Public Health dimension of the world drug problem including in the context of the special session of the United Nations General Assembly on the world drug problem, held in April 2016
6. (…) Successful prevention of substance use and risk reduction is thus an essential approach to achieve better public health outcomes; these include the prevention of substance-induced mental disorders and reductions in injuries and violence (traffic and domestic injuries, child abuse, and gender-based, sexual and other violence), communicable diseases (notably HIV, viral hepatitis and tuberculosis), sexual and reproductive health problems (notably sexually transmitted infections, unplanned pregnancies and complicated pregnancies) and noncommunicable diseases (notably cancer, cardiovascular diseases and liver diseases).
7. Efforts should continue to be made to give effect to the preventive dimensions of international drug conventions, with full respect for human rights, and people in need should have access to a continuum of prevention and treatment options. Because preventive measures aimed at supply reduction have tended to focus on strategies for law enforcement and combating the illicit market, this has led, in some parts of the world, to policies and enforcement practices that entrench discrimination, propagate human rights violations, contribute to violence related to criminal networks and deny people access to the interventions they need to improve their health. To overcome this, it is critical that preventive interventions are legitimately incorporated in national drug control strategies and implemented from an evidence-based, public health-oriented, people-centred and equitable perspective, focused on human rights.
9. Treatment services have been shown to be effective in reducing substance use and associated health and social consequences. The area with the strongest evidence of efficacy is medication-assisted (opioid substitution) therapy of opioid dependence. Contingency management is also well supported by available evidence and can be used in support of other treatment modalities. Conventional psychosocial interventions and therapeutic communities have been shown to be effective in improving the health and social functioning of people with drug use disorders. Longer participation in peer-led mutual health organizations is associated with continued abstinence, lower health care costs and improvements in other indices of functioning. Residential drug-free programmes can be valuable for individuals where removal from their environment may have particular advantages.
10. Efforts should continue to be made to give effect to the preventive dimensions of international drug conventions, with full respect for human rights, and people in need should have access to a continuum of prevention, treatment and care options. Because preventive measures aimed at supply reduction have tended to focus on strategies for law enforcement and combating the illicit market, this has led, in some parts of the world, to policies and enforcement practices that entrench discrimination, propagate human rights violations, contribute to violence related to criminal networks and deny people access to the interventions they need to improve their health. To overcome this, it is critical that preventive interventions are legitimately incorporated in national drug control strategies and implemented from an evidence-based, public health-oriented, people-centred and equitable perspective, focused on human rights.
11. The evidence accumulated so far indicates that prevention strategies, programmes and interventions should be tailored to the age of the target population, risk levels and the settings in which the interventions are planned to be delivered, including health care settings and workplaces. They should also be an integral part of national drug policies and action plans. These should be supported by appropriate public health-oriented governance and legal frameworks conducive to effective engagement of multiple sectors of the governments and civil society and by the use of internationally recognized standards on drug use prevention.
12. Current drug policy frameworks do not focus enough attention on reducing the individual and public health harm of drug use. Harm reduction is part of a public health promotion framework to prevent, reduce and mitigate the harms of drug use for individuals and communities. Harm reduction is often a socially and politically sensitive issue, given that its goal is to keep people alive and safe while not requiring abstinence from drug use. Punitive laws, policies and practices limit, and sometimes exclude, people who use drugs from accessing harm reduction services, compromising the effectiveness of their evidence-based interventions. When implemented as part of a comprehensive drug strategy, harm reduction interventions ensure that drug use is seen in a wider social context, addressing issues of poverty, social isolation, stigmatization/marginalization, domestic and other forms of violence and public health.
13. Given the evidence for the utility of harm reduction approaches in addressing drug dependence and improving broader health outcomes, such interventions need to be a strengthened component of a comprehensive response to substance use. There is also strong evidence that programmes that reduce the short- and long-term harm to substance users benefit the entire community through reduced crime and public disorder, in addition to the benefits that accrue from the inclusion into mainstream life of previously marginalized members of society.
14. A comprehensive package of evidence-based interventions to reduce the harms associated with (injecting) drug use has been outlined in a technical guide issued jointly by WHO, UNAIDS and the United Nations Office on Drugs and Crime in 2009 and revised in 2012. This publication and the package of interventions have been widely endorsed by United Nations bodies and major international donors. The best results are seen where countries have implemented both needle and syringe programmes and opioid substitution therapy, along with other components of the package, and where these interventions are implemented on a scale wide enough to make an impact at the population level. Opioid substitution therapy has a role to play both in the management of opioid dependence and in the prevention and care of HIV and viral hepatitis B and C infection. Needle and syringe programmes substantially and cost-effectively reduce the transmission of blood-borne viruses, and at the same time they have been shown not to encourage drug use or injecting. These programmes also serve as an entry point to other services and engage clients on a regular basis, providing opportunities to facilitate access to other health services.
15. National drug strategies should highlight the public health rationale for incorporating harm reduction interventions and services in national programmes, including evidence of their impact on drug use and drug control. Effective implementation of harm reduction programmes as part of a broader national drug strategy requires an enabling legislative environment and consideration of the related actions that could be taken under the national drug strategy, as appropriate for the national context, such as enhanced child- and family-sensitive practices in drug treatment services, integrated approaches with community, family and child welfare services, and peer-based approaches to reducing the harms associated with an individual’s drug use. Reference should also be made to the importance of providing adequate drug (and HIV and hepatitis) prevention, treatment and care services in prisons and for populations detained in other closed settings.
16. Current drug policy frameworks do not focus enough attention on reducing the individual and public health harm of drug use. The implementation of harm reduction interventions according to national contexts is part of a public health promotion framework to prevent, reduce and mitigate the harms of drug use for individuals and communities. Harm reduction is often a socially and politically sensitive issue, given that its goal is to keep people alive and safe while not requiring abstinence from drug use. Punitive laws, policies and practices limit, and sometimes exclude, people who use drugs from accessing harm reduction services, compromising the effectiveness of these evidence-based interventions. When implemented as part of a comprehensive drug strategy, harm reduction interventions ensure that drug use is seen in a wider social context, addressing issues of poverty, social isolation, stigmatization/marginalization, domestic and other forms of violence and public health.
17. Given the evidence of the utility of harm reduction approaches in addressing drug dependence and improving broader health outcomes, such interventions need to be a strengthened component of a comprehensive response to substance use. There is also strong evidence that programmes that reduce the short- and long-term harms to substance users benefit the entire community through reduced crime and public disorder, in addition to the benefits that accrue from the inclusion into mainstream life of previously marginalized members of society
18. A comprehensive package of evidence-based interventions to reduce the harms associated with (injecting) drug use has been outlined in a technical guide issued jointly by WHO, UNAIDS and UNODC in 2009 and revised in 2012.1 This publication and the package of interventions have been widely endorsed by United Nations bodies and major international donors. The best results are seen where countries have implemented both needle and syringe programmes and opioid substitution therapy, along with other components of the package, and where these interventions are implemented on a scale wide enough to make an impact at the population level. Opioid substitution therapy has a role to play both in the management of opioid dependence and in the prevention and care of HIV and viral hepatitis B and C infection. Needle and syringe programmes substantially and cost-effectively reduce the transmission of bloodborne viruses, and at the same time they have been shown not to encourage drug use or injecting. These programmes also serve as an entry point to other services and engage clients on a regular basis, providing opportunities to facilitate access to other health services.
19. National drug strategies should highlight the public health rationale for incorporating harm reduction interventions and services in national programmes, including evidence of their impact on drug use and drug control. Effective implementation of harm reduction programmes as part of a broader national drug strategy requires an enabling legislative environment and consideration of the related actions that could be taken under the national drug strategy, as appropriate for the national context, such as enhanced child- and family-sensitive practices in drug treatment services, integrated approaches with community, family and child welfare services, and peer-based approaches to reducing the harms associated with an individual’s drug use. Reference should also be made to the importance of providing adequate drug (and HIV and hepatitis) prevention, treatment and care services in prisons and for populations detained in other closed settings.
20. Many internationally controlled substances are essential medicines that are critical for the relief of pain and for palliative care, for the treatment of psychiatric and neurological illnesses, for use in anaesthesia, surgery and obstetrics, and for the treatment of substance use disorders, including opioid dependence. Ensuring the adequate availability of controlled substances for medical and scientific purposes is one of the objectives of the international drug control conventions to which Member States are committed and that has yet to be universally achieved. Implementation of the conventions should aim at fulfilling the “dual obligation of governments to establish a system of control that ensures the adequate availability of controlled substances for medical and scientific purposes, while simultaneously preventing abuse, diversion and trafficking”.
22. The obligation to prevent the misuse and non-medical use, as well as the diversion and trafficking, of controlled substances has received far more attention than the obligation to ensure their adequate availability for medical and scientific purposes. This has resulted in many countries adopting laws and regulations that consistently and severely impede the accessibility of controlled medicines. Undue regulatory restrictions do not reflect the therapeutic value of controlled medicines and the potential risks to health if access to them is limited. A committed public health approach to the drug problem must encompass the availability of and access to medicines for effective treatment and related health care service delivery efforts. In recent resolutions, such as those on palliative care (WHA67.19 (2014)) and on emergency and essential surgical care and anaesthesia (WHA68.15 (2015)), the World Health Assembly has accordingly requested Member States to ensure access to controlled medicines.
23. National drug control policies should recognize that controlled medicines, and in particular those that are on the WHO model list of essential medicines, are necessary for medical and scientific purposes. In addition to calibrating regulatory restrictions to take account of availability, policy-makers should consider drawing up and implementing enabling policies that promote widespread understanding of the therapeutic usefulness of controlled medicines and their responsible use, while preventing the development of drug use disorders associated with prescription drug use. To this end, capacity-building programmes should be strengthened, starting with university training for health professionals. Governments may also include the availability of and access to controlled medicines for all relevant medical uses in their national pharmaceutical policy plans, and include the relevant controlled medicines in national essential medicines lists, specific disease control programmes and other public health policies.
28. Ensuring access to controlled medicines for legitimate medical use as a part of a balanced national medicine policy is an essential element of a number of WHO strategies and action plans addressing broader public health areas, such as effective cancer control, 1 access to essential medicines, 2 strengthening palliative care, 3 improving mental health, 4 and the prevention and control of noncommunicable diseases. 5 WHO will need to strengthen its activities to develop and disseminate normative guidance and provide technical support to improve adequate access to controlled substances for medical and scientific purposes, in collaboration with the International Narcotics Control Board, UNODC and other competent United Nations entities, within their respective mandates.