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Informal Dialogue with WHO

SSDP Australia: How is the World Health Organisation facilitating meaningful inclusion of people who use drugs in the design and implementation of policies and strategies around existing and emerging pharmacotherapies at the global level? 

WHO: The principle of involving affected groups in the development of guidance is strong. To develop WHO guidelines on managing health conditions, there is a requirement to involve representatives of the target group in the guidelines development group. This is ensured in WHO regulations. Regarding the involvement of people who use drugs in the design and implementation of policies, as I mentioned, WHO discusses plans in implementation and development of guidance. Of course, CND is the principal body of drug policy-making, but we collaborate with UNITAID, where organizations of people who use drugs are the implementers. These interactions happen regularly and in some activities, they are very intense. I also want to mention that we have engagement of young people in health policies through several mechanisms in public health areas. The Youth Forum, the Youth Council established a few years back already, and youth culture and health activities also involve young people.

Uganda Youth Development Link: How does WHO contribute to the implementation of evidence-based prevention intervention for youth living in low- and middle-income countries and how are these youth involved in decision making processes and implementation of actions that address local community problems? 

WHO: The involvement of youth and civil society organizations, particularly youth organizations, in WHO’s work is extremely important. Engagement at the highest possible level is essential. The Director-General participates directly in this Council, which includes this involvement. On activities related to the target of these activities being young people, we need to engage and be strongly determined to engage youth organizations. For example, on alcohol, implemented in several countries including Uganda —what is important is that the involvement of youth organizations depends very much on interaction with WHO implemented in-country and civil society on the ground. Very often we don’t have the capacity and knowledge to know which organizations exist subnationally, so we depend on country offices, ministries of health, umbrella civil society organizations with whom we interact regularly like VNGOC.

CSFD in the EU: What guidance does WHO provide to Member States that seek to integrate a holistic approach to mental health in health responses to drugs? 

WHO: The issue of interaction between mental health and substance use is extremely important and often overlooked and improperly addressed. When it comes to the holistic approach, you may be referring to the global report on mental health from 2022, referring to holistic approach to mental health issues. What is defined in this report as holistic is applicable to what we have as the situation, how WHO should do what should do in terms of interacting within people who use drugs and substance use disorders. Inclusion in activities, drug policy programs, outreach programs, which are equally important in mental health and drug use. Social support. When we talk about care targets, if there’s no problem solved as employment, legal documents facilitating access to resources in the community, you cannot do much. This needs to be addressed to consider human rights fully and self-determination of the people involved in these activities. What is also a holistic approach in mental health is an integration of mental health, emotional wellbeing, and physical health. All of these are important for drug user disorders. Thank you.

IDPC: Could you give us more details on the process and timeline for the ECDD’s review of the coca leaf, and what opportunities will be available for civil society, including communities of Indigenous Peoples to feed into the review process? 

VNGOC: Will be responded to later as the specialists are currently at the Plenary.

CADCA: According to the Colombo Plan, with which CADCA works closely, there can be up to 15 different dangerous adulterants, drugs and drug mixtures in the illicit drug supply, including synthetic opioids that are more powerful than fentanyl. What steps will the WHO take to ensure that robust, timely drug testing, analyzing and reporting mechanisms, are in place?

WHO: This question touches upon so many different issues. Our colleagues currently at the plenary have a role in this question because synthetic opioids, NPS, scheduling recommendations —all of this needs to be taken into consideration. They have a surveillance system collecting information from MS on health consequences of emerging substances taken into consideration in terms of what is considered at the next ECDD meetings. The treatment and health services response is also critically important. Almost 80% of all drug-related deaths are related to opioids and in some parts of the world very potent opioids like fentanyls. Prevention and management of these conditions require comprehensive responses —access to treatment for opioid dependence, management strategies (including Naloxone provision, which is now also available in intranasal form and WHO advocates for over the counter access and this is happening more and more). Of course, the management of overdose and deaths presents challenges because of the high potency of these opioids. More substantial supervision is needed and referral to hospitals for these cases.

Youth RISE: What steps is WHO taking to advocate for and support member states in adopting and funding youth-friendly harm-reduction services, ensuring the ready availability of naloxone and drug checking services, and removing barriers that impede young people from accessing these critical resources?

WHO: A very important question. We have developed guidelines on harm reduction over the last decades. In 2014, we had included separate policy briefs for the 5 key populations, including people who use drugs, young and adolescents too. In our latest 2022 guidance, we have a chapter on young people who use drugs and young key populations in general. We advocate to avoid age barriers to accessing life-saving services, including naloxone, methadone, access to clean syringes. You may know because we work closely with Ruby that last year’s consultation before CND was focused on youth and young people who use drugs, so it’s a topic on the top of our agenda and when we work with the global fund, PEPFAR, countries, it’s a topic that we mention and is included in our conversations. But there’s only so much that WHO can do. We can recommend and advise but it stays there.

ENCOD: What would WHO advise to overcome the access disparity between different controlled drugs, in particular some herbal medicines whose use continues to be stigmatized?

VNGOC: The specialists on the matter are in the Plenary so they will respond in written form.

Turkish Green Crescent: How does WHO tackle the issue of drug use among communities that are affected by complex humanitarian emergencies in the field?

WHO: Increasingly important and not just in the East Mediterranean but also elsewhere. Most of the work is in emergency situations. Humanitarian crises are growing around the world. Humanitarian responses and health responses in humanitarian settings and emergency situations do not take into consideration the situation with substance use in displaced populations, people in emergency situations. It’s changing now, however. Again, it cannot be sidelined anymore. This issue of substance use in humanitarian settings is firmly on the agenda —there are guidelines on psychosocial support for mental health in relation to humanitarian crises. One in development on people with substance use disorders in these contexts —most of the time, alcohol. The document will combine issues of alcohol and psychoactive drugs. The funding agencies and developmental agencies, it may take some time for them to include this guidance into their agendas. We have put it strongly on our but when we apply for funding, unfortunately, it’s not successful because it’s still considered not a core part of the response. The involvement of civil society in changing this attitude is very important. Much greater efforts are needed, also in the UN system.

WHO: When COVID hit and WHO was responding to this crisis, there was a development of a document or system to identify essential services. Harm reduction services, including NSP, OAT, naloxone, were part of that —classified as essential services and the document after COVID became broader to cover humanitarian crises.

EHRA: The current standard of care for stimulant dependence is primarily psychosocial interventions combined with case management. However, the majority of evidence does not support their effectiveness. Does the WHO plan to develop guidelines for the psychosocially assisted pharmacological treatment of stimulant dependence? If yes – when is it planned? If not – what are you planning to do in this area?

WHO: Another pressing issue. Debated and discussed at the HLS of the CND. In your question you say no evidence of effectiveness —in fact, not exactly so. Some psychosocial approaches do have evidence in the management of stimulant use disorders. Particularly CBT, contingency management and some level of community reinforcement approach. WHO last year released new guidelines for non-specialised healthcare settings on management of mental health neurodevelopment and substance use disorders. Recommendations on management of substance use disorders. One is psychosocial interventions because of effectiveness. Second is related to pharmacotherapies, the focus of your question. Because these guidelines were developed for non-specialised healthcare settings, without special education and training to identify these situations, recommendation for modafinil, methamphetamine and methylphenidate are not recommended in these settings. However, a lot of research going on now, modifications for pharmacotherapy studies, for instance, no necessarily controlled substances but combination of bupropion and naltrexone —some results there, of course. What I said in the side event, on the SCALE launch, there is a need to develop now guidelines by WHO; comprehensive ones, on stimulant use disorders. To use in non-specialised healthcare settings. When it comes to WHO guidelines, timely and resource-consuming process. Not yet resources to initiate this work. This year we update our guidelines on management of opioid overdose and opioid substance use disorders. No offer to support guideline development in this regard but it’s needed.

Karim Khan Afridi Welfare Foundation: In light of evidence and findings emerging currently in many member states on the rise of deaths and emergency room visits related to use of cannabis and related products since its legalization in some countries, what is the World Health Organisation’s plan for action to address these trends and not allow them to rise to alarming levels? .

WHO: Important but difficult question to answer. When it comes to cannabis regulations, the WHO mandate in relation to cannabis, we have no mandate on how legal international legal framework should be applied to prevent cannabis-related health consequences. But WHO has a role in documenting and disseminating and communicating the health effects of nonmedical cannabis use and this is something we’ve done some years ago with WHO publication health and social effects of unmedical cannabis use. We finished the update of the second edition of this publication and it’s now in the clearance process. To be released soon. Also to better understand the impact of the impact of cannabis on. Thousands of deaths in road traffic accidents attributed to cannabis. Very little related to opioids and stimulants. A lot more work is needed to understand links between cannabis and mental health, psychosis, etc. Much more efforts need to make recommendations on the absence of strong evidence. Unfortunately, in many jurisdictions considering regulation for nonmedical use, the health considerations are not prominent in the discussion. Largely driven by other entities, not so prominent in the debate. We have requests from countries to join this debate. Regional offices and local offices do join these debates. And we share evidence on the impacts of cannabis in places where affordability and accessibility have increased.

Helsinki Foundation For Human Rights (HFHR): With more and more research conducted around the world on the medical potential of psychedelics, and thus the increasing amount of data on psychedelics for trauma healing on the one hand, and the ongoing armed conflicts in various locations around the globe on the other, is WHO considering supporting the psychedelics-assisted treatment of PTSD for veterans, other first responders, as well as civilian victims of war? And if so, how would this support manifest itself?

WHO: In every forum, this issue is debated because interests converge on this topic. When WHO identifies two aspects in the question: using psychedelics in treatment in management of mental health and substance use conditions. And another aspect in relation to veterans in relation to PTSD, mental health and substance use disorders. On the first, WHO in its recommendations strongly based when it comes to this type of treatment consider effectiveness and safety of what is being discussed. Many publications now show case studies, some evaluation of research, effectiveness of ketamine in the treatment of depression. And I’m a psychiatric and when you have served depression ECT which had a bad reputation was a quick way to change the situation —from high suicidal risk to less prominent depressive state. Ketamine shows something similar in terms of speed of the effect and we have to consider. In terms of safety however, that’s an issue. This kind of ketamine assisted treatment and other psychedelic assisted treatment, for safety concerns, in clinical settings, in very clear supervision of potential negative consequences. When it comes to the public health impact, WHO focus on interventions that have a broad impact on population health. Because of safety considerations, this is something that we need to consider in relation to this. We have more and more questions on psychedelics and treatment. Two different settings to consider: clinical settings, which is where most research undertaken happens. Secondly: outside clinical settings, used because of claims, justified maybe, difficult to say, with impacts on wellbeing, emotional status, people with trauma. We need to distinguish these two things. For WHO, the question of health providers if of particular importance. It may be that there’s more evidence for us to act and develop recommendations. We’re monitoring, the evidence is still to be further developed. We may consider that if the request is strong from member states. Second aspect is about veterans. Indeed, PTSD in veteran populations is a significant issue. Very few countries, maybe just one, had a veteran health administration —the US. They have a lot of experience with that. But the situation is changing. This is the second aspect of your question. That special health provision, which might be the platform for delivering psychedelic assistant treatment in veteran population may be of interest, but it’s a developing situation.

Field of Green for All: To comply with the single convention, countries that legalize non-medical cannabis are obliged under article 2(9) to reduce “abuse and ill effects” by any means. What assistance can WHO provide to Member States to develop such compliant harm reduction practices? 

WHO: One issue in your question when I read it that I’d like to address is that it’s not for WHO to decide about compliance. That’s the role of INCB. I would say that according to the INCB statement from last year, the nonmedical use of cannabis is not in compliance with the international drug conventions. It’s implied in your question that it’s compliant. But it’s not WHO’s role to talk about compliance. INCB does that. And they have a position. But I know conversations about this are being had with MS who have implemented these programmes. When it comes to prevention of abuse and ill effects. When nonmedical cannabis is legalized in the country, what is important is to learn from experiences accumulated in dealing with health consequences of licit substances. Licit psychoactive substances like nicotine and alcohol that for years had been (…). Some questions are critical in this regard. Determinants of public health impact were availability, accessibility —how easy they can be reached, affordability and the quality. This is an issue for cannabis-based products. If a jurisdiction decides to legalize nonmedical use, they need to address all these issues, particularly related availability among children and adolescents to prevent and delay initiation among this population and make everything possible to ensure that those who eventually will be the largest burden of cannabis-related harm, which is impossible to predict, but usually people who are not very fluent, a combination of vulnerability, they’ll develop cannabis use disorders and pay the highest price. Important for societies that decided to go this way to provide all things necessary not only to prevent but diminish prevalence, provide and establish and develop health and social services who will eventually develop cannabis use disorders.

WHO: More in the area of ECDD at the plenary at the moment. But they reviewed cannabis scheduling. And there were six proposed recommendations for CND to look at. Only one was looked at. Others were pending. No further details at the moment.

Association Project Hombre: The use of alcohol, tobacco or non-medical use of prescription drugs is very prevalent in all regions. However, as legal or regulated substances, they do not receive the same attention in central bodies such as the Commission on Narcotic Drugs. How can WHO contribute to stress governments to orient drug policies in which health is the priority and not the regulatory nature of the substance? 

WHO: Indeed, if you speak about the impact on population health —for WHO, this is critical, the impact on health of psychoactive substances. The licit substances produce the highest burden. But prevalence of use is lower among illicit substances, however. The most used psychoactive substance is caffeine. Alcohol is 2.3 billion. 1.2 billion use smoked tobacco products. According to UNODC estimates, less than half a million people use psychoactive drugs that are illicit. At the same time, CND has a particular mandate on psychoactive drugs. That’s why their focus is on those drugs. WHO does not have that restriction. We look at all psychoactive substances. There’s the tobacco control framework, and many other initiatives. IN 2022, WHA adapted the global alcohol plan and developed it with member states, now in implementation. What your question probably aimed at is to increase attention to the interaction between licit and illicit drugs. This interaction is not very often the focus of discussions. As well as the question of prescription medicines. Particularly among women, benzodiazepines, and other medicines. This requires much more attention. Recalling the lessons that we have with opioids when the prescription of opioids became a marketing, advertisement campaign to consumer sometimes direct advertisement of controlled opioids. Clearly a significant contributor to overdose death crisis. All these lessons must be taken into account and that’s why this deserves more attention than we probably give to that.

WHO: Just to say in addition to the technical response from my colleague, every occasion WHO recommends to put health issues at the focus of drug policies. Our DG at the opening of this High-Level segment was doing that —balance drug policies towards health and person-centred evidence-based policies.

ICEERS: The use of ancestral medical practices involving psychoactive plants and fungi is integral to traditional medicine in many countries of the world, and often the primary or sole medical service in rural indigenous communities. The WHO Comprehensive Mental Health Action Plan 2013–2030 affirms that greater collaboration with ‘alternative’ mental health care providers, including traditional healers, is needed (Parr. 51). How does the WHO envision this collaboration in cases where these ancient medicinal practices include the use of (controlled) psychoactive plants?

VNGOC: This will be answered in written form because our colleagues from WHO are in the Plenary.

Dianova International: Since 2017, WHO is organizing every two years the “WHO Forum on Alcohol, Drugs and Addictive Behaviours (FADAB)” inviting policymakers, health care professionals, academics and civil society representatives among other. How is the outcome of these forums feeding into WHO’s work? What do you think have been the main contributions of these exchanges? .

WHO: The forum we organised every second year is important for two reasons. One, a platform for civil society, MS representatives, academia and UN and other intergovernmental representatives to discuss common issues. We’re not limited to alcohol or even drugs. We’re expanding to addictive behaviours. Last year in 2023, a significant track on gambling issues. In this forum, we test our plans, activities, draft products and have the feedback which is extremely important for WHO to move forward, defining properties, shaping agendas, forming new partnerships and collaboration. We hope you will participate.

Asia Harm Reduction Alliance (AHRA): Given the unintended consequences of punitive drug policies in Southeast Asia, such as the challenge of controlling infectious disease epidemics like HIV, TB, and HCV, how does the WHO ensure transparency and data-driven evaluations to assess the health impact of these policies?

WHO: Central question for our work at the department of HIV, viral hepatitis and STIs. We work together with UNAIDS and UNODC on assessing policies so that there’s the stigma index that UNAIDS coordinates. At country level, we support questionnaires on this. Are programmes included, are their behaviours criminalised? Given that it may not be easy to put those things in our work as a direct link, what we did when we developed our guidelines for key populations more broadly, we looked at the impact of criminalisation, stigma and discrimination on health. We’re presenting it later at the side event. There’s definitely an impact. People go underground and don’t have access to services. We make the explicit point that structural barriers and punitive laws need to be addressed before successful implementation because if you’re severely criminalised and stigmatised, accessing services is hindered. We look at systematic reviews and literature to see evidence on those links,

WHO: If you want to know more about specific technical activities, there’s a session, a side event at 13:00 in M7 —three programmes will present our update of what we’re doing from the last CND to this one.

VNGOC: One technical announcement. VNGOC is organising the other consultations with high-level officials here in Vienna. Tomorrow, UNODC Executive Direct (the room has changed, it won’t be in CR7 but in CR3). All this information is on our website. I thank my WHO colleagues for this.

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