CND Thematic Discussion / Session 11 – Low availability of internationally controlled substances for medical & scientific purposes

Chair: Good Morning. Yesterday we had a fruitful discussion on the issues of the consequences and risk associated with non medical use of drugs. Today we will be discussing the low availability of nationally controlled substances for medical and scientific purposes, including for the relief of pain and palliative care. Before we start a discussion, let me first give the floor to the Secretary for organizational announcements.

Secretary: (announcements)

UNODC Laboratory and Scientific Services:  My presentation focuses on the availability and access to controlled substances, particularly those for pain management and palliative care. The information presented in the next few slides is essentially taken from the INCB data on estimates reported to them regarding the availability of controlled substances. We have analyzed this information in the present state and in the order of 23, or even in the earlier editions of the report. On the screen, you’ll see two graphs. The first, the bluish one, maps the availability of some controlled opioids in countries against the population of those countries that reported the information. The bar chart shows the changes in the availability of controlled opioids in high and low-middle-income countries between 2017 and 2022. Essentially, what it tells us is something we’ve heard numerous times: low and middle-income countries, home to more than 80% of the global population, accounted for only 7.5% of the total consumption of pharmaceutical opioids in 2019. The per capita consumption of pharmaceutical opioids in these countries amounted to less than 1% of per capita consumption in high-income countries. Looking at the broader picture, there’s a 44% difference in the availability of opioids per capita for pain management and palliative care between high-income and low-middle-income countries. While there’s some increase in the availability of opioids in countries represented by the green bar charts, the disparity is so great that it doesn’t make much of a difference. One caveat to note is that these estimates of available opioids do not take into account those opioids not under international control, such as Tramadol or many falsified opioids available in the illicit market in low and middle-income countries. Moving on to the different regions, there’s still a significant disparity, as discussed earlier. Despite progress, there’s a wide diversity in the availability of opioids, with methadone and buprenorphine being predominant in certain regions. Based on information from our NCP, the main barriers to access to controlled medication include a lack of training and awareness among professionals, fear of addiction, diversion of opioids, and others. Some improvement has been noted in the categories of healthcare providers allowed to prescribe controlled substances. In conclusion, various factors, including legal frameworks, healthcare systems, and patient education, influence access to pain medication. Thank you for your attention, and I’m here for any questions.

UNODC: Delegates, over six decades ago, we made a crucial decision regarding access to narcotic drugs and psychotropic substances for medical and scientific use. This decision was rooted in science, acknowledging the potential benefits to health while recognizing the risks under certain circumstances. The decision aimed to provide essential medicines, such as opioids for pain relief, balancing the right to health with the responsibility to avoid unintended consequences of medication use. This principle was embedded in a rule-based scheduling system, which, however, did not dictate that when circumstances change, the system should change accordingly. As someone who grew up as a pharmacist in Ghana, I’ve lived on the side of the global access imbalance to pain medication. The statistics from Cameroon highlight this issue, and I’ve personally faced the barriers to access faced by pharmacists and doctors, as well as the stigma associated with opioids. Attending the largest opioid summit in the US a few years ago in Atlanta, Georgia, I witnessed the pain of those affected by the opioid crisis but also observed the relief these medicines bring to our loved ones, evident in the smiles during surgeries or in palliative care. Unfortunately, the narrative on access has been challenging. In these difficult times, it’s crucial to acknowledge how far we’ve come and the strength we exhibit when united. A decade ago, in collaboration with partners like the World Health Organization and the Union for International Cancer Control (UICC), we initiated a journey with the Time Program on Access and Availability of Medicines. In 2020, the World Drug Report dedicated a comprehensive chapter to the issue of access, reflecting the collective efforts of civil society organizations and your support. In August 2016, a dedicated chapter on access to medicines for medical use was introduced, feeding into the 2019 ministerial declaration where the challenge of low access and availability was addressed for the first time. Two champions from (…), Ambassador for Belgium and yourself, along with Executive Directo and the leaders of (…) played key roles in changing the narrative on access. Our ultimate goal is to ensure access and availability of drugs and psychotropic substances for medical purposes, and this is achievable with a robust scheduling system and effective measures for international trade. Dispelling myths, such as the inability to access drugs in emergencies or obtain pain medication for mild and moderate pain (e.g., codeine preparations available on supermarket shelves), has been crucial. The significant outcome of these collective efforts is the change in narrative. We engage in constructive discussions on international drug policy, resetting the narrative to align with the vision countries had 60 years ago. Let’s shift from numbers and statistics to focusing on the health and welfare of all humankind.

Chair: Thank you, now floor is open for questions

USA: We have to have access to pain medication for the relief of pain and suffering. At the same time we understand that this comes with the risk of addiction. My question is how can we get rid of that risk of addiction? What is the state of science? Do we have any research going on now that would identify pain medications that could be prescribed or made available that don’t come with the risk of addiction?

International Association for Hospice and Palliative Care:  Thank you very much, and I appreciate the presentations that shed light on the extensive nature of the problem. I am Catherine Pettus, representing the International Association for Hospice and Palliative Care. In response to the honorable delegate from the United States, I’d like to emphasize that completely eliminating the risk of addiction may not be feasible. Dependence has always existed, and regrettably, I have experienced it within my own family. However, there is substantial scientific research on treatment and prevention, much of which UNODC has diligently worked on. When it comes to enhancing the availability and access to medicines, evidence suggests that in Western Europe, a good balance has been struck, resulting in no opioid crisis compared to certain other countries. We also have compelling evidence from very low-income countries like Uganda and sub-national states in India, where local manufacturing of controlled medicines, particularly morphine, occurs without diversion and non-medical use. Personally, during a home visit in Kenya to the largest slum outside Nairobi with palliative care teams, I witnessed the delivery of oral morphine to patients in deep distress. Concerned about potential misuse, I asked if they were worried about others in the shared living space taking the morphine. They responded that there was no concern because the community knew it was meant for the patient, and oral morphine, as produced in Uganda, doesn’t induce a “high” and is not profitable for illicit use. To address these issues, a solution lies in pooled procurement and local manufacturing of generic oral morphine. While not profitable, it’s a worthwhile investment by member states. When done correctly, with monitored supply chains and coordinated communication among relevant ministries and organizations, this approach has proven successful in various programs, including those sponsored by El Salvador, Belgium, Ghana, and Switzerland. Despite the ongoing efforts, funding remains a significant challenge. The INCB learning program has played a crucial role regionally in assisting countries in improving their estimates and reporting. I could delve into more details, but I’ll conclude by expressing gratitude for the opportunity to speak. Thank you for giving me the floor.

Mexico: I am interested in understanding if UNODC has implemented any training or technical assistance programs aimed at addressing the challenges related to the lack of accessibility from a criminal and corruption perspective. We recognize that a significant aspect of the problem involves certain individuals seizing control of substances, making it a profitable business. Improving accessibility to medicines for those in need is hindered by corruption within government ranks. Therefore, we seek insights into how UNODC has approached and linked issues of legal drug accessibility with criminal networks and corrupt officials. Thank you.

Brazil: My question pertains to the significant imbalance in access, as illustrated in the graphic, when comparing developed and developing countries. This marked difference is evident. As highlighted, the graphic does not account for the black market, potentially showcasing fraudulent and unauthorized avenues for drugs. My specific inquiry is regarding the informal channels through which drugs enter populations in developing countries. While I have some insight into the situation in Brazil, which appears to parallel that of the Americas, my understanding of the African context is limited. I’m curious about how people in developing countries gain access to drugs, whether through formal or informal markets. Additionally, in the absence of formal channels, what are our specific concerns, particularly in the African context? Thank you.

UNODC: We have been providing support to several countries. However, our efforts have been limited due to funding constraints, despite the apparent importance of the issue. Over the past decade, we have secured only around $1 million, averaging $100,000 annually. We anticipate a change in this funding scenario. Regarding our on-the-ground activities in supported countries, it goes beyond merely instructing them on promoting access or supplying medicines to overflowing shops or pharmacies. We delve into establishing new regulatory systems, addressing import-export issues, and devising strategies to prevent diversion. As our initiatives progress, we aim to extend our focus to addressing corruption within systems. To expand our impact from a few to numerous countries, particularly on this crucial matter, a key solution is increased funding for the access program. This year, during our presence in Senegal, our offices collaborated on the Trans Organized Crime Assessment Report for Sale. One of the chapters in this report specifically addresses the issue of falsified medicines, providing an insightful perspective on a complex situation. In many African countries and Southeast Asia, there are markets where people can easily obtain various items simply by stating their needs. I’ve witnessed, during my earlier life as a physician, the illicitly manufactured opium or morphine available in the black market. Patients can access these substances either through personal contacts or, at times, even within hospital premises. This facilitates immediate access to palliative care. I recommend reviewing the aforementioned report on falsified medicines, as it describes this phenomenon and its connections with organized crime and corruption, impacting the availability of falsified medicines, including those for palliative care in the region. This correlation is applicable to other regions as well.

Colombia: I am interested in understanding how UNODC envisions and plans for comprehensive solutions that go beyond mere budget considerations. The points raised here underscore the need for a holistic approach, starting with recommendations to institutions and frameworks, including boards, conventions, and CND resolutions. Strengthening national capacities is crucial, as is addressing dimensions that involve making recommendations to pharmaceutical companies through the United Nations. Numerous solutions need careful consideration that extends beyond budgetary concerns. I am curious to know how UNODC has strategically planned, not just at the national level, as exemplified by Colombia, but also on a multilateral level. It’s essential to move beyond goodwill and embark on practical actions, avoiding the convenience of waiting for more programs to be established. I’d like to understand UNODC’s stance on being proactive rather than reactive, ensuring actions are taken in a practical manner, particularly in the context of Colombia.

UNODC: I believe we could dedicate an entire day to discussing the various tasks required in countries. Your point is particularly interesting in that it highlights that solutions don’t always have to revolve around financial resources, and you’re correct. Take morphine, for instance, a substance essential in pain management for over 60 years. No pharmacy is attempting to recover research and development costs from it. Therefore, if we initiate production by utilizing ethical generic companies, we can achieve a very low cost. Countries that had the capacity 20 years ago to produce morphine injections and infusions, for example, can still struggle to provide access to these medications after several decades. It’s not only about money. We need to examine internal collaborations within regions, address tariff issues related to imports, and ensure accurate estimates for each country. Knowing the precise amount needed is crucial. By establishing estimates, we can work on building regional cooperation. I often cite the example of COVID vaccines, which are costly, yet there was a political will to distribute them globally. Similarly, there needs to be political will to ensure access to pain management medications in all parts of our countries. It’s an achievable goal.

Russia: The Russian Federation extends gratitude to the Chair. Good morning to all colleagues. I would like to follow up on the insightful remarks made by our distinguished colleague from Colombia. The Russian Federation is committed to several important initiatives, notably the INCB Learning Project. This cost-effective initiative, requiring minimal time and funding, has the potential to enhance the situation in many countries by raising awareness among local authorities about the problem and providing solutions. It also improves capacity in estimating needs in this context. We emphasize the need to pay more attention to such initiatives and bring the funding difficulties faced by the program to the Commission’s attention. Despite our political commitment to improving the availability and access to controlled medicines, we acknowledge the importance of supporting initiatives like the INCB’s and relevant Global Programs. These initiatives, such as the INCB Learning Project, do not require substantial funding; for several regional countries, it may cost around $200,000 at maximum. However, they play a crucial role in imparting essential knowledge to national authorities on how to enhance education and openness. In our view, the problem lies not only in regulatory barriers but also in the understanding, insight, and awareness at the national level, which needs improvement. Following these deliberations, I would like to inquire about your cooperation with other UN entities, including WHO and the Global Program on Cancer. Additionally, how can interagency coordination be enhanced to avoid duplication of efforts and better support each other’s activities? Thank you.

UNODC: Regarding interagency coordination, the joint program has traditionally excelled in this aspect. It originated as an interagency coordination involving WHO and the Union for International Cancer Control. While we have worked concretely in only a few countries, we strive to maintain contact with all potential partners, including the Atomic Energy Agency, involved in cancer-related work. We actively participate in the task force of the United Nations on non-communicable diseases, which comprehensively covers various areas, including our work on drug prevention and treatment. However, its primary focus is on cancer control, aligning with our efforts. In the upcoming presentation, I will delve into some developments within the joint program. As a sneak peek, one of our initiatives is to establish an informal technical working group, akin to the one we have for drug prevention and treatment. This new group aims to focus specifically on access, providing a dedicated forum to systematically bring together all UN agencies and external partners working on this issue.

Chair: I see no more questions. thank you everyone. We move on with our discussion.

Mexico: (…) comprehend that addressing the issue is within the mandate. We are puzzled by some delegations questioning the connection between drug trafficking, access to controlled substances, and corruption. We want to highlight our commitment to the implementation outlined in paragraph 19 of the political declaration of 2009, emphasizing continued cooperation with INCB and WHO to ensure the adequate availability of narcotic drugs and psychotropic substances for medical and scientific purposes. Despite this ongoing cooperation, a significant collective failure is evident, as reflected in paragraph 29 of the joint ministerial statement of 2014. One operational recommendation, dated August 26, 2016, focuses on improving access to controlled substances for medical and scientific purposes. We seek an update from UNODC on the current situation regarding access, considering the presentations already made and the information in the workbook reports, especially in the 2023 edition. Furthermore, we request UNODC to provide suggestions for simplifying and streamlining legal systems, domestic legislation, and regulatory mechanisms, including distribution channels, to remove restrictive regulations and impediments. This aligns with subparagraph (a) of the original recommendation. Acknowledging Belgium’s leadership in promoting availability and accessibility, we also urge UNODC to share suggestions for fully implementing the commitment in subparagraph (b) of the preparation recommendation. This relates to strengthening the functioning of national control systems, domestic assessment mechanisms, and programs to identify, analyze, and remove impediments to the availability and accessibility of controlled substances for medical and scientific purposes. In conclusion, we ask UNODC to provide information, as soon as possible, about reports related to the action plan of 2009, specifically subparagraphs (a) and (b). This ensures that drug treatments and services for drug-dependent care are included in healthcare systems, be it public or private. We emphasize the importance of progress on commitments outlined in the 2009 plan of action, such as considering gender considerations in prevention, treatment, rehabilitation, and support services, respecting human rights and dignity, and avoiding discrimination based on sex. We also seek updates on progress in line with operational recommendations for 2016.

South Africa: My delegation expresses its appreciation for the morning’s presentation, highlighting the challenges faced in accessing controlled medicines. We also acknowledge the question from the distinguished delegate from Brazil regarding informal market access in Africa, an issue that warrants further consideration. South Africa, like many developing countries, shares the common challenge of lack of access, availability, and affordability of controlled medicines for pain management and palliative care. This is mainly due to incompatible legislation, regulatory systems, national supply management systems, and the capacity of health systems to ensure non-diversion and non-medical use of these substances. In line with the 2023 World Report, we encourage member states to eliminate all tariffs and non-tariff barriers hindering access to controlled medicines, particularly for developing countries. This aligns with the 2016 UNGASS outcomes document, which estimated that access and availability of controlled medical substances for pain relief are low to non-existent in certain areas of the world. We stress the need for enhanced international cooperation and urge member states to improve access to controlled substances for medical and scientific purposes by addressing existing barriers and displaying the necessary political will to do so. Strengthening national control systems and domestic assessment mechanisms and programs would contribute to facilitating access, affordability, and availability of controlled medicines for palliative care. We emphasize the importance of UNODC having adequate resources to provide necessary technical assistance and capacity-building to member states, empowering frontline workers, as mentioned earlier. In conclusion, South Africa firmly believes that increased efforts are required to address all existing barriers related to availability, accessibility, and affordability. Thank you very much.

Belgium (?): National and international reports leave no doubt that, despite some progress, the situation is still alarming. Adding to the available data just presented, I want to share conclusions from studies conducted in 12 hospitals in Kinshasa, the capital of the Democratic Republic of the Congo, funded by Belgium. In 2021, prescribed opioids were often unavailable at hospital pharmacies. Patients and their families had no choice but to search for these products in private organizations or even the black market. Opioids usually had to be purchased out of pocket, with prices ranging from $10 to $14 per unit for oral morphine solutions, making them unaffordable for a large part of the population. Only five of the 12 hospitals in the sample had dedicated palliative care services, and the situation for children was even worse, especially those suffering from hemoglobin disorders like sickle cell anemia. Research on the availability of morphine for children is lacking, and it is a moral imperative to address the needs of these young patients. In efforts to accelerate commitments towards 2029, Belgium organized a panel discussion on November 14 and 15, with UNODC’s support. During this discussion, experts highlighted barriers related to regulation, healthcare organization, specifically in palliative and emergency care, and the role of civil society organizations. The narrative around controlled substances containing opioids needs to be cautious, avoiding portraying them solely as dangerous substances, as it increases barriers in countries with insufficient supply for legitimate medical use. Continuous efforts are required to raise awareness, train individuals, and offer on-the-job support until real change for patients, both adults and children, is witnessed. Rational use of substances can be promoted through more research and the implementation of specific clinical guidelines for different types of pain.

Thailand: The issue of restricted access to medical narcotics is a serious concern faced by many countries. The misuse of these medications leads to stringent regulations throughout the pharmaceutical process, from manufacture to importation, exploitation, possession, storage, and prescription. Ensuring compliance with international obligations is crucial. To address this, Thailand enacted new narcotic laws in 2021, and the FDA has supported private sector research and development to produce controlled substances. We aim to enhance pharmaceutical security and increase the availability of internationally controlled substances for medical use. In an effort to manage critical reserves in our country and neighboring nations, pharmaceutical manufacturers in Thailand are encouraged to supply controlled substances for pain relief and palliative care. The Thai FDA plays a leading role in supporting the use of controlled substances for medical purposes in both public and private healthcare institutions. Thailand appreciates the INCB mechanism for facilitating and expediting the importation of essential medical substances in emergency cases, allowing for an assessment of the need for both controlled substances and medical chemicals. In conclusion, to enhance access to medically prescribed controlled substances, Thailand emphasizes collaboration among various relevant public health entities, leveraging medical knowledge in prescription, and systematically preventing the importation of unsuitable pharmaceuticals. We underscore the importance of international agreements and cooperation between nations to ensure the availability and access to medical narcotics for the provision of appropriate medical treatment.

Pakistan: Ensuring access to quality controlled drugs for medical purposes is a fundamental right for all individuals in need. This commitment reflects the international community’s recognition of the importance of healthcare and underscores the shared responsibility to address global health challenges. The 2019 ministerial declaration has rightly identified the multifaceted nature of this term. Pakistan recognizes the gravity of this challenge, emphasizing that the availability of internationally controlled substances for medical and scientific purposes is a critical component of addressing public health needs. The shortages of essential medications underscore the urgent need for concerted global efforts to alleviate the suffering of those in pain and ensure access to palliative care. Mr. Chair, the key objective of the international drug control system is to ensure the availability of and access to controlled substances for medical and scientific purposes while preventing their non-medical use or diversion into illicit channels. To achieve this end, efforts are needed to address all existing barriers, including closely related legislation, regulatory frameworks, and affordability. The World Drug Report 2023 highlights significant global disparities in the availability of internationally controlled medicines, the stark contrast in opioid availability between high-income countries and low-middle-income countries. Pakistan calls upon the international community to foster collaborative initiatives, share best practices, and provide support to nations facing challenges in ensuring access to controlled substances for medical purposes. Pakistan has evolved a well-defined and conclusive framework to regulate the availability of controlled substances for medical purposes, aligning with international protocols and guidelines. National laws, including the Control of Narcotic Substances Act, ensure the availability of narcotic drugs and psychotropic substances for medical and scientific purposes. Similarly, the precursor control mechanism adopted by Pakistan speeds up the process involved in checking the diversion of precursors. Imports are subject to strict scrutiny and are monitored until the end-user level. Measures have also been taken to avoid any diversion of illegal consignments of precursor chemicals to the black market. Furthermore, the Drug Regulatory Authority in Pakistan maintains an adequate and balanced approach in terms of access to essential medicines for medical, scientific, and other legitimate uses, significantly reducing the risk of misuse. In conclusion, Pakistan emphasizes the importance of collective efforts in addressing these challenges and remains open to enhancing the availability and access of controlled medicines for legitimate purposes to yield positive outcomes.

Brazil: One cannot deny the therapeutic potential that certain controlled substances hold, and ensuring the availability of these substances for medical purposes paves the way for enhanced patient care, improved quality of life, and novel treatments for conditions that were once considered untreatable. Controlled substances are instrumental in scientific exploration and innovation. Substances classified as controlled into their preferred this are not only being studied for their potential risks but also for their promise, holding understanding of mental health disorders and developing targeted interventions. Brazil considers good practices for promoting access to controlled substances in cases of emergency. During the COVID-19 pandemic, Brazil faced a shortage of controlled medicines used for the intubation of patients, especially sedatives and anesthetics. To address this, Brazil implemented extraordinary temporary measures to facilitate the import of these products. Import authorizations for these medicines were created with priority, being issued within a maximum period of 48 hours. Importers were exempt from opening an import quota and prior authorization for the Ministry of Health. Public and private hospitals were allowed to import directly without the need for prior special authorization. The Brazilian National Health Agency issued revised market distribution regulations, and additional airports were authorized to operate as entry points for narcotics and psychotropic drugs. As a result, during the pandemic, more than 3 million doses of sedatives and anesthetic medicines were imported, with midazolam being the most important substance, followed by fentanyl and morphine. In conclusion, striking the right balance between accessibility for medical use and research, on the one hand, and safeguarding against illicit use on the other hand, requires a collaborative effort between healthcare professionals, researchers, policymakers, and law enforcement agencies. By working together, it is possible to ensure the benefits of these substances while mitigating potential risks.

Spain on behalf of the European Union: I am intervening in the capacity of the Presidency of the Council of the European Union. I will read this statement on behalf of the European Union and its member states. The 2016 Ongar SATCOM (?) document highlights the need to address the low availability and accessibility of internationally controlled substances for medical or scientific purposes. In line with a certain era development goal, it is essential that access to safe, effective, quality, and affordable essential medicine is an issue for passion around the world. In this context, the European Union and its member states would like to raise our grave concern over the humanitarian crisis in Ukraine resulting from the rosiest, comparable, and unjustified military aggression against Ukraine. The World Health Organization has documented 1400 attacks on healthcare immigrants since the invasion by the Russian Federation in February 2022, including attacks against healthcare facilities and transport of supplies. This is the highest number the World Health Organization has ever recorded in any armed conflict and emergency. It highlights the difficult and dangerous circumstances in which the country’s health system operates and the challenges it faces in providing both routine and emergency healthcare services. Ensuring access to healthcare for the affected people is crucial, increasing the risk of humaneness under this emergency situation. Regardless of gender, we aim to ensure unimpeded access to medical care and provision, including medicines containing internationally controlled narcotic drugs and psychotropic substances. The European Union and its member states and partner countries have offered assistance, including medical supplies, and are coordinating the medical evacuation of Ukrainian patients in need of treatment, transporting them to hospitals across Europe. The availability of and access to international control system serves for medical and scientific purposes remain an issue elsewhere in the world as well. Even if internationally-absolving results in several regions have been reported in the World Drug Report 2023, disparities in availability and access remained in 2021. Six percent of the global population lived in countries where the availability of pharmaceutical opioids for medical use was below the global average. It is important to consider the existing differences in access to this medicine for people in vulnerable situations, including women and children. The most recent report on the availability of narcotic drugs and psychotropic substances for medical or scientific purposes noted that some countries may not accurately reflect the accuracy of their population in their reports, resulting in disparities. Another problem is the limited access to affordable opioid analgesics such as morphine. According to competent national authorities, the most significant impediments are private sourcing, lack of training and awareness of professionals, fear of Arctic sea, and limited financial resources, as well as the fear of diversion. In this context, the European Union and its member states would like to once again express their appreciation for the special initiative of the previous chair of the Commission on Narcotic Drugs, related to improving the availability of access to controlled substances for medical or scientific purposes. The special events highlighted the remaining challenges in this area, received our list of this important, useful, and will help us move closer to the implementation of our international commitments in the area of liability. In line with the European Union Drug Strategy 2021, we will always continue to promote and implement capacity-building and awareness-raising activities regarding the access to and the availability of controlled substances for medical and scientific purposes. And we will continue working towards the goal of zero that the goal is set in all national drug policy practices. Thank you.

China: … while the Chinese government is intensifying efforts to combat drug abuse and prevent the misuse of controlled substances, it is also actively working to promote the accessibility of narcotic drugs and psychotropic substances, which are internationally controlled for medical or scientific purposes, ensuring the fulfillment of medical needs. Firstly, the Government encourages enterprises to conduct scientific research on and import internationally controlled substances based on clinical needs, providing a diverse range of drug varieties and formulations. Secondly, close monitoring of changes in the clinical use of internationally controlled substances is carried out, and production volumes are determined based on clinical demand. Thirdly, continuous efforts are made to strengthen the supervision and management of the production and distribution of internationally controlled substances. This includes regulating the order of production and distribution, enhancing supply security, and preventing illegal activities. Fourthly, specific regulations for the classification of the international controlled substances are refined when regulating or upgrading the control level of varieties with medical value. The impact of political use is thoroughly assessed, and different control measures are adopted for different formulations of the same type of internationally controlled substance, considering varying levels of misuse risks. Lastly, the issuance of export permits for internationally controlled substances is conducted in accordance with international control convention requirements, providing legal documentation for international trade. Efforts are also increased in publicity and training to raise awareness among the public about the rational use of internationally controlled substances. Thank you for your attention.

USA: As several delegates and our panelists have mentioned, the UN conventions impose an obligation on us to ensure the availability of controlled substances for research and the relief of pain and suffering. At the same time, we must ensure that those controlled substances are not used to contribute to addiction or other abuse. This is not only an obligation under the treaty; it is the very purpose for which we have these treaties. We need to keep this focus not just on enforcement but equally on the availability of controlled substances. The United States has taken significant steps in recent years to strike this balance, particularly concerning the use of prescription opioids for pain care. In 2022, the Centers for Disease Control and Prevention released updated clinical practical guidelines based on the latest science on effective pain treatment, including chronic pain, post-surgery recovery, and pain from injury or disease. This guideline serves as a clinical tool to enhance communication between clinicians and patients, empowering them to make collaborative and informed, patient-centered decisions related to pain care. It addresses the circumstances under which prescription opioids may be warranted, if at all. These guidelines are essential, but more research is needed, particularly in understanding the biology of pain, medication, pain relief, and the science of addiction. Governments must invest more in research in these areas, ensuring that research is not solely directed by the pharmaceutical industry. While the industry plays a crucial role, its motives may not always align with government priorities. Telehealth services offer a way to expand care and increase the availability of prescription substances. Telehealth can provide increased access to individuals with substance use disorders, reduce costs, and mitigate the spread of communicable diseases. Services may include screening, diagnosis, online counseling, consults for prescriptions, and individual and group talk therapy. The United States, under certain circumstances, provides controlled substances, including medication for opioid use disorders, via telehealth appointments. As discussed this morning, the CND should work collaboratively to identify proactive practices addressing gaps in the availability of narcotic drugs and other controlled substances. Today’s discussion indicates eagerness to capitalize on this energy and use the CND to emphasize our focus on availability. Additionally, the estimation system is critical, and we urge countries to collaborate with the INCB to improve the estimation of legitimate drug requirements and ensure medical needs are met. The INCB, mandated by treaties, should work with governments to ensure the availability of controlled substances for medical and scientific purposes. We call on the board to provide regular updates on data and information about barriers to access and availability globally. We also appreciate the contributions of the World Health Organization and UNODC in this regard. Thank you, Chair.

Peru: Addressing the availability of internationally controlled substances for medical and scientific purposes, including pain relief and palliative care, is a critical issue requiring major attention from member states. As outlined in the 2016 ministerial declaration, national efforts have been made in Peru, especially in expanding services and access to controlled substances. Two examples include the budgetary program for the prevention and treatment of drug use and the mental health control and prevention budget program. These efforts aim to integrate actions at the governmental level, strengthen services for people with addictions, and contribute to comprehensive drug management. Despite successes, challenges such as expanding coverage and improving the quality of healthcare persist. The fight against addiction underscores the importance of comprehensive and continuous care. Peru is committed to increasing access to controlled substances for pain relief and palliative care. Thank you.

Japan: Thank you, Mr. Chair. In Japan, opioids play a significant role in global medical care, particularly in cancer treatment and palliative care. However, Japan has a notably lower usage compared to other countries, primarily due to a negative perception of opioids among patients and their families. To address this, Japan has conducted nationwide workshops to raise awareness and disseminate information about medical opioids. Guidelines for medical professionals have been formulated to ensure compliance with international drug control conventions, focusing on the appropriate use of opioids for medical purposes while preventing diversion.

Australia: Australia welcomes discussions and urges all stakeholders to build on the progress made in improving the availability of controlled substances. The medical indispensability of narcotic drugs and psychotropic substances is universally recognized and embedded in the 2030 agenda. Target 3.8 on achieving universal health coverage is crucial in ensuring access to controlled medicines for all individuals. The global disparity in availability, highlighted in the World Drug Report, is alarming, particularly in regions like Southeast Asia and the Pacific. Australia is committed to addressing these barriers through evidence-based interventions, supporting initiatives like the UNODC-WHO-UNICC joint global program in Timor-Leste, Fiji, and Indonesia. The country recognizes that barriers are not limited to legal and regulatory issues, emphasizing the importance of addressing social and cultural barriers. Australia has welcomed UNODC’s efforts to increase awareness and advance commitments to address barriers to the availability of controlled substances, ensuring that no patient is left behind. Thank you.

Colombia: Colombia has listened attentively to the delegations that spoke before us, and it appears we have an agreement in the room that indicates a problem. This problem is shocking and staggering. According to the World Drug Report, 86% of the world’s population lacks adequate access to pharmaceutical opioids for pain relief and basic care. This stark imbalance violates the stated goals of international drug control treaties and fundamentally violates fundamental human rights. Simply put, Western Europe, North America, Australia, and New Zealand continue to monopolize the consumption of these medications, leaving the majority of the global population with limited or no access to essential treatments, resulting in unnecessary suffering. As we approach the celebration of International Human Rights Day in December, it’s crucial to remember that the World Health Organization considers this lack of access to pain relief medication one of the most ingenious hidden inequalities in global health. Only 10% of the world’s wealthiest countries hold 90% of the distributed opioids. The international drug regime is not only about enforcement; it is also about the availability of controlled substances. It is clear that it’s failing to provide the needed controlled substances. While we acknowledge valid concerns about potential harmful effects and diversion, we must not let these overshadow the benefits of opioid use when clinically indicated and employed safely by trained professionals. Colombia urges the CND and UNODC to embrace transformative change and rectify the situation immediately. Thank you.

Algeria: For years, the MCB has noted with concern that the availability of and access to controlled substances for medical purposes is limited in many parts of the world. The list of these substances has been drawn up in accordance with the 1971 convention, ratified by Algeria in 1977, committing our country to compliance with the convention. With the misuse of drug substances on the rise, particularly substances like pika baleen, often combined with cannabis, Tramadol, and deeply Nephin, there is growing concern. Opioid analgesics like morphine, oxycodone, and fentanyl, essential for pain relief, are widely prescribed and also a cause for concern. Despite international efforts to ensure controlled substances are used for legitimate medical and scientific purposes, challenges persist in ensuring adequate and equitable availability of controlled substances for medical and scientific use in many parts of the world.

INCB: The International Narcotics Control Board plays a critical role in thematic discussions regarding the implementation of all international drug policy commitments adopted by member states in the 2019 ministerial declaration. The Board acknowledges the concerns expressed in various interventions and countries, emphasizing that this is equally concerning to the Board. Over fifty years ago, member states, adopting the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances, committed to ensuring and not unduly restricting the availability of drugs indispensable for medical and scientific purposes. Despite this commitment, a significant imbalance in the global availability of controlled substances persists, contravening the goals of drug control conventions and violating human rights. The Board highlights the exponential increase in global opioid consumption over the past four years, particularly in the use of fentanyl. However, stringent control measures introduced in response to the opioid crisis have led to a decline in consumption since 2010. The Board stresses the need for a balance between ensuring availability and access while preventing diversion to non-medical uses. For years, the Board has expressed concerns about the limited availability of and access to controlled substances for medical purposes. Special reports on this issue were published in 1989, 1995, 2010, 2015, and 2018. The latest report from March 2023 aims to provide information to assist in the implementation of operational recommendations related to availability and access. The report confirms a disparity in the consumption of opioid analgesics globally, with difficulties reported by many countries in procuring medications containing morphine. Concerns include the use of morphine for the production of heroin and its limited direct use for medical purposes like palliative care. Accessibility issues for psychotropic substances, particularly in low and middle-income countries, are also noted. The Board identifies barriers to access, such as stigma, fear of addiction, administrative bureaucracy, and the disruption of supply chains during emergencies, including the ongoing COVID-19 pandemic. Efforts are needed to address affordability, lack of training, and awareness among professionals. The Board emphasizes the importance of a comprehensive and multi-pronged approach, data capacity, and a digital network to improve estimation of requirements. Governments must enhance the capacity of health systems to deliver palliative care. Initiatives like INCB Learning are crucial to addressing training barriers. Despite efforts to ensure availability during emergencies, ongoing problems persist. The Board recommits to work with the international community, issuing annual reports with recommendations for action. The ASAP remains committed to assisting in achieving greater availability of and access to controlled substances for medical and scientific purposes. The Board supports the call to action initiated by the previous chair to ensure that no patient is left behind.

WHO: Mr. Chair, distinguished delegates, as the specialized health agency of the United Nations, WHO remains committed to addressing inequitable access to medicines, including those under international control. Safe, effective, quality, and affordable medicines should be available to those who need them, regardless of their international control status. WHO acknowledges global challenges in the availability of medicines, vaccines, and health products, particularly in low and middle-income countries. Medicines under international control, especially psychotropic substances, face additional challenges in availability, including those essential for functioning health systems, pain and palliative care, opioid antagonists therapy, surgical care, epilepsy treatment, and other areas of clinical medicine. WHO welcomes initiatives from CND to improve the availability of internationally controlled substances for medical and scientific purposes. However, WHO emphasizes that, along with availability, factors crucial for ensuring equitable medicine access must be considered, including accessibility, affordability, and quality assurance of proven-effective medicines. WHO recognizes the lack of access to controlled medicines in humanitarian emergencies and highlights the joint statement issued by WHO, UNFCCC, and INCB, allowing greater flexibility in control measures during emergencies. Enhancing partnerships, relying on relevant humanitarian access, ensures the safe, timely, and appropriate use of controlled medicines in emergencies, including provisional and long-term solutions. Several reasons contribute to the inequitable availability of quality drugs and psychotropic substances for medical and scientific purposes. Solutions require collaborative efforts. Issues in implementing national policies to comply with international drug control treaties and pricing and financing challenges persist. Sustainable financing of essential healthcare services, mental health and social care, pain and palliative care, substance use disorder treatment, and training of health professionals remains inconsistent globally. Critical factors such as quantification, procurement, and supply must be addressed to effectively treat clinical applications. Mechanisms to procure and safely store medicines are essential. Effective prescribing, dispensing, and administration, supported by clinical guidelines, are crucial for safe and effective use of controlled medicines. Education, knowledge, and attitudes toward controlled medicines play a vital role in reducing attitudinal barriers to prescribing in various settings. WHO, as the specialized health agency serving the United Nations, stands ready to lead on these issues to ensure access to controlled medicines. I thank you, Chair.

Russia:  In the past decade, there has been no oversight on emissions issues, despite legislative efforts to address environmental concerns. The Russian department responsible for enforcing environmental regulations has expanded significantly. It now actively monitors and reports violations, promoting transparency and accountability. Furthermore, there has been a substantial increase in federal funding for continuing medical education courses and workshops for doctors and nurses, are accessible to everyone. Non-governmental organizations and educational institutions contribute to these initiatives. They aim to address both political and cultural factors influencing the evaluation and usage of opioids. This collaborative effort fosters education within the medical community. Thank you very much.

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UNODC: Thank you, Mr. Chairman, distinguished delegates, and colleagues. In his opening remarks, the Chairman highlighted the changing narrative as a major achievement in recent international meetings. Building on this, I would like to propose concrete ways forward based on our program’s experience in ensuring access to controlled medicines and diversion, in collaboration with the Union for International Cancer Control and other international partners, including those treaty-mandated by the UN. Since 2013, we have concretely mobilized efforts in eight countries, with support from member states like Belgium and the European Union. In September this year, we organized a technical consultation meeting to present findings from 10 years of program implementation. This meeting involved various stakeholders globally, analyzing challenges, barriers, and discussing the future of the program. We are using these discussions to restructure the program, with some key ideas already in progress. Firstly, innovation and digitalization will be central to the program. It will support member states in developing planning and reporting systems, along with rational control systems that do not hinder access to controlled medicines while mitigating associated risks. In terms of capacity building, the program will focus on engaging early career professionals, including doctors and healthcare providers, to establish mental health networks. These networks will facilitate the sharing of tools for assessing patients at risk, enhance rational prescription practices, and strengthen intergenerational communication between senior and young doctors. The ultimate goal in engaging early career doctors is to ensure sustainable availability and access to medicines while preventing diversion or non-medical use. Lastly, the program is operating in key countries, addressing specific needs, and actively participating globally to ensure geographical spread. Regional approaches will be a focus, collaborating with regulatory authorities, civil society organizations, and production entities to address procurement, affordability, and supply chain issues. In conclusion, the commitment to international conventions is crucial for upholding fundamental human rights. The examples of commitment, calls to action, and best practices shared today give hope for positive change. The speaker expresses gratitude for the opportunity to contribute to the dialogue. For the next part of the session, the speaker highlights the global emergence of new psychoactive substances over the past decade, resulting in an increase in substances placed under international control. Seventy-eight harmful psychoactive substances have been controlled since 2015, along with precursor chemicals for drug manufacture included in the 1988 convention. Recommendations from the World Health Organization and the International Narcotics Control Board regarding scheduling additional substances and precursor chemicals will be presented to the commission. The speaker emphasizes the 30% increase in the number of substances under international control since 2015, placing additional responsibilities on member states to implement scheduling decisions. Ensuring access to recently scheduled substances for medical and scientific purposes is crucial. National drug testing laboratories need reference standards to develop and validate methodologies for identification. The UN’s services provide reference materials, but member states often face administrative and financial barriers. There is a need for greater effort to raise awareness of the importance of easy access to reference materials for scientific purposes.

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Chair: (summary of session) Now, according to the rules of procedure of ECOSOC on all the Commission’s I will give a reply to the Russian Federation you have the floor.

Russia: The Russian Federation strongly denies the allegations contained in the statement delivered by Spain on behalf of the European Union. We do not wish to reiterate the well known arguments about the root causes of the conflict in Ukraine intentionally fueled and supported by those countries. Moreover, continued deliveries of weapons to Ukraine by those countries are evidently not aimed at the protection of civilian population and medical facilities and ceasefire. Our delegation regrets that some delegations continue to politicize our expert discussions in the commission.

Chair: Before we conclude this morning’s meeting, I would like to kindly remind everyone about the fireside chat on drug policy that will be held at the on level four next to the Coffee Corner today at 1 pm. These discussions aim to foster inclusive conversations on drug policy and stakeholder engagement. The topic for today’s chat will be on youth. I highly encourage all of you to attend, and I look forward to seeing you back here for our future discussions. Thank you very much.

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