Organised by Sweden with the support of Canada, Norway, the UNODC Prevention, Treatment and Rehabilitation Section, the World Health Organisation, the European Union and its Member States, and the Pompidou Group of the Council of Europe

Moderator: Annika Markovic, Ambassdor, Sweden. I have the privilege of representing the UN International Organizations in Vienna. The topic chosen for this event addresses one important aspect of the growing challenge to drug overdoses, namely that women and men have can be impacted differently and women may even in some situation possibly more. More needs to be done to increase our understanding and prevent drug overdoses especially with regards to the aspects of the child. And first, I’m very pleased to have my side three distinguished speakers to kick off our discussions.

Jakob Forssmed, Minister for Social Affairs and Public Health, Sweden: Excellencies, ladies and gentlemen. It’s an honor to speak before you today to give some opening remarks. At this point. I’d like to thank everyone for taking part in this meeting, Executive Director and all the distinguished panelists, Sweden now has the presidency of the European Union in the first half of 2023. And we want to dig into the pipeline that gender and drugs are part of this program: it is the issue of drug related deaths for women, or gender and drug overdose. Every drug is a personal tragedy and a disaster for the families. And we need to do our utmost to prevent drug overdoses that lead to deaths for the Swedish government. It is a great importance to reduce the number of challenges. Therefore we have introduced zero vision for drug related mortalities as we have the vision is to work and to keep the focus on preventing opioid overdose deaths. We are right now taking several steps to reduce related mortality. For instance, we are working to increase the access of naloxone, but we need to do research shows that men and women die from drugs in different numbers are different places and throw different substances. So therefore I must put on gender lenses to see what we need to do to reduce the number of deaths. This makes it possible to improve responses and drug policies and I look forward to hearing more about this. Today. The European Union attaches great importance to reducing drug users and to gender equality. The European Union strategy incorporates gender equality and health equity. It also says that we need to continue to reduce drug related deaths and non fatal overdoses. It was just recently at a session organized on gender and drug overdoses. In the debate, it became evident that drug overdose is still remains a major issue. We need to collect more sex disaggregated data to improve analysis.

Ghada Waly, UNODC: Our interventions already addressed the unique needs of women. As an example of good practice Morocco prioritizes women for methadone treatment to prevent drug injection related HIV transmission, and to contribute to their social rehabilitation and empowerment by addressing social exclusion, stigma and discrimination. UNODC is piloting HIV prevention, treatment and care services in Tangier to help adapt Morocco’s health and social services for injecting drug users to the specific needs of women, especially those who have children or are pregnant. Our eventual aim is to expand these services nationally, and also in Egypt. Egypt provides HIV prevention and health services to over 10,000 incarcerated women and children. And that is in the process of introducing opioid agonist therapy. But we need to do much more to remove stigma and barriers services for women who use drugs, we need to join forces and step up our investment. UNODC is ready and willing to do its part I invite you all to join us.

Dr Nina Vezzoli (?): It is a great pleasure for me to joining you this very important session on drug overdose which is a growing global concern with deaths rates rising at a faster pace and particularly for women. An estimated 60,000 women died due to the drug overdose globally, of whom 60% died due to opioid overdose. And despite this women are underrepresented. In treatment for drug use disorders. And as a matter of fact, only one in six people in treatment for substance use disorders is female. Women are less likely than men to use alcohol and drugs. But the differences in prevalence of use are decreasing. Women who use drugs are exposed to additional vulnerabilities such as higher risk of depression, post traumatic stress, stress disorders, the gender based violence and pregnancy and parenting. But yet womens needs are rarely considered in planning and implementing policies. As Minister first highlighted there is a need to have gender specific data. We need to have the gender and the sex specific guidelines for diagnosis and treatment protocols. It is just as acute is boosting the capacity of primary health care services to identify and manage substance use disorders in men and women. Achieving universal health coverage is at the top of the agenda. All 53 member states in our region have committed to and to deliver universal health coverage, we must ensure equitable access to treatment for all regardless of gender. That lecture is walking the talk in that lecture UNODC project called Stop Overdose Safely (SOS initiative) has been piloted in several countries in the region among them, Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine. What are the results? A rapid distribution of take home naloxone followed by extensive training for potential opioid overdose witnesses 90% of project participants of which wine for we are women’s reporting, reporting administering naloxone when witnessing overdoses, and in almost all instances the victims survived. Our findings suggest that naloxone was administered by as many as over 4000 individuals and that 1000s of lives saved the past year. Unprecedented health threats including the COVID-19 pandemic, requiring the health systems to be agile and resilient and to reprioritize. This health threats demand the follow dual track approach which means preparing for and responding to better, better to health emergencies and at the same time maintaining essential services. In other words, we need to be able to defend public health on several threats. And one of those strands dear colleagues is equity of access to drug treatment based on gender and the prevention of drug overdose. Thank you for making sure that this issue is highlighted on health agendas across the region.

Dr Vladimir Poznyak (WHO): This is one of the most important public health issues in drug policies and sex and gender have important influence on everything from the treatment of pharmacological treatment of drug use disorders to organization of services and policy decisions, just several definitions at the beginning and the difference between sex and gender. But still both of these concepts have significant influence on how we organize services and how we treat people with the overdose according to who definitions refers to any to the use of any drug in such an amount that results in acute life threatening adverse physical or mental effects. What is important again when we are talking about gender differences to highlight that some of the overdoses in fact intentional, and in some studies, this percentage can be up to 25-30%. And we know very well that prevalence of suicide attempts and completed suicides is much higher among women than men. Overdose does not always result in deaths however, they it depends very much on what substances are being used in what amounts consistently across all psychoactive substances, the prevalence of use among women is lower than men. And you had already in the high level segment that they it’s the ratio between men and women is completely different than treatment settings which are proportionally discriminate women in terms of access to treatment. When it comes to disease burden, it also translates the prevalence of use of different substances including drugs translates in significant differences about the global burden attributable to drugs among men and women, as illustrated on this slide. The factors which are associated with increased risk of drug overdose, drug use disorders and particularly opioid dependence which may amount to approximately 1% during the lifetime of death through overdose, injecting drug use particularly when first using injecting as a way of drug administration. And reduction in tolerance when drug use is restarted after a period of absence, like for example, during the first weeks after release from incarceration after discharge from inpatient or residential detoxification, after cessation of drug dependence treatment, including treatment with opiate antagonist naltrexone. Also, the high risk of drug deaths of drug overdoses associated with the use of highly potent psychoactive drugs like fentanyl or other newly coming potent synthetic opioids. And finally, common use of other psychoactive substances, which might aggravate the breath depressant effects of opioids, like alcohol and benzodiazepines. And we know that prescription of these substances among women is higher than among men. The what are the sex and gender differences which are as modifiers of drug overdose risks? impact on health seeking behavior, late referrals or demand? For treatment, which is well documented for women? There is limited access to gender sensitive, specialized treatment services, because this services needs to provide services and care for pregnancy for pregnant women, for breastfeeding and for childcare. And very few treatment services can actually address these challenges which will make treatment for women accessible and acceptable. Higher levels of comorbidity among women particularly depressive and anxiety disorders and the use of prescribed medicines that increase the risk of overdose. And finally, limited capacity and access to treatment in primary health care and other non specialized health care settings. In view of highly stigmatized in almost all societies of drug treatment services, it’s preferably if you want to mainstream gender in treatment is preferably to provide treatment in less stigmatized in less discriminatory facilities and services. Then, what typical drug treatment services can can do. This is the latest data which is still forthcoming for publishing which shows that 80% of countries do not have services, specifically the amount of drug use disorders specifically designed for women. And for pregnant women, this percentage is 64%. That means that the national level so that means that even no single treatment capacity exists in a significant number of countries to deal with patients with for use drugs or drug use disorders women. So what does it mean gender mainstreaming? And again, I think what what Minister Forssmed already mentioned is applying gender lens to organization of services. Gender mainstreaming is the process of assessing the implications for women, men, and gender diverse people have any planned action within the health system, including legislation, policies, programs, or service delivery in all technical areas, and at all levels. And as my colleague mentioned, this is a part of universal health coverage concept which is critical for things like availability of naloxone, or appropriate harm reduction services or treatment, what else might be needed to address what be a overdose and to apply gender lens to these actions, policy dialogues and technical assistance to build services and programs to fill critical gaps in provision of treatment care harm reduction services for women who use drugs or with drug use disorders, development of gender sex specific guidelines, diagnostic and treatment protocols and other normative documents and information products, including those who are prescribing opioid analgesics, benzodiazepines and addressing alcohol use addressing stigma and discrimination associated with drug use disorders and treatment services, which is more prominent among mainstream in gender in education and training of health professionals and service providers.

Daniell Nikitin, Global Research Institute in Kyrgystan. I’m going to speak about the experience of integrating overdose training into the care model of gender based violence prevention women who use drugs, the synergy of the overdose prevention and prevention of gender based violence. They appear to be quite successful in Kyrgyzstan. Thank you, even after this I would like to acknowledge my friends, colleagues and partners in Kyrgyzstan, Kazakhstan, Tajikistan, Ukraine, Australia, India and USA, as well as donors that UNODC, WHO, Open Society Foundations, and Soros Foundation Kyrgyzstan for their generous support in sharing scientific and practical ideas next piece in thank you but they’re still overdue safely project was implemented as a part of the broader SOS initiative launched a you know deceive in devil who in 2017. The study focused on take home naloxone implementation in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine in Kyrgyzstan, politics into elite training in opioid overdose recognition and response, including the use of naloxone. In 2013-2016, prior to SOS, we implemented the Wings of Hope Project, which utilized intervention based on the evidence based as more to be instance for women initiating new goals for safety and new stands for Screening, Brief Intervention and Referral to Treatment. The community based NGO stream means we are involved in adaptation and implementation of the SOS training that helps us reach more women and maintain uniquely high retention rates. Project participants attended the individual sessions that included raising awareness of different types of intimate partner violence, gender based violence screening for different types of violence, safety planning, social support to address violence, goal setting and building motivation and HIV linkage to GBV related services and overdose prevention training. It was decided to include the GBV after the interviews suggest that exposure to violence increases the likelihood of depression and other symptoms of post traumatic stress disorder, PTSD, as well as physical pain that may lead to cravings for self medication resulting in drug misuse and overdose. We also found that fear of stigma discrimination from calling police or ambulance during violent or overdose incidents that might increase their exposure to both violence and overdose. Data collected in 2013-2016 from women who use drugs who benefited from being services demonstrated higher rates of intimate partner violence and PTSD. Experiencing overdose error was reported by 46% of participants and 6% overdose in the past three markets. Cohort study was conducted as a part of the SOS project the agencies that were trained in beings and as aware of gender sensitive recruitment and retention approaches, we were intimately engaged in the SOS implementation as members of the current production network, please next slide. In Kyrgyzstan, 27% of trainers and potential opioid overdose witnesses trained throughout the project. That was one of the key parameters of the SOS project implementation. GBV prevention interventions has to be filtered explore a path and maintain we are sure that GBV services agencies have to have regular access to Naloxone. That was a significant gap before the SOS came to the region. As of 2022 out of 14 NGOs and crisis centers trained in beings built into wisdom today the seven trained and practicing the SOS overdose intervention essentials Yes, seven out of 14 Yes training peer trained. You know, just a few minutes ago, I received a message from a wonderful colleague in India. She formally confirmed that in the state of Manipur, a Foundation is working in collaboration with the Manipur state AIDS Control society on integrating overdose training and naloxone distribution into the female injecting drug users.

Giovanna Campello (UNODC, PTRS) When I started thinking a bit about how to attend this presentation, I stated thinking about putting a gender lens onto the issue of overdose. But for me it fairly fairly quickly turned into making a call to action to expand services for women who use drugs and women with drug use disorders and I want to hopefully you will follow me in my reasoning and come to the same conclusion. I’m very fortunate that I come my presentation comes after my colleague, who setup the scene so I will I will skip some of the slides that I have prepared for you that gave the this idea that although more men than women die of overdose, it is women that we need to focus on because of the vulnerabilities of their social situation particularly around intentionality and we will ever be seen also in prison setting. And so what can we do? And my thesis is that really we do know what works sometimes we are doing it already, but we need to do more. And as Dr. Pozniak was mentioning, preventing and managing opioid overdose we know how to do largely we know that opioid agonist therapy and naloxone including take home naloxone will help significantly prevent the number of overdoses in your country and manage safely this happen. Of course, the problem is that these are services and we know that women have less access to services. So allow me to go back. Yes. So what can we do to increase women in treatment, health care and recovery management? There is plenty that we can do and that we know how to do and specifically in developing services that cater to our tailor to the needs of women who use drugs and women with drug use disorder. This will mean for example, often having services that are only for women, not necessarily but often that are non judgmental, non stigmatizing non discriminatory. If I could use one word I would use empathetic but I wanted to set them on peace and we want services that are safe and feel safe. Provide trauma informed care every step of the way. And we want services that think about those practical responsibilities that make it easier for the people who need them to participate. The chat there being open at convenient times being easy to reach, maybe cover the transport costs. And of course we need all of those health and social economic support to the people who use the services but here on this slide I underlined specifically because of the issue of intentionality. And because of the right high rates of abuse, the need of being prepared to address comorbid mental health disorder, anxiety, depression PTSD and screening for suicidal tendencies. The core issue: addressing stigma and discrimination. I have a couple of suggestions that can start concretely address this issue, creating meaningful opportunities for women who use drugs and we want with drug use disorder to participate in the planning and running of the services and of course, train the workforce not only in the evidence based interventions, that of course, but those who strong ethos of respect, empathy, and I believe that this will go a long way to start addressing this incredibly important barrier. Dr. Pozniak was already mentioning pregnant women and here you can see the results of a study that looked at motivators and barriers for pregnant women in treatment. The first one is very practical, but the second answer gives you an idea of how pregnancy can be a barrier. Nobody would take me because I was pregnant and on methadone, but also in the right circumstances and motivation. I knew that I would have to deal with child protection services. I knew that being in treatment was a good look. So that was my initial reason for coming. And here as Dr. Poznyak was mentioning, we have been very fortunate to develop guidelines and packages, particularly including clinicians engaged in perinatal care, but of course all of the professionals that are needed to make this an opportunity for the mother to be and for the child. Yes, what about women in prison? I would like to refer here to the words of my executive director. First of all, let us expand alternatives in all possible way. We have good practices, we have strong mandates. There can be ways to make sure that at every step of the criminal justice system, at contact with the criminal justice system moves people as much as possible to health services. And of course, this is where we need to expand those services and link them to those in the community because that continuity of care between prison and community is the single most important protective factor to a lower overdose coming out of the prison. Avail adequate resources, because I think that if we are serious about addressing overdose through a gender lens, there is no way we can do anything else than investing in expanding evidence based services for women who use drugs and women with drug use disorder. And inaction is not an option. And to quote my executive director, as she just mentioned, we are doing our part. Please join us and let us all work together to make this a reality.

Raul Martin del Campo, Mexico: I decided my presentation would focus on the case of the Mexican experience, a country whose efforts to prevent double dose in women and men are still isolated and implemented mainly by a civil society. Since it is a problem that has not been made sufficiently visible. Today, I am representing a group of researchers in Mexico their research seminar on global issues are not viewings. We are a team of researchers from different Mexican institutions. And research ranges from the availability of opioids for medical use to the effects of illicit opioid abuse as well as basic to social research and from collaboration with some redemption NGOs public policy advocacy. In Mexico 17% of injecting drug users have experienced at least one overdose in the last 12 months, with an average of four overdoses during their lives. Second, people who use injecting drugs, heroin or crystal meth, without knowing it contains fentanyl, and not being able to prevent an overdose. We have a significant underreporting of overdose deaths, five recent estimates by non direct methods of opioid overdose deaths in Mexico go from 160 to 1200 per year. We have very few opioid substitution treatment centers, and many with no access to knowledge so opioid users in Mexico resort to practices such as placing ice on the body or of their overdose partner, as well as injecting a highly concentrated solution of salt. I don’t know if you have ever heard about this, injecting a highly concentrated solution of saltwater which according to studies has a very limited efficacy in reversing overdose, especially with fentanyl. In this slide, we can see the story of one of these women a as other studies have found she was a victim of physical and sexual abuse initiated with substance abuse experimentation that 12 years old. She ran away from home at 17. And they will the most tragic part of this story is that he already had an overdose in which a the the authorities to to legally occur. And many professionals state that there are no differentiated care protocols for men and women in Mexico. They also emphasize that in addition to the physiological differences, It is notable that women tend to request treatment in more applications, precarious conditions, and commonly go to the clinic accompanied by their children. Even when these women have been consuming high amounts. of heroin on the street, the clinician of methadone cleans stigma and discrimination on the part of the professional service providers. What we have here another another example in Mexico good example. “La Sala”, which may be translated to English as “the living room” is the first supervised consumption site exclusively for women in Mexico and Latin America. A project created by the NGO web there at Mexicali started its operation on 2018 La Sala for service for cisgender and transgender women. Today they have had more than 1000 admissions to La Sala. An average of three women use these services per day they have had approximately 35 to 50 overdoses on the side, all medically treated successfully. And most of the women who use the service agree to have their substance tested and receive information on safe injection injection techniques, techniques, as well as health promotion orientation. Naloxone in Mexico is unfairly classified on Mexican law as a psychotropic which has led to its inability and lack of programs for its distribution between strategic actors in order to prevent overdose. As a former International Narcotics Control Board member, I realized that there are several countries in which naloxone is overscheduled so initiative a we have a sent to the Senate a to that proposes to reform the agenda now, though, in order to eliminate Naloxone from the list of psychotropic substances in Mexico. Also to allow Naloxone to be available as a safe and effective antidote to reverse opioid overdoses. We are a conscious that this is the first the first step. Obviously, we need to get ready for naloxone distribution programs according to who community management before going over those guidelines.

Alexis Goosdeel, EMCDDA: As the Minister said, this is not only a priority for Sweden, and for the Swedish presidency, but it is also one of the priorities of the EU strategy on drugs. We are already beyond time so I will not enter too much into details. But we have 1000s of fatal overdoses reported every year in Europe with the number of deaths that is likely underestimated but still low compared with other regions of the world. And it’s not coming out of the blue. It’s the result of 25-30 years of joint efforts of the EU. With the EU what has been built over the years as the European drugs policy, which is also trying as much as as possible to be balanced between demand reduction and supply reduction. Still, we see that we we have aging trends in overdose among males and women. While they were the highest numbers are reported among the 30 to 44 years old in both men and women. We see that the biggest increase is in the age group 50 to 64 that increased by 82%, between 2012 and 2020. We see also that often among women, it’s related to prescription opioids, possibly leading to pain management and the misuse of medicines. Metizeneres, the drug consumption room in Barcelona. And basically with the change of practice, and for instance, the use of stimulants. It’s decreased becoming increasing ly more violent due to the profile of the users and the clients. So it’s it’s reducing the possibility of the appeal for women to apply. So we need to change and I think it’s time to really design on basis of gender needs. And not just on general principle. We see also a steady increase among the 65 plus age group among women. But again, I think that if if we were measuring, not only treatment data were made are over represented. And if we were managing to cover more women having a problem or substance use and abuse and related overdose, we would certainly have a higher percentage we see also it was mentioned by some of the other speakers, that the proportion of suicidal intent among the reported overdose deaths with non intent is higher among women. And between one four to 1/3 of the overdoses among women at the sushi Sociedad intent, report that compared with one to 10 or five for men. So if we talk about data availability, what you will see it’s what is in green is the countries that have covered the data that were at least partly aggregated for drug related deaths. And this is the green color for 2020. And the other column shows that those data are much older, and it’s only part of the information and while I support of course, the call for more disaggregated data. I would like to we’d like to remind ourselves that when one of the key concepts of statistics are learned at the university or the some years ago, is that statistics in the best case scenario, it allows us to conclude that an upward one hypothesis is not wrong. So it’s not only about asking for this aggregate the data we should know what is the questions we are supposed to answer because we get plenty of data if we don’t if the question before, then it’s like stock statistics for supermarket we don’t know what to do with them. And they may be not useful. We have a lot of interventions, and none of them are not enough are specific for women but basically each of those measures including specific actions for Naloxone or opioid agonist treatment could include F component and services that are designed for women. There are some examples of women’s specific and gender sensitive interventions in some countries in the EU. Steve, not enough, but already in Sweden, we can see that gender is included in drug policy. Plans and specific services are we not repeat all the list of countries? We don’t have the time now I would like to highlight that. I was informed last week we got a visit from a delegation from the Danish Parliament that for the first time in Copenhagen, they opened the drug consumption room that is reserved for women. And I think that’s the example of what we need to another very interesting program that I had the privilege to visit is coordinates in Eros in Barcelona, which is a nonprofit cooperative based in the centre of Barcelona, which provide sheltered environments for women and non binary gender people who use drugs and who survive multiple situations of vulnerability and again, the fact that it’s CO produced it’s, it’s managed together by the clients the participants in the program. And I think the most important thing that we should seek to promote its dignity and dignity means that at some times, I will not repeat the main factors because of Giovanna them already. I would like to come back to my conclusions and I choose to see this picture and I paid for it, because I think we should try from the onset to stop victimizing women. So instead of showing you victim, I tried to find a woman who’s homeless, who’s smiling and can be happy. We need to stop respective ideologies to decide. Without even listening to women what is good or could be good for them. We need to work at restoring dignity. When we say no stigma, it means also making sure that all ministries in a given country work in the same direction and Giovanna and some others. They spoke about child care, I think to take the children automatically out of the future mother the mother can be for good reason for the good health of the child. It could be the worst disaster for the young mother who could find there just a reason to find a way out of problem situation of drugs. It’s not a question of good intentions. We should avoid to punish to increase the stigma and increase the problem instead of alleviate and this is why I support the call for action. And I will say the same we spoke with leaving prison. It’s a cert more than 30 years that I work in this area. Every year we speak about prison as a priority. Every week. Every year we speak about women and drugs. Let’s stop speaking and let’s stop pushing and get commitments