges. I’m talking about North America and particularly Europe, and the evidence that we have from this region. And you see on the chart what is trending in the United Kingdom and on the right graph from the United States. In a way the control on a national international level and also user choices also influence prevalence. NPS didn’t really establish themselves in the overall global population. The prevalence of NPS used in Austria in 2015 is really low – they controlled them nationally much earlier, in 2012. And you see that that has contained the use of NPS while in Germany, it happened in 2016. What I am saying is that it may take time before the control takes effect on the mainstream populations. There are other countries that are actually in different phases of the NPS epidemic, if I may, and here is an example of Russia and Central Asia, where all the different type of synthetic substances are appearing again, coming and going and a very dynamic market is now at the epicenter, so this is the time where actually this market is blooming. And the question is, will they have the same trajectory that we have seen in other countries where the market shrinks? That’s the question that we have on our table. In terms of what we can conclude is at the macro level… so if we have at the global level the indicators on annual user, or deaths, and so on, the traditional drugs, in a way still appear much more harmful than NPS at this point. If we look at the single individual or at single substances, these are very powerful and potent and much more potent than traditional drugs. And what we have seen also better, even if at the macro level in terms of the mainstream population, as I show you, some of the NPS market have shrunk. And actually what happened in those countries, particularly in Europe and North America, is that NPS use is cemented in marginalized populations, where the users have lot of other issues such as homelessness.

I think a crucial question is whether NPS are actually harmful or whether their harm is increasing or decreasing? And the big question is in combination with other traditional drugs and the systems that we have in terms of epidemiology or forensics, etc. So, the question whether the harm is increasing remains.

[Justice]: Barely seven years ago, when the issue of NPS started featuring prominently on the radar of their CMD, we were looking at just about 254 substances from less than 100 countries. As of this morning, un ODC is actively monitoring 1004 substances from over 124 countries and territories worldwide. If you look at the trend, with ascension of synthetic cannabinoids, which seemed to be going down, everything else seems to have stabilized or on the increase and of concern are the opioids and benzodiazepines. Now, you’ll recall that in 2016, the UN General Assembly made a decision to prioritize the most harmful substances for international action. And that, in effect is what our colleagues who have been doing with the CND with the support of UNODC. Let’s have a look at the figures. And that is where it gets quite startling. Over a period of six years, the international community associated in taking out 60 harmful substances from the market – put that in perspective. Since the ‘61 convention was put in place, we’ve had 300 substances under international control. In five years, we have placed 20% of whatever we have under controls into a framework to help us deal with NPS. Now if those figures are startling, by the end of next year, we expect to have at least a 10% increase in the number of harmful substances, which have been controlled. Two years ago, you will notice information on post mortems on drug use and driving on emergency room admissions. And the idea was to be able to get away from just using seizures as an indicator of what is happening on the market. I’m very conscious of the time allocated to me so I will try to rush through this. It is important for you to notice that when you look at toxicology data gathered over the past 18 months, we are seeing some worrying trends. For example, we’ve seen sedative hypnotics being used a lot in driving. The dangers are not just to the people who are using the substances, the dangerous to you and I everyone walking by the streets. And this is global. We’ve all heard of the opioid crisis in some parts of the world in America’s in parts of Africa. Now, when you look at opioids, they are not the substances you would want to see floating on the market because they are potent, and when used in the wrong way, can lead to death. We’ve seen an explosion of new chemistries, new substances. I would invite our colleagues in the room and online to have a look at two publications we released last week, the current NPS traits. It will tell you all the story about what is happening with NPS over the 18 months past 18 months in terms of their harms and about the growing complexity of the opiate crisis, which gives you a summary of the way that opioids are rising. I thank you.

Mexico: Is UNODC well equipped in terms of the mandate, precisely to address the issue of the new chemistries? We saw a couple of years ago that there is this new trend, especially in Asia, using the chemical component that is found in toiletry diapers to get a psychoactive effect. And when I address that issue with UNODC, I was told that they were not dealing with it, because it was not a substance? So with this, what is going on? That would be the question… Is there something that we, member states have to do in that regard given the new trends and patterns?

[Justice]: I believe what you are talking about what we call toxic adulterants. The question is, are we looking at that? No. If I have a product, oxycodone on the market and it contains a toxic adulterants in the form of fentanyl? Yes, we are looking at that. It falls under our mandates. If you look at a product, and it’s got a substance which has no psychoactive activity, we will take note of that… so it depends on on the chemistries, if it’s got a psychoactive activity and can fall under one convention then it comes under our mandates. If it’s a new psychoactive substance, with potential to duplicate to one convention, yes, it falls under the mandates. But if you’re looking at chemicals, which have no psychoactive effect, that is where you go beyond what I’ll call a grey line …

Mexico: Chair, if I may, very briefly, I’m satisfied with the response. But I’m more worried than before. Because if we go into the original mandate of the CND, established in 1946, is to address all matters related to drugs? And when we have kids getting high on chemicals, different chemicals, which are not substances, and then we can because of the limits of the conventions, we’re not addressing need… I’m worrying that there’s a huge area that we’re not addressing that it’s causing harm to kids and youth and therefore to societies. Thank you. Again,

[Justice]: I think you put on a very, very key point with the word, highs … you are referring to a psychoactive effect? Yes, we need to look at it.

USA: So, to follow up on the discussion we just had, because my colleague from Mexico raises an excellent point. We had a discussion just this last week, at the Conference of Parties to the UN Convention against transnational organized crime, where we were talking about falsified medicines. And there was a hesitancy among the conference, to deal with falsified medicines that are either within the competence of the Commission on narcotic drugs, or are not within the competence of the Commission, but still deal with substances that are trafficked not controlled. And the two examples that Angela raised of ketamine and Tramadol were the ones that we were looking at. So, for the Justice, perhaps two questions. And the first would be, how can we, as the commission grapple with this issue of the problems in criminal justice that are on the margins of our institutions? How do we remain faithful to our mandates, but also being honest in the in the way we approach the problem? I know, there was a major law enforcement takedown just two weeks ago, I believe. And the substances that were seized included a full range or controlled and uncontrolled substances, plus weapons, but also substances that were marketed as oxycodone, but were not oxycodone. In fact, they had fentanyl in it. You know, it’s, it’s just an entire mix. So, the criminals don’t care about the differences in our mandates, and we have to be more effective. And then the second question I would have for the Justice: what is the cause of this dramatic increase? Is it perhaps the marketing the internet? What is it that we need to be focusing on in terms of this problem? And what is causing it to explode so much?

[Justice]: I think from the point of the Commission, it is important to raise awareness around this issue of falsified medicines. Traditionally, the narrative was about counterfeit medicines, and it was all about pharmaceuticals. But let’s not lose track of the fact that most of the compounds and others in the schedules of the conventions are actually pharmaceuticals. The delegate from the United States made a very good point about oxycodone. If you take a pharmaceutical oxycodone and you add heroin or substitute that oxycodone for a run, does it fall under that CND mandates? I think we need to wake up to that. Moving forward, I think the CND needs to perhaps work on raising awareness on the issue. But it’s also the falsified element to it… So there is a need to summarise to raise awareness of the fact that we’re not looking just at pharmaceuticals. But we will be looking at pharmaceuticals which contain or as opposed to contain compounds under the 61 or 71 convention. Another example, if you look at what we’ve seen from toxicology, you go out looking for a stimulant, and you find pharmaceutical antidepressants in it. So, SSRIs antidepressants are being sold in place of perhaps mephedrone. There is a fraudulent element to it. But what has been presented to the public is supposed to be something we worry about a controlled substance. So here again, there is a place for us to act when it comes to falsified substances. The second part about Why the numbers are increasing. It is important to appreciate that we’ve seen a displacement or replacement effect. And this is part of a complex cycle. If you look at the charts, and what was done for the past few years, a number of opioids have been controlled, but we see newer ones on the market, a number of synthetic cannabinoids are being controlled that we see in replacements. As Angela mentioned, for some substances, they have disappeared on the market because there is no appetite for them. What we realized over the past five years is that the UNODC and other organizations such as the INCB have been able to put in mechanisms of tracking these compounds, we are getting closer to making those cycles shorter. The cycles where you see lots of substances coming on the market, if you look at the trends, there seems to be a plateau. And Angela did mention that in some countries, there is evidence that the controls are bearing fruit. So hopefully we get into the stage where we see the plateau. And hopefully after that plateau, maybe we see that green shoots of spring, where the charts will come down. But for now, while the trend is still upwards. It should not just be early warnings; it should be early action. How can we pick it up faster? How can we work as a commission faster to be able to schedule these substances and break a cycle? Thank you, Mr. Chair. Thank you,

Nigeria: I think that NPS are very harmful on the global trend. So it is good that we are having this conversation. I’m glad that Angela may pointed out that the non-medical use of Tramadol as well as the harmful effects seems to be on the rise globally, and in particular in Africa. And we are also aware that the world drug report of 2020 also highlighted this challenge, as well as the latest INCB report. And in the just concluded extraordinary sessions of heads of law enforcement agencies. Almost all the UNODC regional representative highlighted the increase in use and harmful effects of Tramadol within the African region. Virtually all of the sub regions have the same experience. However, the greatest challenge has been that we have not been able to place these NPS under international control, owing to a lot of reasons, and we have actually left this substance to domestic control that are hardly adequate to address the increase in non-medical use. And some of the arguments that we have had for why is not been placed on international control includes the fact that there is not adequate evidence of its harmful effects and also the fact that we should strike the delicate balance between assets and then control. So my question: do you think, given the challenge of a data collection within the Africa sub region who seems to be the worst heat for Tramadol, do you think they can improve the data collection with particular focus on those harmful effects? Miss May you always like to cite our 2019 National Drug survey… Tramadol was the second most abused drug in that report. Thank you very much.

UNODC: Not only the commission, but also national authorities need to take action where we lack information. Indeed, I think we have a critical lack of data in terms of all the non-medical use of pharmaceuticals in general, particularly in developing countries. And because also the difficulties in the data collection is to find the right methodology and to test the methodology that can sharply distinguish the nonmedical user with the medical user. So, indeed, I think in order to improve the action that we can make to address the nomadic producer of pharmaceuticals, definitely the issue of data collection is political. And this was an emphasis also of expert consultations that we had when we prepared the new FAQ.

Colombia: We have some questions for Angela, and maybe for Justice, could you elaborate a little bit more on the harmful effects at macro level of NPS when compared to traditional drugs? We are especially interested in the effects regarding cocaine. Is there a need of additional global studies on that trigger, or in the use of the combination of NPS with cocaine?

UNODC: I think you’re bringing up also an issue of combination. So that is the hardest element to be able to invite you to understand. Because as I said, the way how we collect data, we focus on the main drug.  We know that the cocaine deaths are increasing in some countries and many of these drugs are relating to combinations of cocaine and with other substances – some NPS and some may relate to fentanyl or other substances. And so the big question is, do we need the global study? Do we need a global report on cocaine? I think this posea also challenges on the way how we take research. And then indeed, I think the inspiration of your question is to, for us also to think about to move away from single substances to think about how we monitor more effectively, the combination of substances. So thank you for your question.

[Cameron] As Angela was saying, in order to understand the harmfulness of substances, currently you have the emergency room cases or case reporting from the emergency room or toxicology and death report. And what you commonly come across is that, in any adverse event that you have, there are multiple substances that are involved in the case of an adverse health reaction. So I guess the challenge always remains is how do you look at the single substance that has caused or the multiple substances that could have also been added to that effect, and that’s where the challenge remains. And as I said, I guess it’s time that we start looking beyond the single substance effects and looking at look at the whole concept of poly drug use.

[Justice] I think it’s important when we’re talking about NPS to realize that we’re not talking about pears and apples, NPS and traditional drugs. If you look at the definition of NPS, we are talking of substances which are not controlled under 61, or 71 conventions but they work like those substances and produce the same harms. Let me give you some examples. Take fentanyl, which is an opioid and you take an NPS: alfentanil – They work the same way. So let’s not try to separate them as NPS and traditional substances, the pharmacology is the same, the chemistry is sometimes identical. And in addition to the desired effects they give, they can all result in the same undesired effects. These came on the market to replace traditional drugs. Now on the second pair of combinations, just to put some numbers to it. Looking at the toxicology data we’ve collected over the past 18 months, drug use in driving, postmortems and adverse interactions address or emergency room admissions. We’ve realized that drug use in driving, you only find in about 10% of cases where the person has taking one substance. In most cases, it’s a cocktail. You look at postmortems, and similar to drug use in driving, you only have about 9% of the reports we get in being only due to a single substance. What is this telling us? It’s time to change the narrative? Like my colleague Cameron said, these are time to perhaps move beyond which single substance is responsible for causing the adverse effects to think about drug use in general. What is happening? It’s not just cocaine we see in pharmaceuticals, we see in controlled substances. And it’s about time we started taking the narrative in a more comprehensive way. Thank you.

Professor Owen Roden Jones, United States: I’m going to provide you with an update on recent advice to the UK government on novel psychoactive substances by the Advisory Council on the misuse of drugs. So the Advisory Council on the misuse of drugs, is an independent expert Advisory Committee, with a statutory duty to advise the UK government on matters relating to the misuse of drugs in the UK. The membership of the Advisory Council is multidisciplinary, and it includes pharmacology toxicology, pharmacy, criminology, medicine, law enforcement, among others, and it plays a key role in providing scientific advice to the UK Government. So it can take a number of measures in tackling NPS. So the approach the council takes to NPS is a very systematic one, we have a dedicated subcommittee, which systematically monitors the evidence of changing prevalence of MPs in the UK, but also the emerging harms. We also very closely monitor what we describe as a watch list of NPS, which looks at NPS which are not a problem yet in the UK, but which are causing problems in other countries. When we develop recommendations for governments, we have a standardized process, we first identify the particular NPS. We then review the literature. And specifically, we will look at peer reviewed literature, we’ll look at government statistics, we’ll look at international data. And from that, we’ll get another pool of evidence that will then synthesize and compare against our health and social harms framework. And we use the same framework for every NPS so that we have a consistent approach to understanding the harms. Once we have put the evidence through that framework, we then present conclusions and recommendations to the UK Government. So, I’m going to present you with be very brief summary of two reports we’ve produced this year. The first one is on synthetic opioids, like fentanyl and fentanyl analogues and the sort of areas we specifically focused on with the diversion and misuse of pharmaceutical fentanyl. It’s also the registered deaths, but particularly the risk of fentanyl infiltrating the UK heroin market. The recommendations, I won’t go through all of them but to give you a flavor of the types of things we looked at. We looked at further research on the study of diversion. We looked at reviewing international drug strategy approaches to fentanyl markets. We had a training recommendation on the therapeutic use of strong opioids by clinicians, and also recommendations on toxicology and analysis. The second report we’ve produced this year is on novel benzodiazepines. The key conclusions from this report was that there was evidence of increased prevalence of harm for three benzodiazepines in the UK, three novel benzodiazepines. We found that there was no legitimate medical use for these substances, and recommended that all three should be placed in the class C of our misuse of drugs act and be placed under schedule one of our misuse of drugs regulations. We have two reports on NPS coming up this year. So, one report is on synthetic cannabinoid receptor agonists. And the second is on GHB, GBL and related compounds. And both of those will be published by the end of this year. Finally, I would like to direct you towards our website. So if you would like to know anything more about the Advisory Council on the misuse of drugs, or indeed look at any of our reports, these are archived on this website, and are all freely available for download. I will finish my presentation there. Thank you very much for your attention.

Amrita Davey, Indonesia: I’m Rita from the National narcotics board Republic of Indonesia to address the issues on NPS challenges in Indonesia. New psychoactive substances or novel psychoactive substances commonly known as designer drugs, legal highs, research chemicals, and in our country, commonly known as cyndy have been under incessant production as early as 1929 when methadone was first produced. The term new does not necessarily refer to new inventions because several NPS were first synthesized decades ago. These synthetic substances were engineered to replicate the efforts of control… When we are talking about MPs there are still numerous homeworks at the International, regional and country level like awareness trainings, not only for treatment practitioners, but all those in the front lines such as law enforcement & development of treatment guidelines

Dr. Gaddy Sabiki Sirat, Mexico: I will be talking briefly about the adverse effect the adverse health consequences and risks associated with the new psychoactive substances in Mexico. I would like to say that it’s very interesting to notice how the view of this problem shifts and changes from country to country and from region to region. In Mexico, our greatest problems nowadays with new psychoactive substances are stimulants and synthetic cannabinoids, opioids and the abuse situation. In Mexico, we do not have a health problem regarding injecting narcotics, less than 0.1% of our population has ever tried one of these drugs, but we do have a moral compromise. And we do have also international agreements to try to stop the flow, especially of fentanyl from our country, to the northern part of the continent. Mexico is kind of a hinge between Central and South America culturally and regarding drug traffic, and the big North American subcontinent. So we do have a bit greater flow of fentanyl through our country, especially to the north, which is one of the most important markets of drugs in the planet. There’s a very important economical factor regarding that. The Mexico – USA border is the longest land frontier between a developed and developing country and Mexico in the United States are the two neighboring countries with the widest gap of per capita incomes. So, this creates a lot of economic pressure. There’s a lot of money in trafficking these drugs up to the north. So, this is a situation that we are dealing with. Although we do not have a health problem to ourselves, we have to take care of these drugs being processed and going to other places around the world. In South America, the number of new psychoactive substances increased, very notably between 2013 and 16. And more than 16 different substances were reported in that year 2006 – 16. And then it went up to 130 reported in 2017. We are seeing a greater number of substances whit stimulating and hallucinogenic mixed effects, and our synthetic cannabinoids are probably the most important of the substances that we can witness. We also believe that the market is ruled by the supply and demand laws. And we can see also a shift to these more potent and less expensive drugs which is very worrying in a developing country like ours. We can see that the market is very much focused on the on the international internet  that delivery is also diversifying specially in COVID times. We see a lot of people delivering drugs like if they were pizzas you know by a telephone call, they go straight to your house. And we also see a lot of money going through banks and all these international systems that are so hard to control. Now we are seeing a very important increase in amphetamine type of stimulants. So, regarding the Mexican reality, this is an emerging substance. Some use of crystal meth in Mexico has gone up dramatically and in places where we didn’t see it before, we are seeing a lot of crystals very cheap and with a very widespread use. We are doing a lot of harm reduction maneuvers. We are making a huge national effort to train all of our physicians And psychologist to be better prepared for Mental Health assistance and we’re trying to help these with huge campaigns in the media.

INCB / Ambassador David Johnson: As we’ve been discussing here this morning, we live in some interesting times that we’ve been focused on COVID of course. So we started off our discussion talking about that, but we also as professionals working here talking about another pandemic or another epidemic that is causing additional pain and suffering: Since 2000, much of the world, particularly high income states, witnessed a significant increase in the consumption of opioid analgesics, but a lot of non-medical use and an increase in drug dependence and overdose deaths. We found that when governments sought to introduce more effective controls over the medical side, many who had become dependent on these prescription opioids when they had difficulties obtaining them switched to illicitly produced prescription opioids or heroin. And in many cases, both of these products were adulterated.

According to governments in North America, the region suffered more than a half million opioid overdose deaths in the last 20 years. And while the rate of overdose deaths appear to have plateaued in 2018, it accelerated again in 2019, and is believed to be climbing yet again during the current COVID pandemic. There are a number of reasons the traffickers favour NSP based opioids. A challenge for governments is that they’re so powerful that small quantities can be moved easily and with COVID-19 driven limitations on border crossing and a sharp drop in civil aviation, this small quantity advantage has allowed traffickers to use alternative channels to get dangerous substances to markets. Express home delivery services coupled with frequent lockdown rules and increase the volume of goods shipped to us by express mail, and traffickers have rapidly exploited this opportunity. As the world continues more small amount shipments can be expected. The board strengthened its work with the Oceania customs organization, universal postal union and the world customs organization to enhance their programmes to provide alerts to shipments potentially containing NPS and to train customs officers and Postal Inspectors on intelligence sharing and safe handling. The board’s expanded its operational support to member states’ supply reduction programmes focused on nonscheduled substances, including new designer fentanyl replacements, emerging NPS and other synthetic opioid related dangerous substances. Building on the board’s position as a trusted place for member states to exchange data, using the board’s secure incident communication systems, picks for precursors and […] for NPS and non medical synthetic opioids. In 2019, the board launched its programme more effectively to support timely information exchange and intelligence development to help prevent, identify and interdict NPS from being trafficked. The board’s also been supporting states parties to the ADA convention in implementing article 13, helping them to prevent trade and the diversion of materials and equipment unquote, since illicitly acquired equipment such as pill presses has been a significant driver of fentanyl and other NPS trafficking. In March of this year, for example, the board launched its guidelines to prevent the diversion of equipment used in illicit drug manufacture. We want to allow a wider, more effective public-private partnership with manufacturers, online marketers and movement and monetization sectors to exchange information and build national capacity to detect drug traffickers’ attempt to exploit legitimate industries for illicit purposes. The grid based efforts to more effectively utilize the board’s data exchange platforms allow the board to discover enhanced trafficking and a new class of dangerous synthetic opioids. Professionals reports further expanding its public-private partnerships to governments to encompass legitimate regional e-commerce and b2b brokers, Internet service providers and global search engines, marketing and social media platforms, online financial service providers and express mail and courier services. These efforts were providing our partners with expertise as well. The board’s work with its partners in the governmental, inter-governmental and private sector has continued and expanded during the COVID period. Since March, we’ve trained almost 1000 officers representing almost 100 governments in six languages. We reiterate our commitment to use our authorities and resources under the conventions as well as the relevant General Assembly and ECOSOC resolutions to support and assist member states in addressing the problem of new psychoactive substances.

World Health Organization:  The past several months have been challenging to regions, countries, communities and individuals worldwide as the COVID19 pandemic presents a serious threat to public health. However, the public health issues posed by synthetic drugs have not ceased, and WHO continues to receive requests to guide and support member states in various ways to protect their populations against the health threats posed by NPS. Therefore, WHO continues to fulfil its obligation to act in accordance with its role and mandate within the international drug control conventions by considering the health effects of persistent NPS and making recommendations to the Commission on their appropriate level of international control. The international scheduling of psychoactive substances, including NPS, is an important multilateral mechanism to mitigate and prevent health related harms due to their psychoactive properties – WHO is mandated by the conventions to make recommendations to the CND regarding the level of international control for psychoactive substances. WHO fulfils this mandate through its expert advisory body, the expert committee on drug dependence where the ECDD recommendations are guided by provisions in the conventions and consider the risks posed to public health, as well as the need to ensure the availability of substances with medical value. Since 2016, WHO has advised the CND on the international control of 43 synthetic drugs that contribute to drug related deaths, road traffic accidents, overdoses and other health related harms. All WHO recommendations on the control of NPS have been adopted by this end, effectively increasing these harmful substances under international control. Last week, WHO convened in a virtual format, the 43rd expert committee on drug dependence took place to critically review 11 synthetic drugs that have been reported to WHO by member states and partner agencies due to concerns about new trends and drug use, and about their impact on public health. Whilst these NPS may be persistent and prevalent, their health effects are not always clear, due to sparse or limited data, challenges and their detection and reporting as well as other confounding variables, such as their frequent use and detection in combination with other substances. Consequently, a scientifically rigorous and independent process carried out by the WHO enables the determination of the health effects of a particular substance, so as to recommend appropriate international control measures. The ECDD reviewed 11 new synthetic opioids, cannabinoids stimulants, dissociatives, hallucinogens and benzodiazepines that have recently emerged in countries and have been detected in drug seizures and toxicological samples globally. The substances reviewed by the 43rd ECDD have been reported to cause fatal and non-fatal intoxications, impaired driving emergency room admissions and hospitalizations. Some of these synthetic drugs are sold online as falsified medicines and consumed by users who are unaware of the toxic effects. These substances have been detected across multiple countries and geographic regions. Thus, the scale of any adverse health effects can be quite significant. Recommendations of the 43rd ECDD will be presented to the WHO Director General for endorsement, and then presented to the UN Secretary General for consideration by the CND and these unprecedented times WHO carries on with the committee to fulfil its mandate within the international drug control conventions by providing scientifically independent advice to member states and the Commission on health related departments and international control of NPS. In light of today’s theme that the adverse health consequences and risks associated with new psychoactive substances have reached alarming levels, I thank you once again for this opportunity to speak on behalf of who and reiterate the organization’s commitment to addressing this important health issue through the ECDD. Thank you

Dr. Shane Baku nominated by the Vienna NGO committee on Drugs – to be added.

China: I would like to present NPS control and research gap in China. As you know, NPS is a complicated issue. In 2015 we started NPS scheduling, we have a list we call it the list of non-medical Drugs and psychotropic drugs. And we have a standard how to schedule them. We have an expert committee to estimate the risk of NPY by scientific literature, animal experiments and cast report determining whether substance should be controlled. Last year, fentanyl and analogues were all under control in China. This is a significant step for control and now we have 117 kind of NPS listed.

I’m a psychiatrist and I report some clinical cases on NPS. Our problem number one is ketamine. After COVID-19, I have some patients with abuse, but I have a totally different manifestations such as aggressive behavior. And actually, the Ketamine was mixed with other substances. This is a long problem in China, especially with heroin dependence. We also have cough syrup that is very popular among young people who abuse this medication. I have two patients who used the cigarettes with synthetic cannabinoids and we also have some problem with nitro. […] Thank you.

Dr. Antonia Pascal, Uruguay: I am talking about my experience as a medical clinical toxicologist in the field I am working in assessing and treating users with substance use related problems in the emergency department and clinics for substance use disorder so … This is my toxicology point of view.

As it was said in one of the interventions today, the emerging substances mimic other substances that are already under national or international control. So, there are some aspects to consider their health perspective. The alarming numbers reflected by the high prevalence of NPS speak for itself in term of public health and their effects in countries and in NPS users. The way of obtaining the substance also turned out to be relevant particularly in this particular situation this year, for example the sale by internet played a more important role. NPS are mostly used by vulnerable populations as is the case of synthetic cannabinoid receptor agonists showed us for example, homeless or imprisoned people. The poly drug use or the polysubstance use will determine some difficulties which we will analyze later. There is a lack of strong evidence about the abuse or dependence. There are substances in which it is not expected to generate dependence for its own pharmacological properties and mechanism of action, like some harmful algae for example, this fact does not reject any technical risk. The form of consumption is another important aspect to highlight when we refer to health concerns. The presence of adulteration and substitution is also a large issue, because overdose can happen when users haven’t achieved the effect expected for the substance that the user think they had.  During the pandemic, changes in the pattern of use can also cause issues. The evidence of the acute toxicity of NPS and acute intoxication that we have, that they are similar to the classic drugs or even with our more harmful effect. So, the substance use implies limitation in clinical diagnosis, increase acute toxicity for example the combination of stimulant-stimulant-depressed and depressant with dissociatives. And the chronic use is another thing that it’s very important because we have evidence of cognitive impairment, respiratory diseases. Okay, so, very briefly, this is our early warning system and I want to highlight the importance something else. The information that we have about tablets, crystals and blotters are analysed – for example, we have an analysis of LSD blotters, which contain fentanyl, and we have a public health intervention and vigilance in Nepal, Poison Control Centre and the availability of Naloxone in all the medical salvages in your world. Perhaps the use of NPS are more related to rave and electronic music festivals. And we have some studies that were performed by the faculty of chemistry that detect NPS in the urine of festival goers.  I want to highlight the acute toxicity, the chronic effects the poly substance use associated.

China: I would like to talk about Ketamine and Tramadol.  As a doctor, I know the adverse effects of these chemicals. Unfortunately, these are not under international control. So are there any agencies who proposes these two chemicals into the national control list. Thank you very much.

[Justice] I think when you’re looking at opioids, you get a dilemma of having a bad drug and a good medicine. And it’s important to have a balance between drug control and the public health responses, especially with regard to adequate access to opioids for medical and scientific use. When WHO presented a review about Tramadol – it was very clear in the report that it recognized the adverse effects of Tramadol. But it also recognized that taking Tramadol out of the market, in some areas where there are no alternatives is going to create another crisis. So, it’s been a case of balancing two opioid crisis, misuse and access to medicines. A number of activities are going on in the field as part of the UNODC opiate strategy, one involves working with countries in Asia, where most of the Tramadol was coming into places like West Africa. We have seen progress, but there’s still a lot of work to be done. And I think maybe my colleague from the health and treatment branch might be able to expand on that. But one has to be careful that when you are pushing for drug control for a very useful medicine, you do not end up in a scenario where you deprive people will really need those substances for medical use.

UNODC: In my interventions that I have later on, I would touch on this issue. Indeed, many NPS are pharmaceuticals – in all of these cases, whether they are controlled under the conventions are not, there will need to be a balance between making sure that the people who need it for medical use have actually access to it, and preventing diversion and no medical use. Now, this is a tricky balance, but it is entirely possible. We have a lot of experiences in working at national level, and together with many international partners to try and get that balance better. In many of the countries, mostly low- and middle-income countries, where this is still not completely balanced, and where, in fact, who is paying the price is the people who actually need the substances… we believe that working on this aspect might also have a positive effect on the illicit market. Many people start using – why? Because they don’t have access to the pharmaceutical in the normal health system. So, putting that balance right, would also have a positive effect on the on the illicit trafficking and market. There will be many experiences tomorrow. So, can I invite everybody to be active participants tomorrow as well? Because many of these examples will be shared tomorrow.

UNODC: I will talk about some health risk associated with the use of new psychoactive substances a bit later. I will stress that there are these critical enablers, strategies that needs to be put in place to make the interventions, the prevention interventions or treatment and care interventions, effective. These are also looking at the legislative framework and involving the community in the response.

El Salvador: Especially given in geographically speaking, we may share some of their problems regarding the flow, and trends of NPS use. It’s about two clusters of questions. Number one: Is international database network in real time good enough to adequately allow us to detect these trends in order to be better prepared to face and control abuse before it even happens, or counteract intoxication cases effectively? Second, will surveillance on the tendencies with closer follow up data on a typical case, intoxication cases be gathered from hospitals or by law enforcement units to better fill such database and aid stopping flow of substances through customs? And are there any new international efforts on strengthening such information network for a better suited early warning system? And then the other group of questions are as follows: In the pandemic setting, is data being gathered about the abuse of NPS related to depressions or distress related problems caused by prolonged confinement? Has a trend already been established? And are there any prevention plans  being formulated in order to better support new vulnerable groups afflicted by confinement? That will be it. Thank you.

Mexico: I would like to answer point by point. First of all, it is very important to have kind of a Sentinel system and real time information regarding all these phenomena. In Mexico, we are working in our new and very robust National Drug Observatory, which we think is a very important tool. And we do it together with the district attorney and the law enforcement units. It’s also very important to take into account what happens in hospitals because this is a very sensible thermometer and as you can imagine, today, with the pandemic, we have a little bit less capabilities – or a lot less capabilities to follow these situations especially regarding post mortem studies. Now, it’s very difficult to conduct them because of the situation that explains itself. And I do think that the international collaboration, the multilateral action is absolutely necessary. Regarding our brothers and sisters from the cerebral border from an example, we have in Mexico now more than a million migrants marching through our territory. And we do believe that they may be some implications in these migrations with drug phenomena. And of course, once again, the COVID pandemic has not stopped us, but it has put a lot of weight on our institutions. And in Mexico, we are creating a great plan to attend the mental health needs of our population. And this is a challenge for the long time. Thank you very much for the floor and your questions.

United States: We do have a couple of questions: one of them concerns the grits programme, which I think is perhaps a new programme for a lot of the delegates in the room. I wonder Ambassador Johnson, if you might be able to expand and give us some description of the practical effects of the grids programme, some operational successes, if you will, that we might have seen in the short time that we’ve had the grids programme? My other question is to the medical professionals on the panel: when we look at the drugs under the drug conventions, my primary area of inquiry is the risk of abuse. What I heard today, particularly from Mexico and from Uruguay, is that issues with potency, toxicity, chronic impact, whether it’s renal failures or chronic mental health issues, that these are aspects of the dimension of the problem that are very important. And yet our drug legal framework doesn’t capture these, should we perhaps as the commission, take a greater role in evaluating the harms caused by the substances by looking at these factors. Thank you very much.

INCB: Thank you. I’d say that, that there are a group of four areas where we believe the grid programme has had a rather practical and rather rapid impact. One is the discovery issue where the use of the data platform has allowed us working with a broad array of partners to discover NPS that we weren’t aware of that are becoming substitutes; the control of fentanyl in China has eliminated it from international commerce coming from and illicitly. But the people that are in the business of trafficking substances are finding new paths… Then, the second I’d say is operational and this is that we’ve been able to find many small shipments which would not to be of interest to an individual police agency. But we’ve been able to see a web of transactions and allow police agencies to work together using the data that they’ve discovered on these platforms. Third, I’d say is training, I mentioned that we had vastly expanded our training opportunities, using the incentives of attending to get together this way, rather than coming together physically, and have been able to train almost 1000 people just in the last several months, on the platforms that they use, as well as how they can work together. And finally, the working together piece … that’s the convening opportunity that we have to bring together people across industry – in the IT world and help them to work together better and help them discover issues that perhaps they didn’t know about. When famously a search engine provider, who’s everyone to use but I won’t mention their name, thought that they had eliminated many opportunities from their programme, but discovered that the photographic opportunities that they were providing, still people could be looking for drugs. We were able to help them understand this, and they were able to pull this, if you will loophole from their site. Thank you very much.

Mexico: Thank you again, as a clinician I believe that we have to pay a lot of attention in everything regard to the health-related consequences of consumption. There is a gap in time between what’s happening with the health of the population and the time that we are actually taking measures to focus on one single single substance. In Mexico, we do not have an epidemic of overdose deaths regarding the use of opiates. This is concentrated in a few cities in our northern border today. Thankfully, because we have a very restricted medical narcotic market. In Mexico, we do not have cases or almost no cases of HIV or hepatitis C by injecting… we have sexual epidemic. It’s not an injecting epidemic. We do have a very dire situation. As I said earlier before, with the people that use crystal meth, we see a great degree of decay, both mentally unhealthy, and they develop what we call triple diagnosis, which is mental health problems, drug addiction, and HIV Hep C complex. In Mexico, we have very little control over Tramadol, and we do not see widespread use of this drugs. We do not understand exactly why. But this is an interesting point I would like to point out.

Uruguay: I think that this question is very important, and I want to highlight, as a clinical toxicologist the abuse potential is very important. But also, the health consequences of these substances include all the aspects related to acute toxicity and acute intoxication – intervention is mixed with a poly drug use at its enhanced toxicity, perhaps limit some clinical diagnosis. The one problem that we have with NPS is that in the clinical settings, we don’t know how this composition works. So, acute toxicity is determined by the substance, but we are talking about risk of public health… So, toxicity is involved but also other risks are associated – for example, impaired driving, risky sexual behavior and the prevalence of. So I think that health consequences must be on the floor when we analyze NPS, it’s a very important issue to highlight. Thank you.

[Justice] I’d like to perhaps reassure distinguished delegates from the United States that international drug control conventions make, make an effort to look beyond liability to abuse, it actually looks at the risk to public health as well. If you look at schedule two, you’re looking at a substantial risk to public health and limited usefulness. So in the scientific evaluation, we do go beyond liability abuse, go beyond the dependence producing activity and also look at different levels of risk to public health.

Nigeria: Apparently, the responses are more about the concern that placing Tramadol under international control could affect medical availability. We are a country that is highly affected by nonmedical use of Tramadol – we think it is a consequence of the lack of international control. Everybody who require Tramadol would have to get it from a licensed place, but the black market is very accessible. My question is in regard to achieving a balance: where could Tramadol be placed?

UNODC: I would just like to underline; it is possible to address through legislations and regulations to address the management of the supply chain and to support health workers. A great way so as to make sure that the people who need that medication have access to it. And indeed, there are places where the balance goes off kilter.  But let us not forget in many, many countries, what is available on the illicit market, the potency is so different.  So let’s be realistic when we talk about the diversion and make sure people who need medication have access to it.

[Justice]: I had a chance to practice pharmacy in a region where Tramadol is largely abused. Like UNODC said, when you look at medical purposes, the strength is very different in the settings we are talking about. If you look at the last scientific assessment for Tramadol, we see that we do have a problem with non-medical use. We do have a problem with high levels of Tramadol being translated into violence etc. If you know about the pharmacology of Tramadol, but here again, it’s that tricky balance. I will leave the scheduling recommendations to WHO.

[Indonesia]: I would like to respond to the United States being psychiatric myself and seeing Patients coming in with issues on NPS…The practical issues go way beyond Tramadol and Ketamine. So, taking this floor I would like to actually propose that we go beyond just looking at the toxicology but also prevention at large starting from. Right now, we see people coming in with substances that are not actually what they think they are taking and are experiencing adverse effects – taking this aspect into prevention and how we are dealing with NPS is important. There are not only psychological issues, there are liver failures etc. We know those who use NPS, they are also using classical drugs and when they don’t have access to their first choice, they use NPS.

Russia:  I would like to start thanking the panelists for their interesting and insightful presentations which clearly show the NPS situation now. I have two questions. So, the first one to the ambassador and the second one to the representative of the WHO. I understand that in order to assist member states in tackling their spread of new psychoactive substances, several UN entities are involved in such activities. So, we are very much appreciative to receive an update on New programmes of the INCB Secretary – My question Ambassador Johnson would be whether the INCB is cooperating on this issue within this programme with the UNODC. My second question relates to basically the risk in response to the comments made by our distinguished colleague from USA regarding a necessity to improve the legal framework for cooperation on addressing the NPS threat. The conventions already provide this legal framework and moreover, their division of labor between the different entities. So, I would like to just to clarify it with an expert of the WHO, whether they will continue providing this kind of assessment to the commission.

INCB:  The short answer is yes. We work closely with the UNODC as well as others and we’re focusing on where we believe the board has a comparative advantage and that is training and data collection so States Parties can more effectively provide services to their populations and protect them. And, and also, I’d say as a convener, we have a special status there that we are using we believe in the best interest of all concerned.

WHO: We work in close collaboration with partners – UNODC and INCB in addition to other Regional agencies such as EMCDDA to determine the kind of substances that are being detected amongst countries and causing some of the most significant harms to public health. So multi faceted coordination between these agencies continues to be a priority for us, both in determining which substances should be reviewed by the ECDD and also I’m working with INCB to ensure that the recommendations are being implemented and forwarded to this end.

Mexico: Clearly, on the challenges and priorities section of the joint ministerial declaration 2014, we said we’ll deepen our knowledge of the challenges posed. Whereas paragraph a 28 of that section speaks about better understanding the new and increasing challenges by collecting and sharing data on the production distribution. So we need to strengthen our working now with regard to not only the effects on the user but also in the communities, the families, societies and states – perhaps the UN common position policy paper would be of a very good use. My question is for INCB: UNGASS recommendation 5 develops a number of tasks or commitments for addressing NPS, but in particular, my question is related to the use and the actual impact of the guidelines, the voluntary code of practice for the chemical industry of the model for memorandum of understanding between governments and private sector partners. […]  So the concrete question is: what has been the effect of those guidelines? Have they been useful or should we revise them or should we develop new ones as was foreseen at the time?

INCB: Will respond in writing.

Chair: We are experiencing some technical issues, so I close this interactive session. Now, we continue additional experts from delegations of NGOs and civil society.

UNODC: Thank you, Mr. Chair, for giving me the floor and the opportunity to present to you today the UN toolkit on synthetic drugs. The toolkit assists member states to find practical solutions to address the synthetic drugs problem by giving them a wide range of tools and resources all in one place. I’m now going to walk you through the toolkit – it is a platform that acts as a one stop shop to pull together comprehensive and practical resources from multiple disciplines across the UN system under one umbrella. The toolkit is divided into different modules, and each module covers different areas such as forensics precursors, legal postal security, and continuously we will be adding more areas to it. So, this month, we relaunched the toolkit on a new website. And I wanted to quickly demonstrate, but I’ll try to explain as good as I can without my screen. We will be dealing with lessons learned for strengths and responses during COVID-19. Within these modules, you will find key messages and responses, information as well as guidance on health responses. More specifically, you will find guidance on different areas, such as responses to the evolving online trafficking, the impact on border control and how to ensure postal security. The toolkit also profiles the protecting those that protect us initiative, which focuses on how to protect online officers, our frontline officers from the risk of exposures to synthetic drugs, as well as COVID-19. To ensure the safety, for example, you’ll notice we produced a video series for frontline officers on how to use PPE while executing that duties. Lastly, the module also identifies guidance from WHO, pointing to where to find the latest information from WHO on how to protect yourself and others from COVID-19 a well as guidance from UNODC on how to address the needs of vulnerable groups, including people with drug use disorders. Once again, the UN toolkit on synthetic tracks, with its practical tools and resources, has been just relaunched on its dedicated website and can be accessed directly at Thank you very much, Mr. Chair.

Global Forum for Teachers and Educators, Pakistan:  Pakistan is committed to eliminate the menace of drugs, and to make Pakistan a drug free nation. We have been in cooperation with many organizations to combat trafficking. However, drugs are still easily accessible to the people of Pakistan. The market of new psychoactive substances is a threat to Pakistan, as is an emerging phenomenon. Synthetic drugs, such as the use of ecstasy are accessible to young people within the educational institutions in cafes, kiosks, parks, blind corners, and restaurants. Young people, both males and females usually start using drugs, due to many reasons, including but not limited to, as an experimental thing, or due to peer pressure. In most cases, it turns into a chain addiction. The highly increased use of psychoactive substances among youth, particularly students has escalated mental health challenges among them, such as memory loss, fatigue, psychiatric diseases, hallucination, social isolation, depression, schizophrenia, and suicidal tendencies. It has also resulted in their participation in drug peddling violence and extreme crime. One of the reasons is the lack of awareness about its consequences, including of courses on drug education at any education level in Pakistan, which in my viewpoint can play a significant role in preparing youth to keep themselves away from drug abuse. The National anti-narcotic policy of 2019 is a promising document that has highlighted the emerging trends of new psychoactive drugs. It is underlined to prevent and counter the emerging challenge of synthetic drugs and new psychoactive substances. By developing the capacity to detect and identify those substances, and strengthening law enforcement, criminal justice, and health responses. For the prevention spectrum, I request the policymakers in the educational institutions to introduce a mandatory course on human rights, education and education at the national level, so that young people can take ownership and refrain to get indulged in drug practices. Alongside this, we need to provide them guidance and counselling to the establishment of social counselling units at the institutional level. I present my social equal ethical model of human rights education to the competent authority that may help in promoting human rights values among youth.

UNODC: So, in my presentation today I will talk about HIV, hepatitis B and C prevention, treatment, care and support among people who use new psychoactive substances. The previous speaker gave a lot of information about the new psychoactive substances, we call them new because they recently came on the market as and as you heard earlier, they mimic the properties of substances that are already under international control. But despite of ongoing schedule, there are three times as many identified new psychoactive substances then there are that psychoactive substances under international control. There are stimulants and synthetic cannabinoids. There are the opioids as you as you heard, before, there are fentanyl analogues.And depending on the formula, then you have psychoactive substances can be taken orally, smoke inserted annually or ingesting. And I am giving you this information because we will talk about the health risks related to stimulant NPS use.

I will talk today about HIV Hepatitis B and C and the transmission is through injecting route where risk is higher because these substances have a short lasting and they need to be injected more frequently and by injecting more frequently. There is a greater risk to share the injecting equipment, to reuse them and to share the rest of the paraphernalia, plus there is all sorts of scope for sexual transmission. And of course, these substances will inhibit and will make those people who use them to take more risk behaviors. And there are certain groups that are more vulnerable to this like men having sex with men, people involved in sex work and transgender people. Acute intoxication with NPS was mentioned here several times – it constitutes a high risk because very often the first responders or the people in the emergency health services have a lot of difficulties to identify what substance this was. Also we talked about the high number of substances. So what was UNODC’s response so far? Last year, we launched the technical guide for HIV prevention, treatment, care and support for people who use stimulant drugs. And this guide describes a set of interventions we call them core intervention, eight interventions that are proven to be effective in the attempt of preventing HIV and hepatitis B and C spread among people who use these substances. And these interventions, as you can see, on the screen are condoms and lubricants and safe sex programmes, needle and syringe programmes and other commodities. Because you know, there are smokes or can be pipes or other use of transmission, HIV testing, antiretroviral therapy, evidence based psychosocial interventions and other drug treatments, prevention and diagnosis of sexual transmitted infections, hepatitis and tuberculosis, targeted information and education as mentioned before the management and prevention of acute intoxication and overdose. For these interventions to be effective, there are critical enablers like supportive laws and policies, community empowerment, addressing stigma and discrimination, providing alternatives to arrest incarceration and compulsory treatment and preventing and addressing violence. So a training package was developed based on these interventions and we had trainings in many parts of the world when this was possible face to face in Eastern Europe and Central Asia – we had a regional training addressing specific the new psychoactive substances and HIV prevention and hepatitis. And to conclude, during the COVID epidemic since March, we issued technical guidance, and we had a series of 10 webinars addressing all sorts of issues related to the continuity and sustainability of the HIV prevention interventions and one of them was focused on stimulants and new psychoactive substances.

NGO Corporation Accion Technical Solution Colombia: Colombia has become not only a drug producing country but also has an increasing trend of drug consumption. According to studies performed by the National Drug Observatory of Colombia, increasing consumption is related to our offer of new psychoactive substances. Harm Reduction programmes have a preventive effective. Drug checking is a strategy that lets people look to know the composition of the samples through chemical analysis. There is evidence that drug checking has helped to reduce the number of risks as well as short- and long-term adverse health effects of drug use. In line with it, my NGO accenting analyzed more than 1000 samples since 2013 and had a positive impact on over 102,000 people. Most of the chemical analysis was carried out with a reagent testing kit during Music Festivals and another events. These testing kits are not able to identify every single component nor its concentration. During the 2019 laboratory tests that the NPS like cathinones phenethylamines, ketamine, and in some parts MDMA, crystals, ecstasy, LSD, and an imagined drug cocktail […] the constantly changing adulterants like synthetic cathinones increasingly are present in MDMA and ecstasy samples. These psychostimulants carry an abuse potential and have a vast number of negative effects on different organ systems. The appearance of new synthetics on the market is growing. Furthermore, drug to drug interactions and knowledge of their effects are not well established yet. But it is an extensive habit among people who use drugs, but it is usually performed with the objective of counteracting some undesired effects of any substance for improving the psychoactive experience. However […] in our tests, we saw caffeine, MDMA and ketamine in samples. It is important to the highlight that checking with modern instrumental analysis like proton spectra, metric, chromatography, analysis, and other techniques are needed to detect the real composition of those complex samples. For this reason, my NGO would like to invite civil society organizations, private entities and government to strengthen our responses with integral, timely, early warning alerts. When your provision has not been able to eliminate either production or consumption, it’s time to take care of user needs, with new tailored strategies, and policies based on evidence on the legal regulation exists to allow for safe access. Thanks for your attention.

UNODC: I want to look at prevention, treatment and care and mentioned access to control medicines. As we were saying before we start with prevention. It gives me this opportunity to show you again a graph that Angela used yesterday showing the association between perception of harm and use with us clearly increasing as perception of harm decreases and vice versa. And this is relevant because of course as we have mentioned, some NPS are in fact pharmaceuticals and they might be perceived as less harmful. Now the challenge with preventing drug use is that perception of harm is a key vulnerability factor. We have heard this before. But other factors are also important as shown here. And especially in the case of very marginalized groups, in fact, in the prevention standards that we have published together with WHO in 2018 we have found that there are many interventions and policies policies that are effective in preventing drug use, not only increasing the perception of harm, and the vast majority of these evidence based strategies are not specific to different substances, because they’re really about the healthy and safe development of children and youth. So, the effectiveness of evidence based prevention education in school, that is the green line. Or combined with family-based prevention, that is the blue line [in my presentation]. If a country has an NPS problem, the first response is the building of an actual long term investment in a prevention system, which would include interventions for settings or groups that are particularly at risk, such as marginalized population or, for example, multicomponent prevention programmes in entertainment venues, of which there are good examples all around the world, and they are included in the standards. Now, if people start to use or worse develop drug use disorders, they will need treatment and care. And this is where specific attention to the actual substances does come into play. Because as you can see from this study from the UK, clinicians do feel less confident in managers cases of acute toxicity of NPS. And this is very understandable given that these cases can present with different or more severe harms than usual for from the very high potency risk of overdose of fentanyl to the increased risk of psychotic symptoms and cardiotoxicity, of synthetic cannabinoid receptor agonist. Too many substances come into the market too rapidly for the clinicians to keep up. And particularly with NPS, no one really knows what has been used. That is why it is necessary to join forces, it’s necessary to train clinicians in the management of these acute medical complications. And this should include what to do in the case of an unknown drug abuse. And we had the possibility to do this, to join forces with the governments of Kazakhstan and the United States – a real tripartite initiative, everybody chipped in to provide much needed training to frontline clinicians. And we should all do more of this. In addition, it should be noted that many people who use NPS are reluctant to access traditional treatment, because they feel the services do not understand their culture. And to address this, there is no way around it, we need to build strong treatment system that combined outreach and evidence-based services tailored to the needs of the population. And such system can be built by applying the standards, the training and accreditation and quality assurance tools that we are developing. And by looking worldwide, thanks to the generous support of the United States. I have one final call about stimulants. It has been already mentioned why they are so relevant in the context of HIV but the fact of the matter is ,unlike for opioids, we do not yet have every option format for pharmacological therapies to provide treatment and care to people with stable disorders. Last year, we have published a review of existing science and I would like to call to the international community to join forces with us and develop trials for pharmacotherapies to complement existing psychosocial therapies for people who use stimulants, including NPS stimulants. And finally, let me conclude by saying as I was mentioning before, that because some NPS are in fact pharmaceuticals,  that are controlled under the convention to promote the health and wellbeing of everyone is crucial to balance the need to ensure access to the substances for those who need them. So, I warmly invite you again to participate actively tomorrow as well.

Singapore: Singapore’s approach towards controlling, like some of the other member states, is  a proactive approach to control NPS. In 2013, Singapore amended our key drug legislationand introduced generic and temporary shuttling to prevent the proliferation of NPS. The generic approach allows Singapore to control a large number of substances that share similar molecular structures. While the temporary rescheduling allows us to take specific NPS, research and industrial consultations take place to determine if they are legitimate users, or the listed substances. Our national forensics laboratory also has a critical role to play in identifying new NPS to place under national control, and redefining the definition of assisting generic NPS groups to ensure its effectiveness. As the NPS market is highly dynamic, it is paramount for enforcement agencies and national forensics laboratories work closely together to ensure that we keep up with the latest trends. However, it’s important to do this … alone in Nepal supports the 2016 UNGASS outcome document, which calls for member states to enhance the capacity of law enforcement agencies to detect and identify NPS and more cross border operation and information sharing inhibit the proliferation of NPS. On our share on international cooperation, Singapore welcomes UNODC’s efforts in the regular sharing of information […] Our Forensic Laboratory also regularly communicates with counterparts from around the world to exchange information on NPS. In July last year, Nepal collaborated with the Colombo Plan drug advisory programme to host a second International Symposium on forensic drug and  in August, Singapore also collaborated with the UNODC to host the 11th global smart open regional workshop for East and Southeast Asia. Such collaborations are part of our commitment to work closely.

European Union: I have the honor to speak on behalf of the European Union and its member states and the following countries align themselves with this statement: Turkey, the Republic of North Macedonia, Montenegro, Serbia, Albania, Bosnia and Herzegovina, Ukraine, Iceland, Norway, the Republic of Moldova, and Georgia. Mr. Chair excellencies Ladies and gentlemen, according to you and UNODC’s world drug report, in 2020 roughly 500 new psychoactive substances or NPS are found on the national markets. While the overall number of NPS has stabilized, their types have changed an increasing number, but some are also from diverse and new groups. Synthetic opioids have proved both potent and harmful, fueling overdose deaths in some regions of the world. When many NPS tend to be transient on the drug market markets, patterns of NPS use have been observed among marginalized and vulnerable groups. And we’ve heard about that earlier today. In particular, the use of synthetic cannabinoids. This is true also for Europe. In a 2016 study of the EMCDDA, over two thirds of countries reported that they are used by higher risk drug users and result in health concerns. In particular, the use of synthetic cathinones are used by people who use and inject opioids and stimulants have been linked to severe health and social problems. In addition, the smoking of synthetic cannabinoids in marginalized populations, including homeless people and prisoners, has been identified as a problem in a number of European countries. Mr. Chair, according to the European drug report, 2020 new psychoactive substances have become a more persistent problem. Over the past three years NPS have been selected for the first time in Europe at the rate of around one per week. 53 substances were detected for the first time in 2019. The US early warning system is monitoring around 800 new psychoactive substances, of which more than half are available on the European drug market in any given year. The international community has reacted in a timely manner to assess the harms caused by NPS and to schedule those that weren’t under international control. The EU early warning system and the UNODC early warning advisory helped to keep the international community abreast of developments. Both the European Union and the Commission on Narcotic Drugs have acted swiftly in recent years to schedule the most harmful new psychoactive substances. The European Union adopted new legislation in 2017, to speed up the process of banning NPS. All this helped reducing the growth in NPS. The overall consumption levels of NPS are still relatively low in Europe, and few people currently enter treatment in Europe for problems associated with the use of NPS. Nevertheless, NPS continue to represent a serious threat to health and security due to the number of potent opioids, synthetic cannabinoids and benzodiazepine appearing on the market and the associated health emergencies and deaths. It is our responsibility to continue to address these problems while paying special attention to younger consumer groups, as well as vulnerable and socially disadvantaged groups, including the homeless and prison populations. Mr. Chair, we are convinced that our full attention needs to focus on further strengthening national, regional, and international action. In order to address the challenges of NPS including their adverse health consequences. We need to develop appropriate measures including early warning mechanisms, and appropriate prevention and treatment models. And we have to suppose the scientific evidence-based review and scheduling of the most prevalent persistent and harmful substances. In conclusion we reaffirm our commitment to promoting and protecting health, including access to safety, and the wellbeing of humanity. Thank you for your attention.

Chair: Thank you. Lunch break.

Nazlee Maghsoudi, Centre on Drug Policy Evaluation: Distinguished participants, I represent the Centre on Drug Policy Evaluation and will focus on our experience operating the first and only drug checking service in Toronto, Canada. Opioid overdoses continue to rise in Canada and elsewhere and have been exacerbated by the COVID-19 pandemic. Given the primary cause is highly-potent synthetic opioids in the  unregulated drug supply, drug checking has been adopted across Canada to prevent overdose. Toronto’s drug checking service offers people who use drugs information on the contents of their drugs, helping them make more informed decisions while also uncovering in real-time the makeup of the drug supply. Our service has detected NPS that cause health harms, including  scheduled NPS. I will focus on one trend among many. Last month, an alert was issued by our service as carfentanil was detected. Carfentanil is an  ultra-potent synthetic opioid that was internationally controlled in 2018, yet has remained available and is responsible for deaths in several countries. It’s important to recall that the opioid supply moved towards carfentanil after less potent opioids were controlled. In 2016, one fentanyl analogue and two fentanyl precursors were scheduled by  the CND. Carfentanil was subsequently detected in Toronto’s drug market, and has remained  despite itself being scheduled internationally two years later. This reflects a reoccurring phenomenon across drug classes, described as the beforementioned  “displacement/replacement effect” or the “Iron Law of Prohibition,” that scheduling is followed  by a move towards more highly-potent – and thus more easily trafficable – comparable  substances. “As law enforcement becomes more intense, the potency of prohibited substances  increases.” Scheduling has been unable to stem the rise of highly potent synthetic opioids, much like the so called “cat and mouse” game experienced with NPS in other regions. Blanket bans, new  prohibitions, and enforcement crackdowns have been unsuccessful in curbing supply and  demand globally and have invariably led to market mutations that increased harm. Member states must examine the ramifications of supply reduction interventions before implementing them and consider if health interventions are better equipped to reduce harms. Balance has not been achieved in this regard. Resources for law enforcement could more usefully be redirected towards tailored health interventions, developed with people who use drugs and civil society. Decriminalization of personal use and possession, as recommended by the UN System Coordination Task Team, must be seriously considered. Expanding access to pharmaceutical-grade alternatives, or “safer  supply” as discussed yesterday by Canada, is a critical response to the poisoned drug supply. I urge member states to acknowledge what the evidence shows: scheduling drugs and pursuant enforcement approaches have been ineffective in reducing global demand and supply, and have had severe negative consequences on marginalized populations. I further urge member states to act where efforts are most needed and effective – by prioritizing and investing in evidence- and rights-based policy, health, and harm reduction interventions. Business as usual has proven ineffective and harmful. It’s time to reimagine how the global drug control system can best uphold our collective obligation to protect the health and welfare of humankind. Thank you.

Chair: I see we have no questions, then I would like to continue with the National statements,

USA: Thank you very much, Mr. Chair. I would like to congratulate today’s presenters who have provided excellent contributions to the discussion. The rapid proliferation of new psychoactive substances is one of the greatest challenges that we face as drug manufacturers and traffickers are constantly innovating. These manufacturers and traffickers are creative, resilient, shifting sales online to the dark net and using noncontrolled precursor substances, known as designer precursors, to circumvent international and domestic controls. NPS are not the only evolving threat, drug availability and use patterns are changing. As the evidence indicates, synthetic drugs, including methamphetamine contribute to the existing opioid crisis. In other words, we’ve been experiencing the impact of both synthetic opioids and rising methamphetamine substance use disorders, despite our best efforts to keep up with these bad actors, we are not working fast enough, and it is adversely affecting the public health and safety of citizens across the world. Just as was mentioned this morning that we are now tracking over 1000 synthetic substances – this is of great concern. We must remain committed to working together to broaden international controls of these dangerous substances and stay up pace with traffickers. We must continue to leverage international cooperation to share information and intelligence at the national, regional and international level. As NPS proliferate and new illicit flows and modalities emerged to reach markets. Real time information exchange is paramount – sharing of information on changing substance, use patterns and public health harms, from emerging drug threats such as NPS to informing responses at the national, regional and international levels, such as providing WHO’s expert committee on drug dependence, with specific evidence enabling assessment and subsequent recommendations for international control of several dangerous NPS. Robust and accurate information is vital to inform our neighbors and the international community of a nutrient or modality of a criminal organization. The United States is dedicated to bolstering the capacity of member states to detect and report new trends substances and flows. The US applauds the work of UNODC to turn information into actionable outcomes. Recently INCB’s operations translated into the arrest of a darknet trafficker, which had hundreds of NPS around the world, these programmes strengthen the capacity of member states to generate and manage data and use information on illicit synthetic drugs. Furthermore, we’re proud to support a new effort to train national law enforcement entities to identify and interdict cyber assets, used to facilitate online trafficking of drugs and the precursors. The UN toolkit on synthetic drugs offers a library of national level interventions that can help guide countries in identifying and addressing network synthetic drug threats, including legislative approaches such as class wide scheduling models, forensic capacity building and enhancing controls and precursor chemicals by utilizing these strategic tools and improve our ability to rapidly recognize substances. We are not alone in this fight, our partners in the private sector are committed to sharing information on new trends securing supply chains and keeping illicit substances, out of the hands of traffickers, as a follow up resolution this year on enhancing public private partnerships to combat the world drug problem. We look forward to our newly established programmes with UNODC and INCB to enhance public private partnership programme activities, including the development of a platform to share best practices, and the toolkit component and meetings of government and industry representatives to develop recommendations for collaboration to address synthetic drug trafficking. I will end by stating that as criminal modalities change the need to sustain evidence-based prevention, treatment and recovery for people with substance use disorders remains the same. We urge member states to increase the amount of voluntary resources to address this issue commensurate to the magnitude of this increasing challenge which we are facing in today’s international community. Thank you very much.

Paraguay: Many thanks to our presenters and panelists for their contribution to the meeting, and for having focused on like on these recent developments on the world of illegal drug trafficking, and particularly on NPS. In this scenario, and within the storage practices of illegal markets, investigative authorities from Paraguay have noted the shifting in dependency, where organic drug producers are not often synthetic drug producers, and thus become either transit, or destination countries … the issues will go far away and we do not have a health problem caused by NPS. We know the danger that they pose, and we’ll continue working with the UNODC, the INCB and other governments from the region to strengthen our early warning systems, investigative efforts and on the type of drugs, and our reporting system to the UN agencies; we reiterate our willingness to start working with aircrafts from UNODC international airports. On the adverse health consequences and risks associated with NPS and its trade: First we need to emphasize the fact that we need to find a proper balance between the misuse of non-controlled pharmaceuticals, the diversion of internationally controlled substances to illegal markets with proper illegal traffic. In recent years, I have seen a rise of consumption, that increased NPS within young people in large scale, accompanied with the appearance of ecstasy – we have seized a large number of MDMA and ecstasy pills. That is all from our Chair, thank you very much.

Australia: Australia remains concerned about the significant dangers and challenges posed by synthetic drugs such as New psychoactive substances which continued to constitute a serious threat to public health and safety. We’re concerned about reports, increasing purity availability, and about the potential opportunities for transnational serious and organized criminal groups to exploit the market for these substances. For Australia, our synthetic drug problems are often associated with significant health, social, economic and community harms that are disproportionate to those of other illicit drugs. We have sought to address this problem through an evidence-based, balanced health and law enforcement approach to the management of methamphetamine use in 2015, the Australian government introduced laws to ban the importation of synthetic drugs on the basis of their psychoactive effect or appearance, rather than their chemical structure. These laws ensure that untested and potentially dangerous substances cannot be important for use as alternatives to other illicit drugs. Under these rules, Australian border force officers have the power to stop and see substances that they reasonably suspect are NPS, it is then up to the importer to show that the substance has a legitimate use. This legislation defines a psychoactive substance to include any substance that has the capacity to induce the psychoactive effect when consumed. We welcome the UNODC’s latest global smart update which identified the adoption of national legislation of this kind, as an effective way to address the general supply of NPS without needing to list all substances individually early indications on the impact of this legislation are promising. The Australian criminal intelligence commission recently reported an 85% decrease in the number of NPS bought or seizures selected from further analysis, and a 63% decrease in the weight of analyzed for seizures for the years 2018 and 2019.In addition to our legislative response, the Israeli government funds a range of research organizations to support the delivery of innovative high quality research on methamphetamine and other emerging drugs of concern, and to support activities that align with the three pillars of our National Drug strategy, being harm reduction, demand reduction and supply reduction strategies. So, Australia is pleased to support the global smart programme, including through a recently announced contribution of 300,000 Australian dollars. Too often we have been playing catch up with illicit drug manufacturers, we need to work together to get ahead of the illicit drug curve. Australia is pleased to collaborate with other countries to learn from each other, as we work to overcome these challenges. Thank you again for the opportunity to share our national experience, and for facilitating this panel discussion today as part of our work on cmd.

Egypt: Mr. Chair, the widespread abuse of Tramadol has become an alarming public health concern specifically in the African continent, the misuse of Tramadol effectively had a negative, social, and economic impact on a lot of communities, Mr. Chair. Despite the fact the substance is not under international control, Egypt has monitored developments on the market, intercepting the illegal trafficking and seizing large quantity of the substance over the past years. Moreover, Egyptian law enforcement authorities exerted their effort to ensure the visibility and control over the required legal quantities of Tramadol to prevent the establishment of illegal markets of that drug. Mr. Chair, international control should not hinder the accessibility to Tramadol for medical use, but rather, prevent illicitly manufactured production and thus the negative consequences of Tramadol abuse. We find it necessary that it’s controlled beyond a national control mechanism. Thank you Chair.

El Salvador: We would like to say a little more about the educational focus of Pakistan on NPS. How has it worked for them, or if there’s already some measures on the effects that could be perceived by the population, or if there’s any kind of special programmes in any sustained country policies of Pakistan that we can also consult them take advantage of advice of?

Chair: Thank you, distinguished delegate. We could not find Professor Musab, but the Secretary will make the contact and you will get a call from Professor Moosa for a written answer to you. Before I’m closing the meeting of today, I would give the floor to the Secretariat for some information because of COVID-19. Thank

Secretariat: I would also today like to finish the meeting by kindly asking once more to please fill in the sheets on the tables with your contact detail as we explained this morning we will only use this for contract tracing purposes, in case there would be a suspected case. So, but if something like that was to happen it will be extremely important that we have your contact details so please leave them on your table. Thank you.

Chair: The meeting is adjourned and we meet tomorrow morning at 10:30 sharp.

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