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Informal Dialogue: WHO representatives

(Please note that, unfortunately, the first half of this informal dialogue was not recorded. If you have a copy that we could use to produce transcriptions, please do not hesitate to get in touch).

Ricardo Pareyda, Veterans Action Council: How can cannabis and cannabinoid medicines benefit from the numerous WHO programs on patient safety & pharmacovigilance, including in the context of traditional and complementary medicines?

Gilles Forte, WHO: So, basically, cannabis based medicines like Epidiolex, for example, that receive marketing authorisations from national regulatory authorities, should be treated like any other medicine, with their safety and side effects being monitored at country level but also at global level. In terms of what WHO can offer, the WHO global pharmacovigilance programme aims at collecting information on medicine side effects, including for cannabis based medicines, reported by national pharmacovigilance programmes. With regard to cannabis-based medicines, only side effects related to recommended medical use will be collected through those programmes. This global pharmacovigilance programme is coordinated by the WHO Collaborating Centre in Uppsala in Sweden.

Steve Rolles, Transform Drug Policy Foundation: The WHO provides detailed expert guidance on best practice in legal regulation of alcohol and tobacco markets that has an important role informing the development of policy and law amongst member states to protect the health and wellbeing of the public. There now over 300million people living in jurisdictions with legal (non-medical) cannabis markets in place. When will the WHO provide member states with best practice guidance on this?

Vladimir Pozniak, WHO: Indeed, we observe now such rapid changes with cannabis’ availability, marketing, use and societal responses. But, let me upfront make a clear distinction between cannabis, tobacco and alcohol from the perspective of international regulations and control. As you know, cannabis continues to be under international control, as specified for substances in Schedule I of 1961 convention, and all the requirements for regulation apply, which are usually more stringent than regulations for tobacco and, of course, alcohol; because for alcohol there is no internationally, legally binding regulatory instrument. And I’m talking about the international aspects of that. For those very few jurisdictions that legalised non-medical use of cannabis, there are attempts to apply lessons learned from alcohol and tobacco regulations, and this is entirely within national jurisdictions or subnational jurisdictions on developing and implementing these measures, which indeed have a record of impact and effectiveness in the field of alcohol and tobacco. And I’m talking now about such measures as a complete ban on advertising and marketing, plain packaging, pricing policies enacted and enforced, age limits, licencing, regulated density of outlets, driving laws under the influence of cannabis, etc. (…) and, of course, the same challenges that regulators face with the implementation of tobacco and alcohol regulatory measures. And these challenges are very significant, as we all know, and they’re significant not only at the national level but also at the international level. And they can be of course expected in jurisdictions which created the markets for the recreational use of cannabis. And they already experience that. For example, I would say that Canada is an example of quite a comprehensive (…) this type of regulations, which are based on the experiences accumulated in the tobacco and alcohol field. But, again, at the international level, cannabis continues to be regulated under the 1961 convention that allows use of schedule one substances only for medical and scientific purposes.

Eric Siervo, Community Anti-Drug Coalitions of America (CADCA): Substance use prevention is a sound investment, with every dollar invested having the potential to result in savings of between $2 and $20. However, substance use prevention has been underutilized and under-resourced relative to its ability to reduce population level rates of substance use disorders and related issues. Please explain how WHO will work together with other agencies to ensure that substance use prevention is a higher priority for emphasis in designing, developing and implementing responses to the world’s drug problems.

Vladimir Pozniak, WHO: Practically in all areas of public health, prevention and health promotion, could be considered as the most cost effective approach, while, and let’s make it clear, not denying the cost effectiveness or feasibility and importance of other approaches like, for example, treatment or harm reduction interventions. Wow WHO will work together with other partners in promoting prevention. Well, again, using every opportunity when WHO activities can make an impact. And let me underline that when resources are available for this area, because we definitely struggle with conflicting priorities on what to concentrate our efforts, in a situation of very limited resources that we have for the work in this area. Let me give several specific examples of such collaboration with other entities that aimed at strengthening primary prevention, and providing opportunities for countries to implement these measures in their jurisdictions. The second edition of the International Standards for Prevention of Drug Use, and, the first edition was done by UNODC, but for the second edition we engaged several programmes within WHO. We applied our methodological approaches for a review of the evidence and we worked very nicely, and very well with UNODC on producing the second edition, which currently is, to my knowledge, being quite widely implemented. And, of course, we informed all our country offices about the availability of such resource. The second example is that we worked with the UNICEF and UNODC on prevention approaches in educational settings. And again, this publication was released,  translated into several languages, and is being used for advancing evidence based prevention in countries. Also, WHO has several programmes where prevention is at the core of the activities. The Health Promotion programme, and we have a special department on health promotion; the programme on child and adolescent health; the programme on maternity health,…so there are several programmes which are instrumental and we work quite closely with them on ensuring coherence of messages and using all opportunities for primary prevention. And, as we know from the scientific evidence that effective prevention measures for different populations might not necessary, unless this is very targeted interventions, not necessary should be very specific in terms of substance use, drugs, or alcohol or something, that more general approaches which are aimed at social skills, at (…), these approaches, even more, have shown to be more effective in terms of prevention, and this kind of horizontal collaboration, multi-sectoral collaboration, is so important to advance prevention efforts in countries. We work with all these UN partners and other programmes within WHO, we work with civil society organisations, including those represented in our conversation today. But, again, with the available resources which may prevent us from doing direct country support, and for our country offices, of course, they struggle with different priorities, particularly now in the context of COVID 19 pandemic, when activities on prevention of drug use may definitely go to the periphery of their attention. I think we have the potential with the SDGs, with the sustainable development goal health target 3.5, which is not yet realised fully this potential, because it’s quite remarkable that from very few health targets which are included in SDG agenda, one of them are calling specifically to strengthen prevention treatment of substance abuse. This potential is still to be realised. Because there’s not much time  left before 2030, when implementation of all these measures will be evaluated. And I think it’s very difficult to underestimate the role of civil society in making and realising this potential, and of course it links with other SDG targets and objectives, but this is very specific and this is something that definitely provides a very strong mandate for advancing this work.

Adrià Cots Fernández, IDPC: What are the next steps for the ECDD in relation to medicinal cannabis, following the CND vote on the WHO scheduling recommendations in December 2020?

Gilles Forte, WHO: So, it is planned that scientific and communication material on the rationale of the ECDD recommendations will be developed and disseminated to increase awareness around the recommendations. At the same time WHO ECDD Secretariat will continue to collect information on medical use, as well as information on harm, abuse and dependence of cannabis and cannabis products as part of our ECDD monitoring work. If a substantial amount of new information, including from member states, or international agencies, is provided to the ECDD Secretariat and information on public health harm, dependence, abuse, the medical use of cannabis and cannabis preparations, that could justify further review, the ECDD may then consider review at a future meeting.

Filip Nyman, Ungdomens NykterhetsförbundYoung people are especially vulnerable when communities shut down during the corona crisis. How do we work to protect youths from substance abuse?

Vladimir Pozniak, WHO: Well, thank you very much for this question, which, again, is very pertinent but at the same time it’s very difficult to provide a comprehensive response to such question. Let me try to respond to this question by highlighting just several aspects of WHO’s messages and WHO’s work, which was developed and disseminated during the pandemic and lockdowns. First, effective communication, also through social media, that psychoactive substances should not be used to cope with stress and anxiety, and not to start using substances in this circumstances for the purpose of dealing with stress and anxiety or isolation. Second, I think it’s important to address mental health and well being of young people, and to, by all available means, again, to prevent substance use or an increase in substance use as a coping strategy, and ensure, to the extent possible, the fulfilment of all the needs and very specific needs of young people. Another important issue that I would like to highlight in this regard is to ensure that regulatory measures in place for protecting the health of young people, like, for example, age limits for selling or buying alcohol, are fully respected through relaxed schemes of home deliveries; and this is important that, of course some regulations, like, for example, when we see some relaxation of regulations on opioid maintenance treatment, which are really beneficial for people on treatment in this circumstances, but some relaxation of regulations might be detrimental when it comes to, for example, easy availability of alcohol, be it web based, or through home deliveries. So this, I think, in every case, should be monitored, and should be taken care of. Fourth is to monitor the situation among young people in populations; of course, it requires resources, but this kind of assessment is needed to generate information, critical for informing responses. And finally, advocacy for the importance of this part of societal response to the pandemic, which is often neglected, and this is something again when civil society organisations can play a significant role.

Youth RISE, Uganda (Ruby Lawlor): We still know very little about the impacts of the COVID-19 pandemic and consequent safety measures such as lockdowns and social distancing, on global mental health, youth mental health and substance use. Experience of peers suggests that health and support services have decreased severely. How does WHO plan to address this in order to ensure that the health of all young people, including young people who use drugs, is adequately protected and supported?

Vladimir Pozniak, WHOI think partially the answer to this question was given when we discussed the previous issues raised because, first of all, this is a long standing position of WHO, that peers need to be involved in designing and implementing any response when it comes to young people. This is a must and this is a consistent position, that is being expressed in numerous WHO documents. Again, now, when we are in a state of emergency, in a pandemic, it’s… for WHO to be directly involved in the country level activities in this particular area is definitely very challenging. And I’m not sure that we can cite any example when it’s happening, but at the same time WHO supports, directly or indirectly, the efforts at national level; for example, through the harm reduction services which engage peers in providing essential critical harm reduction services to people who use drugs; it’s about the use the involvement of peers in primary prevention activities, which continue during the pandemic. By providing normative guidance, which was mentioned already in our conversation, which underline the importance of these issues. But again, this point is well taken, we will discuss with colleagues internally, to explore better what is happening. And second, what can be done from the Secretariat in order to address these issues in a better way.

Johan Lindskog, Association For Safer Drug Policies Sweden: The UN System Common Position is a groundbreaking document that should guide the work of all UN entities on drug-related matters. What is the WHO planning to do in its implementation?

Vladimir Pozniak, WHO: Yes, indeed, as you know, WHO has been actively contributing, of course, as a UN entity, to the development of this common position. But let me remind you that this position was developed by an internal UN Task Team, under the leadership of UNODC, and we have contributed significantly; you can recognise in the UN Common Position, probably, the paragraphs that come from the World Health Organisation. But, also, UNODC is also the leading the Task Team on implementation and dissemination of this UN common position, and what is currently the focus of this Task Team is to ensure proper communication and dissemination of the position among the country teams. So, that means that, as you know, many countries have UN country teams, which are usually under the responsibility of a resident coordinator, which is often the UNDP representative, and this is now the effort, to frame it, and to put it in the proper communication with clarifications to the UN country teams, and now this is one of the focuses of the Task Team on implementation of the position. But, of course, WHO disseminates the Common Position through its channels, as appropriate, and uses the Common Position in designing and implementing its relevant technical activities, also following the guidance provided to the Secretariat by the member states. At the same time, let’s admit that drug use and drug related issues are usually not at the top of priority list of UN country teams, particularly now, with the COVID 19 pandemic. And this also relates to some answers to previous questions that were raised. But, again, let me emphasise that this is internal position of UN agencies and their internal mechanisms, not only for developing this position but also for implementing this position.

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