MHIN at the WHO: Substance use disorders and how they matter to GMH (Pt 2)
As promised in Part 1, here are some impressions and points that stuck out to me from the first ever WHO Forum on alcohol, drugs, and addictive behaviours.
Are the bad cops coming around? As I touched on in Pt 1, the representatives from the UNODC (UN Office on Drugs and Crime) and INCB (International Narcotics Control Board) got quite a bit of air time, thanks to a recently formalised collaboration with the WHO that was made explicit in the 2016 UNGASS (UN General Assembly Special Session, focused on the world drug problem) outcome document. Both admitted that to date, their approach had focused more on supply reduction (trying to decrease drug availability) than health considerations (trying to decrease consequences of doing the drugs that are nonetheless available), and the INCB even called itself “quite insular” and a “newcomer to the health-based point of view, having endorsed a punitive approach for 50 years.” Both insisted that their agencies were now committed to an evidence-, health-, and rights-based future, and acknowledged that “people with addictions need help, not punishment.” (Sound familiar?) There was also a bit of finger-pointing as Member States got blamed for mis-interpreting the international drug control conventions, widely thought to prescribe a punitive criminal justice approach to drug policy. Turns out that this is, in fact, “unbalanced and ill-suited,” and that the conventions have the flexibility to accommodate alternative approaches. (This might have been comical if it hadn’t been so globally destructive.) In any event, going forward I hope that the UNODC and INCB will stand by this more flexible approach and become powerful allies, given their unique reach and credibility with even the most hard-line governments. It was also encouraging to hear that the collaboration will invest in revision of international standards on prevention, treatment, and monitoring – and in fact some of this is already coming to fruition: The newly unveiled ‘Listen First’ campaign uses evidence-based prevention methods to decrease vulnerability in children, while the S-O-S initiative provides community management of opioid overdoses.
*Note: The S-O-S team is keen to implement and monitor the programme in more countries, so if you want in on the initiative, get in touch!
The opioid dilemma. Speaking of opioid overdoses, one of the most troubling conversations was around the “perverse effects” of the North American opioid crisis, which on the one hand is leading to epidemic overdose fatality rates in one part of the world, while in most others, those in need have little to no access to opioid medications. There are no easy answers; just something to chew on.
Why isn’t there more SUD/GMH overlap? I was a bit disappointed, and very surprised, to find that there isn’t much overlap in the conversations we’re having around GMH and substance use disorders (SUD). In theory they’re related fields so would likely benefit from similar solutions, but it seems that many of the innovative mental healthcare solutions we routinely showcase on MHIN have not made their way into practice - or perhaps even consideration - in the SUD world. Sure, there are issues around substance use that GMH may not be equipped to address (and in some cases doesn’t want to – the stigma is strong, and goes both ways). But many of the ‘priority needs’ that were flagged in the sessions echoed those in GMH: training up a non-specialised workforce; community mobilisation; low-threshold psychosocial support; facilitating access to treatment; shoring up political will through economic evaluation; stakeholder involvement in development of tools; treatment tailored for women... It took me by surprise that GMH staples like task shifting, de-institutionalization, cultural sensitivity, and strategies for transition to scale weren’t default parts of the conversation. A particular gap here was around MHPSS in humanitarian situations, where alcohol and substance use problems are often neither measured nor addressed – a situation our WHO colleague Fahmy Hanna calls a “hidden crisis.” If the MHPSS and GMH communities are coming closer together, it must be possible to draw in the SUD community as well, no? We may still be working on finding the answers to these priority issues ourselves – but wouldn’t it be far more economical to find them together with another field that is also looking, and learn from each other in the process?
*Note: One of the recommendations for action in our stream was a rapid review of evidence-based alcohol/SUD treatments for refugees – if you want in on this, get in touch!
Prevention prevention prevention. Among all the topics mentioned, prevention probably came out as the strongest priority (and in my mind is also the best opportunity for bringing together the SUD and GMH communities given the overlapping target populations). Time and again it was argued that resources would be better invested in building resilience and preventing problems than in “repair,” particularly in the primary healthcare system – although it sounds like evidence-based, non-proprietary (ie., affordable) programs are hard to come by. Fortunately the UNODC, now advocating for a framework of health, welfare, and wellbeing, will be revising international prevention standards and guidelines together with the WHO. Just don’t expect this to happen anytime soon: in another comical-yet-tragic moment, we were told that budgets will be slow to shift, as “change in UN is slow, even if it’s change towards evidence-based actions.”
Platforms platforms platforms. Another recurrent theme was platforms (lucky for me, as it was my chance to plug MHIN :)). SUD stakeholders across the globe are eager to exchange knowledge, improve communication, unify a voice for advocacy, collate internet resources for teaching, learning, and collaboration, and gather best practice in an effort to build capacity. According to one participant from Zambia, knowledge transfer and capacity were even more important than monetary support. I originally thought this was unique to my track, but when the other two tracks reported back in the final session, both had also marked platforms as a priority. As validating as it is to know there is an appetite for what MHIN offers, I don’t think we’ll ever be a substance use platform – organisations like SAMHSA and EMCDDA are much better situated. But I do think we can use this opportunity to build up a repository of relevant knowledge among our community, and have our evidence, experience, and expertise at the ready as a valuable resource for those focused on the mental health and wellbeing of people who use drugs in LMIC.
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)