The Harm Reduction Coalition and Physicians for Human Rights, with input from other members of the IDU Working Group of the Global AIDS Roundtable, have prepared the attached sign-on letter to the President-elect to alert the transition team to the fast-approaching and very important meeting of the United Nations Commission on Narcotic Drugs in Vienna next March.  At this two-day meeting, a political declaration will be agreed on that sets the framework for the next phase of international drug policy and by implication will set the course for the global response to the HIV epidemic. 

I know you are receiving many sign-on requests, but please do not ignore this one.  We need to alert the transition team so that they have the opportunity and time to prepare.  We are also asking for a meeting to discuss our concerns and recommendations in greater detail.  Allan Clear has been in Vienna all week and has posted 2 helpful blog pieces – found below - that provides background on the meeting and the issues. 

If you would like to include your organization on this letter, please respond to me (pbarahona@phrusa.org) by December 30 with your organization’s name.  We will then forward the letter to the transition team and re-circulate the final document.  Don’t feel you have to wait until the 30^th though.  Early responses are strongly encouraged.

____________________________________________________________

Vienna U.N. Drug Treatment Meeting Day Two: The Clockwork Orange
Brainwashing Day (12/18/08)

Ah, the Clockwork Orange brainwashing day. There's nothing in my cranium. I've
blocked it all out. A windowless auditorium and a set of presentations
where the direction from the organizers to the presenters was "keep it
tedious and repeat the information from the day before."

I sat for 9 hours or so waiting for some kind of stimulation that was not
arriving. Supplied with powerpoint presentations of the most unimaginative
kind, graphs and pie charts and tables, presenters made a great show of
their learning and authority, but speakers had a complete inability to
talk in either a compelling or dynamic fashion. Did no one on the
organizing committee check to see if presentations would overlap? John
Strang, National Addiction Center, United Kingdom, talked about methadone
as Herb Kleber, Columbia University, USA, did the day before; a panel on
brief interventions on which presenters both used the same WHO tool as a
discussion point.

You can't blame the presenters. The organizers clearly had a concept in
mind and that's where it stayed - in someone's mind or in a folder in a
cabinet hidden behind cleaning supplies that had been pilfered from the
commissary.

The conference is presenters from university settings and addiction
centers from the USA, Canada and the UK who have failed to adapt their
presentations for their audience. I cannot imagine that Herb Kleber
actually put any thought into what he presented. His secretary pulled a
canned presentation from his presentation file in 'My Documents' and
handed it to him at 4:00 pm on Friday afternoon. How does science on
methadone translate into practice for someone who is dealing with an
emerged heroin epidemic in Dar es Salaam? Yes methadone and buprenorphine
is very effective but how do you deliver it to drug users in a country
that has no history of addiction medicine, where methadone is not
currently in the country, where users are not going to pay for medication
and where the government is going to be looking over their shoulders for a
reaction from the International Narcotics Control Board if they deviate
from a clinic based system?

I might be the only person who really cared. Three quarters of the
audience didn't show up today. After all, there is Christmas shopping to
be gathered up and taken home. "From research to practice" is the tag
after the colon in the description of the conference. The absent audience
didn't get that on day 2 and maybe they knew it wasn't going to be
delivered anyway.

Perhaps, however, none of this is the point. As Gilberto Gerra, Chief of
Health and Human Development Section of UNODC indicated on the first day,
UNODC is gathering steam to launch a big demand reduction initiative.
However, to make it work, UNODC needs US buy-in. Therefore a US dominated
event is a perfect sop to butter them up. It's a solid way of branding
drug treatment as the demand reduction approach. The estimable John Strang
choked nervously during his presentation when he mentioned 'harm
reduction', lamely explaining that it's not a controversial term in
Europe. European governments do see harm reduction as part of a health
care continuum for drug users and hopefully can ensure that not only can
they continue to fight for it through the UNGASS process but can see it
assimilated into the new UNODC demand reduction initiative.

Thomas Barbor from the University of Connecticut School of Medicine
delivered a fairly decent albeit guarded presentation on brief
interventions. It would have been nice if he could have stretched out a
little and talked in more detail about applications. Screening, Brief
Intervention and Referral to Treatment (SBIRT) fits snugly into the harm
reduction fold. It's aimed at non-problematic users in settings that are
generally not used to discuss alcohol and drug use. Essentially, workers
at needle exchange programs deliver brief interventions everyday but SBIRT
takes it to emergency rooms and other venues and approaches a different
audience. It's not a technique aimed at cessation of drug use and it's not
necessarily targeted at people with problematic use although if those
individuals are ferreted out, then they get the treatment referral. It was
interesting watching Herb Kleber grapple with the concept (although it
can't be new to him). He wanted to know what the sustained effect was on
keeping use down after the intervention. However that's not the point. If
use remains down, that's cool. But if the user can be more conscious of
their use and not drink and drive for instance, then that's great.

Kleber wasn't the only one confused. I had dinner with a confused David
Joranson from the University of Wisconsin. He's working with Scott Burris
from Temple University and Dave Burrows from aidsprojects.com from the
Land of Oz on providing access to pain medication to people in need. "So
why are we lumped in with harm reduction?" was his plaintive cry. No
reason that makes any sense, David, except when you get involved with
providing pain medication to people who are suffering you come up against
control mechanisms and fear. And when you provoke those feelings in
authorities you get lumped in with all the other transgressors - the
queers and the junkies and the sex workers - and life becomes a series of
negotiations and compromises. Good people get hurt and great projects get
unreasonably scrutinized because ideologues cannot get over their dogma
and paranoia. Methadone and buprenorphine are essential medicines
according to the WHO.

However, some funding for the pain medication issue has been applied to a
short film that covers the health-oriented side (as opposed to the deviant
side!) of opiate use. Called "The Two Faces of Opium" it shows the need
for pain medicine and shows methadone as an addiction medicine.
Unfortunately only about 25 people got to see this film as it was shown as
an evening side event. I think the daytime audience would have benefited a
great deal more from the film than the anything else on view today.

Allan Clear is executive director of the Harm Reduction Coalition. _________________________________________________________________

Day One at the U.N. Drug Treatment Meeting -- Slightly More Interesting Than Predicted

More than 200 people from around the globe have shown up for the first day of this drug treatment meeting at the United Nations Office on Drugs and Crime (UNODC) in Vienna. (If you're just tuning it, it may be helpful to read my first post, from yesterday, where I set the stage for what's to come.) Tantalizingly titled "Technical Seminar on Drug Addiction Prevention and Treatment: from Research to Practice," the tag line at the bottom of the conference program awkwardly hawks "NOTHING LESS than a qualified, systematic, science-based approach such as that used to treat other health conditions" — a fair enough goal. I tell you, the crowd was on tenterhooks for the event to begin.

In truth it was the most subdued, dead crowd ever gathered. Perhaps the most exciting event of the day was kangaroo hotpot on the canteen menu. To be clear, I have less interest in the science on show than on the subtexts of the dialogue and what is said and not said — all with an eye on the Commission on Narcotic Drugs (CND) meeting occurring next March. At that convening, countries will gather to review the last decade of UN-approved international drug policy, set forth at the first United Nations General Assembly Special Session (UNGASS) on Drugs in 1998, and issue a new UN Political Declaration. I suspect that the goings on at this prior conference may offer hints of what's to come.

Antonio Maria Costa, the Executive Director of the UNODC, was in fine fettle opening the event. True to his pompous, unapologetic manner he was disrespectfully late, but his opening remarks were good. He wants the CND/UNGASS process to put increased money into demand reduction in order to put health at the center of the equation and reduce drug related crime. Consequently, Costa called for the rebalancing of drug control (by putting a greater emphasis on health), expressed concern that too little is spent on treating drug addiction, and acknowledged that law enforcement should not be used as an alternative to treatment. Costa also rejects the over-incarceration of drug users (he's been consistent about this).

I'd like to think that Costa's comment re: over incarceration was an unsubtle dig at the US, where 1 in 31 US citizens live under the auspices of the criminal justice system. However, I suspect he's directing his remarks at the world below the equator or at Central Asia. In so many words, he admonished member states for not protecting their drug users and respecting their human rights.

The day went downhill from then on in, as the conference morphed into a showcase for the disconnect between the science around drugs and addiction and the current reality re: which research-based policy recommendations are ever actually applied or funded or prioritized by governmental bodies. Consider the presentation of the keynote speaker, Dr. Nora Volkow, who heads the United States' National Institutes on Drug Abuse. I like Volkow. She cares about people who use drugs, and exudes compassion and even fire when she defends them. Before her presentation, we had a conversation about the federal ban on the funding of syringe exchange, and she expressed real excitement about working for Barack Obama.

	Ingo Michels, representative of Germany's Ministry of Health

Certainly Dr. Volkow's presentation on the science of addiction was well done, and it affirmed much of what has been said for years by those of us who are involved in harm reduction. She ran through her Positron Emission Tomography (PET) Scan studies (they show the effect of drugs on the brain) and noted that there is hope of our someday being able to know in advance who is vulnerable to problematic drug use. In stating that abstinence is 'magical thinking' and addiction has a smorgasbord of serious medical consequences, including hiv/hcv, cancer, and mental illness, associated with it, she laid out a fine argument for embracing harm reduction without connecting the dots of course. She noted that people are people are at risk due to environmental factors.

But looking at the blues, reds and yellows in the dissected brains on show, one would be hard pressed not to consider the color of the person who possessed this brain to begin with and then the hard, cold facts re: the skin color of who actually gets locked up for long periods of time in the US for having what Dr. Volkow was describes as a brain disease. The drug war in the US has disproportionately affected people and communities of color. Looking at the science of addiction doesn't dispel the effects of institutionalized racism. Nor does it reunite families, deliver education, or prevent HIV transmission. Scientific discovery is only the first step; it won't do us much good unless and until it's translated into real world policies and services. Hopefully that's Dr. Nora Volkow's dream under Obama (and Obama's dream as President): to put the theories that come out of what she and her colleagues are learning in the lab into practice.

Most of the rest of the presentations were equally predictable. Drug treatment works. Drug prevention is cost effective. Drug treatment is cost effective. Addiction is a brain disease. Methadone works. Buprenorphine works. And that's all to the good. But will any of the policy recommendations that come out of this research ever actually be applied or funded or prioritized by governmental bodies? Anywhere?

Vladimir Poznyak, from the Department of Mental Health and Substance Abuse at the World Health Organization (WHO), was the first person to bring up harm reduction. Clearly there is some tension between WHO and this UNODC meeting. Given the consistent commitment WHO has expressed for harm reduction, Poznyak pointedly highlighted needle exchange and harm reduction as HIV prevention in a WHO technical manual during his talk.

But for my money the Man of the Day was Ingo Michels from the Ministry of Health in Germany. Michels' presentation, which detailed Germany's comprehensive drug treatment system and included information on safer injection sites, heroin prescription, and drug user organizations, clearly rejected the extent to which harm reduction had remained hidden and unspoken during the first day. It was also the first indication that harm reduction is more than just a means of HIV prevention.

Your intrepid reporter then got the first question in. Prattling on in my usual fashion that is never succinct and always more about making a point rather than asking a simple question, and bearing in mind what I said in yesterday's post about the way in which US governmental representatives at these UN meetings always suppress the extent of harm reduction and needle exchange programs in the US and their success, I went at it. I detailed out the number of needle exchange programs in the US; noted out that the larger programs are federally funded (except for needles); and pointed out that they represent a continuum of care for drug users, act as a safety net for drug users who are "out of treatment," and make referrals to drug treatment. In short, I argued that the UN is cornering itself by limiting harm reduction programs as just an HIV intervention.

Well, that set Michels off. He slammed the US representatives for blocking the UNGASS process and said he hoped the Obama Presidency would mean that there would be a new UNGASS delegation at this March's meeting. (Being fairly new to this process, I think he probably overstepped his bounds. Excellent stuff.) Surprisingly, the conservative panel facilitator, Gilberto Gerra, Chief of Health and Human Development Section of UNODC, also animatedly joined the discussion by saying that UNODC believes that harm reduction should be part of the "comprehensive package."

I'll be damned.

More battle to be joined tomorrow.

Allan Clear is executive director of the Harm Reduction Coalition.

_________________________________________________________________