MHIN at the WHO: Drugs, brains, and how they matter to GMH
This 26-28 June, MHIN was privileged to attend the first ever WHO Forum on alcohol, drugs, and addictive behaviours. While there is clearly a lot of overlap between the Global Mental Health and Substance Use Disorders worlds (after all, they live in the same department (MSD) at the WHO; we profess to address MNS (mental, neurological, and substance use) disorders; and addiction is in many ways just another mental health condition*), it was interesting to look at the parts that are unique to each, and consider how they could intersect more.
*I know… this is speaking from an individual, biological perspective – on a population/global level there are a lot of unique dimensions, from an extra layer of stigma to unique social determinants to the troublesome criminal justice element to treatment/management options often still being controversial themselves…
The first day was a high level segment that started with introductory statements from Drs Shekhar Saxena (MSD Director and MHIN co-founder) and Vladimir Poznyak (Coordinator of the MSD’s Management of Substance Abuse program), followed by WHO and UN agencies presenting their stake in the issues (see bottom for publications that were discussed), and finally civil society. I was expecting quite a clash of opinions, given that UN agencies mark June 26 as “International Day Against Drug Abuse and Illicit Trafficking” (a name that underscores just how much a personal behaviour and a global crime have traditionally been conflated…), while civil society celebrated “Support. Don’t Punish.”, an advocacy campaign calling for drug policies based on health and human rights. But to my pleasant surprise, the two stances were not the worlds apart that they once were! Compare, for example, the statements from the UNODC (UN Office on Drugs and Crime) and INCB (International Narcotics Control Board) – traditionally the “bad cops” – with the joint statement from the International Drug Policy Consortium, Harm Reduction International, and International Network of People Who Use Drugs. Evidence-, health-, and rights-based arguments abound! Let’s hope this shift in rhetoric is accompanied by a swift shift in action.
I also appreciated that all points were made with reference to the Sustainable Development Goals (SDG 2030), as it’s very helpful and motivating to see in how many (sometimes unexpected) ways alcohol and substances affect the global development agenda. These included not just the explicit SDG 3.5 (“prevention and treatment of alcohol and substance use disorders”), but also most other targets in SDG 3 (“Good health and well-being”) and beyond (eg. SDGs 4, “Quality education”; 5, “Gender equality”; and 16, “Peace, justice, and strong institutions”). See the resources below to get a glimpse of what was discussed (and check out some slides from a Global Mental Health MSc lecture I gave that also made this point).
In the afternoon, NIDA Director Nora Volkow gave her well-worn talk on the role of dopamine in addictions – an odd choice I thought, given that this story –albeit fascinating!– mostly deals with individual, molecular-level explanations and solutions. We've no doubt made great strides in tying brain chemistry to real-world psychosocial phenomena, like vulnerability and resilience to drug use or behavioural patterns governed by an addicted brain – but to me, these still don’t naturally translate into the kinds of population-level policies that are of interest at the WHO. This is a disconnect that I, as a neuroscientist landed in GMH, have struggled with as well, so I was very much looking forward to having a pro break it down for me at last – but was disappointed to find that she, too, kept them largely separate. For example, she explained that social deprivation and stress changed the dopamine system in ways that actually put people at higher risk for addiction, making jail time (a stressful, socially depriving experience) counter-productive – but then didn’t show any policy change based on this knowledge. Conversely, she argued that prevention was the most important aspect to address, since the strongest predictor for use of a drug is perceived risk of that drug – but do we have, or need, a brain explanation for that? Maybe it's because my training as a neuroscientist has well familiarised me with implications and I'm anxious to see action, but to me it felt like a bit of a blow to addiction neuroscience, underscoring just how small a piece of the puzzle the biology behind the ailment really is. Hers was also the only presentation that didn't reference the SDGs, and she ended on a rather U.S.-centric note, advocating for medication-assisted treatment options that simply aren't available to many LMICs. Of course, brains are still cool and the presentation, as always, was extremely well received. I just wish I'd been able to gain more insight than I could have at a standard addiction science conference. But then again, maybe the answers just aren't there yet.
The remaining two days were split into tracks, and I spent most of my time on the ‘Public health dimension of the world drug problem’ track (the other two were ‘harmful alcohol use’ and ‘behavioural addictions’). I dipped into the alcohol track on occasion, but caught almost nothing of the addictive behaviours track – would be curious to know what the interest in this topic is in the GMH community! So much of it is related to access; where there’s no internet or gambling, do analogous behavioural addictions develop?
The first of the days consisted of ‘situation analysis’ presentations (spoiler: the situation is rather dire in many parts of the world. Low coverage of basic harm reduction/treatment services or availability of treatment guidelines; high levels of stigma, in some cases even on the part of healthcare providers; and a dearth of data in many regions), while the second day was dedicated to discussion and future-facing problem-solving.
The sessions were absolutely packed with information and brilliant points, but I don’t have the word count to go into them… so I summarised my favourite ones in Part 2.
In the meantime, visit some of the resources that were discussed at the meeting below.
Global Health Observatory
- Really cool Interactive Tool that lets you browse global health data by SDGs, allowing for direct visualization of SDG 3.5 (substance abuse) as well as 3.4 (NCDs and mental health)
- ‘Country Success Stories’ including Preventing early deaths due to alcohol in the Russian Federation and Preventing suicide in the Republic of Korea
- UNGASS Outcome Document (2016 UN General Assembly Special Session on the world drug problem) – this document explicitly prescribes UNODC/INCB collaboration with the WHO to integrate health-based solutions (more discussion on this in Part 2)
- Memorandum of Understanding between the World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC)
- Listen First, a new evidence-based initiative to increase support for prevention of drug use
- S-O-S (Stop Overdose Safely), a new initiative to scale up emergency community management of heroin and opioid overdose
- International Standards for the Treatment of Drug Use Disorders (draft for field testing)
- Principles of Drug Dependence Treatment (discussion paper)
- From coercion to cohesion: Treating drug dependence through health care, not punishment (discussion paper)
- World Drug Report 2017: annual report with up to date information and policy implications
- TreatNet Training Package: capacity building on substance use around the world (UNODC/Treatnet collaboration)
- International Standards on Drug Use Prevention
- Prevention and Treatment Of Drug Use Disorders In Rural Settings
- Community Based Treatment: Good Practice
- Community Based Treatment and Care for Drug Use and Dependence: Information Brief for Southeast Asia
- WHO’s role, mandate and activities to counter the world drug problem: A public health perspective
- Public health dimension of the world drug problem
- ATLAS on substance use 2017: resources for the prevention and treatment of substance use disorders
- WHO ATLAS-SU 2010: Global report on substance use disorders
- Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence
- Community management of opioid overdose
- Global strategy to reduce the harmful use of alcohol (unfortunately one of the talks argued that we are not on target for meeting most goals in the global strategy... setting up monitoring systems has been the only successful outcome to date)
- Policy in action: A tool for measuring alcohol policy implementation
- Alcohol e-help intervention: This was a particularly interesting project presented by the WHO Research Initiative on Alcohol, Health, and Development, consisting of online ‘portals’ for CBT-based hazardous/harmful drinking interventions now being implemented in Brazil, Mexico, Belarus, and India
WHO Violence & Injury Prevention Programme
- Save LIVES: A road safety technical package including recommendations on alcohol use and impaired driving
- Strategy on Education for Health and Well-Being: Contributing to the Sustainable Development Goals including guidelines on the education sector’s role in prevention and promotion
- Education sector responses to the use of alcohol, tobacco and drugs (joint UNESCO, UNODC and WHO publication)