Yale Psychiatry Grand Rounds: "Addressing Substance Use in Humanitarian Emergencies"

December 08, 2023

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December 8, 2023

Jellinek Lecture: "Addressing Substance Use in Humanitarian Emergencies"

Speaker: Anja Busse, Program Officer, Prevention, Treatment and Rehabilitation Section, United Nations Office on Drugs and Crime

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00:00I can still see some of you.
00:03Let me really say that it's a pleasure
00:05and an honour to be here with you.
00:08I will share my slides.
00:09Now let's see that that works. And give
00:15me a second. Yep, Here we are.
00:21Pleasure and an honour to speak
00:23to you about addressing substance
00:26use in humanitarian emergencies.
00:28And I would really, really like to
00:31thank for this invitation and also
00:33the warm welcome and introduction
00:35and the interest from all of you.
00:38And as we are going into the
00:41topic and before we start,
00:43you've heard a lot of maybe
00:46abbreviations in my introduction.
00:48So maybe also just to say where
00:49I work the United Nations Office
00:51on Drugs and Crime, you know DC,
00:54we're part of the United Nations
00:56Secretariat and we have been given
00:58a mandate to address together with
01:00Member State challenges such as drugs,
01:03crime, terrorism,
01:04human trafficking and so on.
01:07So and in addition to our
01:09headquarter which is in Vienna,
01:11Austria,
01:11you know DC also has field offices in
01:15around 150 countries around the world.
01:18The section where I work within UNODC,
01:22sometimes it's also referred
01:23to as the health section.
01:25So we're working on prevention of drug use,
01:27treatment and care of drug use disorders.
01:30And there's also a team that
01:32works on access to controlled
01:35medicines for management of pain.
01:39Let me give a quick
01:41overview of my presentation.
01:43I will speak a little bit about
01:46what we know about substance use
01:48and associated health problems
01:50in humanitarian emergencies and
01:52among displaced populations.
01:54I will mention the policy
01:56framework to address substance
01:58use and humanitarian emergencies,
02:00which of course is very important
02:02for us as AUN agency.
02:04Then I will speak to some of the
02:07work that we have been involved
02:09in around prevention of substance
02:11use and other risky behaviours
02:14in humanitarian emergencies,
02:16then come to treatment and care of
02:18substance use disorders in such settings.
02:21Mention briefly an implementation
02:23framework that we have developed and
02:26kind of show some examples of the
02:28work of our agency in this regard.
02:30As mentioned,
02:31I mean we are developing currently
02:34a handbook and technical guidance
02:36on this topic,
02:37but this is very much an emerging
02:39topic for which not so much
02:41evidence exists as we would like.
02:43So we're really really also inviting all
02:45of you to provide comments, feedback,
02:48share your wisdom and knowledge.
02:50Maybe also mention if there are
02:52any red flags and what you see
02:54what I'm presenting because much
02:55of what I will be presenting will
02:57be one way or the other.
02:59You will find similar and maybe more
03:02expanded in this handbook that we are
03:05currently putting together on the picture.
03:07Maybe just to mention you see
03:09the UN flag at half mast because,
03:11I mean this year we have lost
03:13as many colleagues,
03:14humanitarian workers and in no other
03:16year before and that's why the flag
03:19was blowing at half mast for a while.
03:23So as that,
03:24what do we know about substance
03:26use and associated health problems
03:28in humanitarian emergencies?
03:30Well,
03:30we know not so much it's the honest truth,
03:35but we do know something.
03:36And I will look at that kind of from
03:39different aspects and would say,
03:41let's maybe start with some general
03:44information both on substance use,
03:46drug use and humanitarian settings,
03:48refugees first,
03:49and then see how we can bring it together.
03:52So UNODC publishes every year
03:55in June the World Drug Report.
03:58And from that we have estimated
04:01that there are around 296 million
04:04people that have used an
04:06internationally controlled substance.
04:07So that would be referred to as a drug in
04:11the year 2021 for non medical purposes.
04:14And there has been quite an increase
04:16over the last decade in this number,
04:19which can not only be
04:21explained by population growth.
04:22Also here on the slide you see that
04:26cannabis remains the most widely
04:28internationally controlled substance
04:29and then in reality followed by the
04:33different classes of stimulants if you
04:35put them all together and then opioids.
04:38So in the whistle view to drug use
04:41disorders and drug use disorder treatment,
04:44we're estimating that more than 9039
04:48million people worldwide are suffering
04:50from drug use disorder would benefit
04:53from treatment also that heavy
04:55increase of 45% over the last 10 years.
04:59And only one in five people with a drug use
05:02disorder has any access to
05:04treatment of drug use disorders.
05:06And there are vast regional differences.
05:09In many, many regions that treatment gap
05:12is even much wider than here on average.
05:15And the situation with access to
05:17treatment it's even worse for women.
05:20On this picture, you see Maggie,
05:21who has been involved with one of our
05:24projects in West Africa and she's
05:26actually standing in what is her house.
05:28And it is also worth, for example,
05:30for adolescents and as a vulnerable group,
05:33such as people in prisons or refugees,
05:35people in humanitarian settings.
05:38So on this slide,
05:40we have mapped out the regional
05:42differences in terms of for which
05:44substance people are seeking treatment
05:46in different regions of the world.
05:49And while this might also be
05:50important as we're speaking about
05:52displaced populations that are maybe
05:54coming from a region with a certain
05:57prevalence or substance use pattern.
05:58And then finding themselves in a
06:01region with very different substance
06:04use patterns which sometimes might put
06:06them at risk kind of of being exposed
06:09to to new substances and sometimes
06:12then also these new patterns when
06:14they return to their home countries
06:16are carried over there which we have
06:19seen for example in Afghanistan.
06:22Also what you see here is obviously
06:25what's very concerning for all of
06:27us that the drug related deaths has
06:30equally increased like drug use,
06:32drug use disorders over the last 10 years.
06:35So when it has been estimated that
06:37close to half a million people have died
06:40in 2019 alone due to suggest directly
06:44or indirectly related to drug use,
06:48you already see my agency does not
06:50have a mandate on alcohol and tobacco.
06:52But I just wanted to share this data
06:55from the Global Status Report on
06:57Alcohol and Health from the World
06:59Health Organization that has also shown
07:01that the per capita consumption among
07:03drinkers has increased in most regions
07:06and that why there are differences
07:08also here in terms of prevalence of
07:11alcohol use in different regions and
07:13Europe remaining the region with a
07:15higher per capita consumption of alcohol.
07:18So with that being a bit of substance
07:20use data,
07:21let me also walk you through some data
07:24around refugees and humanitarian settings.
07:27So in 2023,
07:29it was estimated that a record number
07:32of over 108 million people were
07:35forcibly displaced worldwide and
07:37this data from earlier in the year.
07:40So I think we will have to say 108
07:43million and counting unfortunately and
07:46when we look kind of how refugees are
07:50distributed or hosted in different
07:53socio economic settings,
07:55we can see that low income countries
07:58continue to host a disproportionately
08:00large share of the global refugee population.
08:05This is an estimate again.
08:06And counting on the number of people
08:09in need of humanitarian assistance,
08:12more than 339 million people And
08:15counting again, unfortunately.
08:17And when we think now what is
08:21a humanitarian emergency?
08:23The Interagency Standing Committee,
08:25which is the oldest body for
08:27the coordination of humanitarian
08:29responses in the world
08:31has defined it as a situation that
08:33threatens the lives and well-being
08:35of a very large number of people or a
08:38very large percentage of a population
08:40and often requiring substantial multi
08:42sectorial assistance which may then
08:45include support also from external actors.
08:48This is a slide from the world drug Report.
08:51And just to summarise the bit which you
08:54know maybe you're all obviously aware
08:56of the different social and mental
08:58health problems that can be associated
09:00with different stages of displacement.
09:02So some people obviously already
09:04live with the mental health disorder
09:07prior to being displaced or becoming
09:09a refugee or in human mobility.
09:11And then there are factors of displacement
09:14in itself which can precipitate such
09:17conditions further due to stress,
09:19family separation and other factors.
09:23And then as mentioned a little bit before,
09:27the conditions that are resulting
09:29from protracted displacement and
09:31being in a new situation with also
09:34possibly new living conditions,
09:36including which could be also
09:38new substance use patterns and
09:40prevalences in the host community.
09:43So it has been estimated what's the
09:45extent of mental health disorders
09:47among populations affected by conflict.
09:49It's much higher than in the
09:51general population as such.
09:53But I think it's also important to
09:55notice that not everybody who has been
09:57affected by conflict has been assessed
10:00with having a mental health disorder.
10:03Here you know the C has looked at
10:06different and protective and risk
10:07factors for a substance use in general,
10:09now not in humanitarian settings.
10:12But you can see in the red box that poverty,
10:14conflict, war, homelessness,
10:16refugee statues and so on have been
10:19considered as risk factors for substance
10:21use and substance abuse and disorder already.
10:25And much of this can likely be explained,
10:28for example,
10:29by Adverse Childhood Experiences and
10:31their association with substance use and
10:33substance use disorders in later life,
10:36or kind of the association with between
10:39traumatic experience of traumatic
10:42events and the onset of substance use.
10:45This is a very nice graphic that
10:48was developed by a group around the
10:51International Society for Addiction
10:52Medicine that also summarizes how
10:55substance use plays out in the
10:57different stages of displacement.
10:58I'll not go into much detail on this one,
11:02but I think it's really interesting
11:03to have a look at this article also.
11:06So in summary a little bit,
11:09there is not so much we know about
11:11substance use and humanitarian emergencies.
11:14The good news is there is a growing
11:16number of studies being conducted
11:18I would say especially or a really
11:21we see much more coming up maybe
11:23in the last 2-3 years.
11:24So it's good that there is an interest.
11:27So what we know is that,
11:28you know,
11:29we know more or less what are the physical,
11:30psychological,
11:31social consequences of substance use in
11:34a stable population and that might hold
11:38true also for displaced populations.
11:40But,
11:41and there is only limited evidence as
11:43said but the studies that are available
11:46have found similar or lower prevalence
11:48rates among displaced populations
11:50that the host community despite
11:53the described likely increased
11:56vulnerabilities which some have
11:58framed as a refugee paradox.
12:00So this is the study from
12:02Danielle Horniak from Ising 2016.
12:04And I mean, what basically it shows is
12:07the vast differences among different
12:11populations of migrants and refugees
12:13when it comes to substance use.
12:16So far hazardous or harmful alcohol
12:18use there was a range from 4 to 36%,
12:21which is obviously huge difference.
12:24But alcohol dependence that is found from 1
12:27to 42% for drug dependence from 1 to 20%.
12:31So huge heterogeneity and and I mean
12:36Ezzard had in the ISAM handbook also
12:38mapped out what type of substances
12:41are being reported in the available
12:43studies and alcohol was no surprise,
12:46maybe the most prominent one reported.
12:48There were also reports on cat
12:51use stimulant mainly used in East
12:53Africa for example,
12:54then reports on opioid and cannabis
12:57use among displaced populations for
12:59example in West Asia and other studies
13:02also or other documented evidence was
13:06around ATS use glue or other inhalants,
13:09so UNODC.
13:10We also did a rapid assessment on
13:13substance use in a refugee camp in
13:16north of Kampala in Uganda and in
13:19urban settings in Kampala in Uganda.
13:21And I mean we found that the population,
13:24the refugee population was concerned
13:26with substance use and that especially
13:29in urban settings there were more
13:31severe patterns of substance use.
13:33I've also just taken out a few
13:36examples of studies that looked
13:38kind of into describing situation
13:41with substance use among refugees.
13:43Here is 1A qualitative study
13:46from Lebanon with qualitative so
13:49small number of participants and
13:51identified was opioid injecting,
13:54also alcohol consumption.
13:55But very few of those interviewed at
13:59any contact with treatment services
14:02and did not really consider maybe
14:04substance use so much as a problem
14:06for which help could be offered.
14:10This is an example for people that
14:12have come as first generation
14:14refugees to Europe and that have for
14:18example reported histories of trauma
14:20and the use of pregabalin as self
14:22medication including for anxiety,
14:24depressive disorders or also
14:27for chronic pain initially.
14:29And some had also initiated non medical
14:32use of pregabalin in their home countries.
14:36So that was a little bit
14:38kind of where we're at,
14:39right huge heterogeneity and not A1
14:42prevalence number in terms of what's
14:45the situation with substance use in
14:48humanitarian settings among refugees.
14:50So we do have a policy framework to
14:53address substance use in emergencies.
14:55And I mentioned some of the convention
14:58and agreements that are available.
15:00Common reference point is of course
15:03the Sustainable Development Goals,
15:05including the Goals 35 to strengthen
15:08prevention and treatment of Substance abuse
15:10and narcotics and harmful use of alcohol.
15:14And that would obviously include
15:16refugee populations or populations
15:18and humanitarian emergencies.
15:21The United Nations or the
15:24international drug control Conventions,
15:26you know,
15:26not specific for humanitarian settings,
15:28but in general the parties to the
15:31conventions countries have agreed and
15:33have taken a commitment to provide a
15:36continuum of care to address drug use
15:39and drug use disorders from prevention
15:41all the way through to treatment,
15:43aftercare and rehabilitation and
15:45also kind of vulnerable members of
15:49society find special consideration
15:51in the drug policy frameworks.
15:54So the General Assembly,
15:55as well as the Commission on Narcotic Drugs,
15:57have passed documents and resolutions
16:00that pay attention to the specific
16:03needs of vulnerable members of society,
16:06which obviously would include
16:08refugees and others.
16:10There's also an additional resolution
16:12from the Economic and Social Council of
16:15the United Nations already from 2004,
16:18around drug control and in
16:21countries emerging from conflict.
16:23And there is kind of attention
16:26given member states should address
16:28drug problems and that agencies
16:30such as UNODC should also consider
16:33addressing drug problems in
16:35integrated and comprehensive manners.
16:38So there are mandates that include
16:41the topic of our conversation
16:44today on the other side,
16:46not in the drug control framework,
16:48but more looking at humanitarian
16:50sector refugees.
16:51Obviously the guiding document
16:53is a 1951 Refugee Convention
16:55that asks the same treatment,
16:58including with respect to public
17:01relief and assistance is given to
17:03refugees than to host populations.
17:07The World Health Assembly also
17:10has this framework for migrants
17:14and refugee health that just
17:16has been extended to 2030 and
17:20refugees. And this maybe gets
17:22us again closer to the topic.
17:24Refugee health, according to
17:26the global contact on refugees,
17:29includes also and with growing
17:31prominence and mental health and
17:34hopefully also substance use disorders,
17:36even though as such not as
17:40often mentioned specifically.
17:41So when we come to humanitarian
17:43action and how health and
17:45substance use play a role in this,
17:47it may be important to know that
17:50humanitarian action is mainly
17:52taking place in certain clusters,
17:54sectors where health is 1 but the
17:58coordination among the clusters,
18:00but also the different actors and
18:03traditional actors in humanitarian
18:05emergencies are UN agencies,
18:07Red Cross and Red Crash and movement,
18:09civil society organizations with
18:11lots of experience and of course
18:14always the countries in which an
18:16emergency or displacement takes place.
18:18So there is this huge need for coordination
18:21to avoid duplication and overlap,
18:23and mental health and psychosocial
18:25support has kind of been a special place
18:29in this humanitarian coordination.
18:31And what we are advocating
18:33for is for a better place of
18:35substance use in these frameworks.
18:37The slide has a little video
18:38which we are not seeing,
18:39but I'm happy to show the slides
18:42to you afterwards in order to make
18:45substance use better placed in the
18:47humanitarian responses already in the
18:52UNODCWHO program on drug dependence,
18:53treatment and care.
18:55We have included this as one of our
18:58priorities since 2009. In reality,
19:02and bringing this all together now,
19:04the question will be how international
19:07standards on drug use prevention and
19:09treatment of drug use disorders can
19:12be linked with this intervention
19:14pyramid for humanitarian settings,
19:15which goes from more generic services
19:18to more specialized services.
19:21So maybe I will not see your
19:23responses to in that sense,
19:24it's more a rhetoric question,
19:26but have you heard about the international
19:29standards on drug use prevention?
19:31If not, we'll definitely be happy
19:33to share them at the words and that
19:36kind of leads me over to speaking
19:38a little bit about prevention
19:40of substance use and as a risky
19:43behaviour in humanitarian emergency.
19:46The international standards on drug use
19:48prevention that are developed by UNODC
19:51and the World Health Organization map out,
19:53as you can see here,
19:54different evidence based interventions
19:56by setting and by age group,
19:59parenting skills being one of them,
20:02but parenting skills also being the
20:05one which UNODC has mostly taken
20:08further into humanitarian settings and
20:10the work we are doing with refugees.
20:13And these are mainly my colleagues
20:15from the prevention team.
20:16And the rationale behind is that
20:18healthy parenting is obviously
20:20essential to early child development,
20:23including to parents in stressful context
20:26or maybe situations of displacement.
20:31Effective family skills programs,
20:33including those developed by UNODC are
20:36really there to enhance communication,
20:38trust, problem solving skills,
20:41conflict resolution within the families
20:44and to maybe strengthen the parents
20:47in the behaviour that they are,
20:50that they have a protective role
20:52towards their children even in
20:55very complicated situations.
20:57So you and ODC together with the
21:00University of Manchester has
21:01developed this multi level parenting
21:04framework which may be similar to
21:07this pyramid that we have seen
21:10before for humanitarian settings
21:11goes from more generic interventions
21:14to more specialized interventions.
21:16And I'll show you some of the
21:19examples that we have developed here.
21:21So one was for example,
21:22the bread rapper study in Syria,
21:24where basic parenting advice was shared
21:27with families in a refugee setting.
21:30In Syria,
21:31something that really doesn't cost a lot,
21:33reaches a lot of people,
21:35and the vast majority of parents
21:38found this useful and then later on
21:41reached out For more information.
21:43Also,
21:43similar parenting leaflets have
21:46now been distributed,
21:47for example in Ukraine together
21:50with other audio visual material.
21:54The kind of Light Touch Family Skills
21:56program is this one on Caring for
21:58children's for Conflict and Displacement
22:01which has been implemented for example
22:03as you can see here documented
22:05in 2019 in the in the West Bank.
22:09And some of the evaluation results
22:11that they had there was the Strength
22:14and Difficulties Questionnaire was an
22:17improvement in the intervention group.
22:19But I think also interesting is that
22:21even the waiting list group that
22:23knew they were starting a parenting
22:25program improved to some extent,
22:26which maybe gives us hope that these
22:29kind of leaflets that are shared might
22:31also have at least a limited impact
22:34on parenting in conflict settings.
22:38And then Strong families is a
22:40slightly more intensive program
22:42which has really been developed for
22:44families under stress or in special
22:46circumstances has been implemented in
22:48quite a number of countries already.
22:51And I'll just show you one of the study
22:55outcomes here where they kind of applied
22:58that with populations in Afghanistan,
23:01but also displaced populations from
23:04Afghanistan in reception centers in Serbia.
23:10And you see that in both kind
23:13of groups the SDQ scores have
23:16improved through the intervention.
23:19So that's a little bit kind of
23:20on the work that's being done
23:22on substance use prevention.
23:24Here you find much more information
23:26and I'm sure the colleagues will
23:28be happy if somebody reaches out.
23:31So which takes me to the next part
23:33where we will be talking about
23:34the international standards for
23:36treatment of tracuse disorders
23:37and how treatment and care can be
23:40possible in humanitarian settings.
23:42Again, my rhetoric question who's
23:45familiar with these standards?
23:48So, and let's see what we are currently
23:50developing and really decide things
23:52for which your feedback will be
23:54very helpful as this will be part
23:56of guidance that goes hopefully out
23:59by the end of the year or next year,
24:02sorry.
24:02So the international standards for
24:04treatment of drug use disorders are
24:06guided by a number of principles,
24:08among them kind of the attention to
24:10special treatment and care needs of
24:12different population groups we are
24:14thinking including refugee populations.
24:17The treatment standards are
24:18developed kind of around different
24:20levels in which different types of
24:23interventions can be implemented,
24:25both healthcare and social services settings.
24:28And not in any way,
24:29but I mean following a public health
24:32principle so that the most effective,
24:34least costly,
24:35least invasive intervention that
24:37benefits the highest number of
24:40people would be implemented first.
24:42And it follows a non one-size-fits-all
24:45approach right?
24:46So where a variety of services
24:48are available for people depending
24:51on their needs,
24:52and he just a few examples kind
24:54of from our project,
24:55this is from outreach work in South America.
24:58This is kind of a pharmacological
25:01treatment service in Central Asia.
25:03This is assessment and counselling session
25:06in a treatment centre in West Africa.
25:09And the question really is how can we
25:12adapt and implement the international
25:14standards now to the special
25:16challenges in humanitarian emergencies.
25:19And again reminding this implementation
25:22pyramid from the international
25:28IASC the and based on that maybe also
25:31looking how the other pyramids are,
25:34we are offering prevention and treatment
25:36kind of can be brought together with this.
25:39So there are certain challenges when we
25:42think of substance use in humanitarian
25:44settings or among displacement
25:46that would have to be addressed.
25:48And they can have to do with a sudden
25:52interruption of substance use or a
25:54discontinuity of treatment services
25:56including opioid agonist treatment
25:58services which then might be leading
26:00to life threatening withdrawal,
26:03transition to other substances or other
26:05routes of administration as well as
26:08if kind of substance use is taken up
26:11again after a period of abstinence
26:13and increased risk of overdose.
26:15So these are considerations for offering
26:18services in such settings and there are
26:21kind of guidance documents available
26:23that speak about what needs to be done.
26:25For example,
26:26this year handbook has very basic
26:29information that speaks about minimizing
26:31harm related to alcohol and drug use and
26:34training staff and brief interventions,
26:36harm reduction,
26:37withdrawal and intoxication.
26:39Also again the interagency standing
26:41committee has some sort of guidance
26:44similar to some extent you see
26:46again screening brief interventions,
26:48preventing harm,
26:49treating withdrawal and maybe re
26:52establishing or establishing as feasible
26:55opioid agonist treatment services.
26:58So this would be kind of dream.
27:00We're looking at the comprehensive services,
27:03psychosocial and pharmacological,
27:05that meet all the needs.
27:07But the reality unfortunately
27:09is quite different.
27:11There has been a mapping done by Claire
27:14Green and colleagues that looked at what
27:16do we know in terms of interventions
27:19in humanitarian settings or displacement.
27:21And they could only identify 9 studies
27:24that either are looked at prevention
27:27or harm reduction interventions.
27:30And further,
27:32and this is also Claire Green,
27:34but with another team of authors,
27:36they have kind of looked what
27:38substances were being addressed
27:40and where there's documented
27:42information in humanitarian settings.
27:44And alcohol was by far the
27:47most considered substance,
27:48followed by unspecified substance use
27:52and then to a smaller extent different
27:55types of more maybe problem drug use.
27:59So their key findings are really that
28:02from the studies they found there's
28:04mainly a focus on a sub threshold or
28:07milder cases of alcohol use disorder.
28:09Maybe the good news that they found
28:12is that certain community based or
28:14PLM programs to work in addressing
28:17substance use in refugee settings,
28:20that brief interventions have
28:22a high potential.
28:23But that's a challenge really will
28:25be for the future to also find and
28:28evaluate in interventions that can
28:30address more complicated or complex
28:33and comorbid substance use and mental
28:36health intervention in such settings.
28:38So and this is the little bit where we
28:40are hoping to develop further guidance.
28:43And as you can see here,
28:44really what I'll say now is for discussion,
28:47for intervention and for we would love
28:51to hear from you as we are developing.
28:53As you can see,
28:54certain guidance because there is a need,
28:57but not all the evidence that one
28:59would love to have to come up with
29:02such guidance is really available.
29:03So what is the priority?
29:05That was one of the question
29:07we asked ourselves.
29:07And what we did was a Delphi survey
29:10among a number of experts that had
29:13participated in an expert group
29:15meeting that we have put together.
29:17And this was some of the themes that emerged.
29:19So for example,
29:21focusing on a do no harm approach,
29:23ensuring that programs
29:25are culturally adapted,
29:26that they are intersectorial,
29:28integrated, inclusive,
29:29inter layer to include the community
29:32but also people with lift and living
29:35experience and reducing stigma.
29:39Another thing that we have decided
29:42to integrate will be to make all
29:44the interventions and the guidance
29:46following a trauma informed care approach.
29:49Obviously given the high possibility
29:52for traumatic events that people
29:54in displacement or humanitarian
29:56emergencies have been through and
29:58then we will separate or come up with
30:01slightly different guidance for acute
30:03emergencies and protracted emergencies.
30:06And in line with what I said before,
30:07especially in acute emergencies,
30:10we will be focusing on life
30:13saving and basic support.
30:15As you know in general aim of
30:17healthcare and crisis is to reduce
30:20excess mobility and mortality.
30:21So addressing that to substance
30:24use disorders,
30:25focus will need to be on identifying
30:28and treating life threatening
30:30withdrawal potential overdoses,
30:32further reducing and negative health and
30:34social consequences of substance use.
30:37Implementing for example take
30:39on naloxone programs,
30:40needle syringe programs,
30:41seeing if at all possible there can
30:44medication that people have received
30:46before can be continued and offer
30:48basic basic basic psychosocial support
30:51including through self help strategies
30:53or maybe remote services as possible
30:56because obviously the situations
30:58are very different including in
31:01terms of Internet availability and so on.
31:04So,
31:04and this is a little bit now,
31:05the pyramid put on the side where we would
31:08be saying that for acute emergencies,
31:11Same as I said before,
31:12addressing life threatening concerns
31:14would maybe be an initial step
31:17to be taken in a in a context of
31:21course where other interventions
31:23need to take place and in close
31:26coordination with other service
31:28providers or local health systems.
31:30But that life saving will be
31:33our mantra likely when we will
31:36be providing guidance for what
31:37to do in acute emergencies.
31:39And as I think especially for
31:41acute But extense later will be
31:44to say that people with substance
31:46use disorders to use drugs and so
31:48on should be included at least
31:50in all of the other services that
31:52are being offered from housing,
31:53food,
31:54healthcare and not be left behind
31:56due to stigma and so on.
31:59So with this and of addressing
32:01life saving interventions or
32:03emergencies and the inclusion,
32:06we hope that in acute emergencies already
32:08some sort of a difference can be made.
32:11And then as we're moving
32:13to protracted emergencies,
32:15the idea would be that things become
32:18more closer to what's recommended
32:20in the international standards for
32:22treatment of drug use disorders.
32:24And that guidance for example from
32:27the WHOMH gap package which is for
32:30non specialised health services,
32:32can at least partly be implemented because,
32:36I mean protracted emergencies in
32:38many ways have the well advantage
32:40or disadvantage that there is a
32:42lot of time and in refugee camps
32:45often for people not so much to do.
32:48Resources are of course very limited,
32:50but at least kind of this time
32:53pressure maybe is a little bit out.
32:55So it might help to develop and include
32:58substance use in the existing health
33:01cares or health services that are being
33:05developed or included in host countries
33:09services so that refugees put in those
33:12using drugs are again not left behind.
33:15So seems throughout you
33:17have seen there is really,
33:18really a need and I know why
33:20I'm speaking to people with a
33:22lot of research experience.
33:24There's really,
33:25really a need for more research
33:27and information sharing to develop
33:29further evidence on how we can best
33:32address substance use and substance
33:34use disorder in humanitarian settings
33:38and situations of displacement.
33:41A few, as I said,
33:42kind of more studies are emerging,
33:44including recently,
33:44and I'll just share a few examples with you.
33:48So the common elements treatment
33:50approach of CETA that was developed
33:53based on the finding that evidence
33:57based psychotherapy interventions
33:58could be developed already in other
34:02studies with lay counsellors and
34:04low middle income countries.
34:05That was in 2020,
34:07this study that also included this
34:11approach looking at reducing interpersonal
34:15violence and hazardous alcohol use
34:18among refugee populations in Zambia
34:21and one year following treatment they
34:24could show that CETA was clinically
34:27effective in both of these areas.
34:32There is currently a randomized
34:34controlled trial going on and as far
34:36as we know it's likely the first ICT
34:39really in a refugee setting where
34:41SITA will be implemented together
34:44with the screening brief intervention
34:47intervention also again in Zambia
34:50and among Congolese refugees.
34:52And we're also not only alcohol uses
34:54and focus but also as a drug use.
34:57So that's a study.
34:59We're definitely looking forward
35:01to have the evidence emerging from
35:03here because that will be really
35:06a novel in terms of what we have.
35:08And then maybe to mention another project,
35:10this change project by the London
35:14School of Tropical Medicine.
35:17They have adjusted an intervention
35:19that's called problem management
35:21Plus that has been developed by
35:23the World Health Organization as a
35:26psychological intervention for a
35:28psychological distress and people as
35:30opposed to adversity and have adjusted
35:33that with an alcohol treatment component.
35:37So again,
35:38I mean the project is running for a while,
35:41including in Uganda,
35:43Ukraine and also here we're looking
35:46for the results emerging and hoping
35:50the evidence base will increase soon.
35:53Now maybe as the last example,
35:55I mean when Ukraine,
35:57the war in Ukraine started,
35:59there was a lot of concern around the
36:02continuity of opioid agonist treatment
36:04there and with a question mark.
36:06But it seems that the services
36:09have been relatively robust and
36:12that more or less kind of people
36:14could be maintained in treatment
36:16obviously when they had to go to other
36:18parts of the country.
36:20And that there could even be a
36:23slight increase and people receiving
36:25opioid agonist treatment in Ukraine.
36:28We have also, as you know,
36:29DC been part of a coordination
36:32group in Ukraine on mental health,
36:35psychosocial support.
36:36And very quickly there was an
36:38additional group developed
36:39around especially addressing
36:41opioid business treatment led by
36:43the World Health Organization.
36:45So I mean despite a lot of
36:48challenges in this case in Ukraine
36:50and that seemed to have been at
36:53least partly resilient system.
36:57So I'm coming and this will be good because
37:00then we have a bit of time to talk to
37:02the really last parts of my presentation.
37:05Just to show you also the implementation
37:07framework that we will be including
37:10in our technical guidance document,
37:12which is much more maybe the,
37:14the how to or nearly the the project
37:17management of how all of this can be done.
37:20And with this let's say guidance or
37:24a thought in mind that interventions
37:26for substance use disorders really
37:28need to be considered as as essential
37:31components and not as nice to have when
37:34it comes to providing health and social
37:37services in humanitarian emergencies.
37:40So and as I said,
37:41it's a bit of project management framework.
37:43This implementation guidance will
37:45go from assessment to preparation
37:48to deliver and evaluating to assess
37:52the situation and number of guidance
37:54documents are available,
37:56especially there is one from World
37:59Health Organization and UNHCR on how
38:01to do rapid assessments of alcohol
38:03and as a substance use in conflict
38:06affected and displaced populations.
38:08But also,
38:09I mean it will be important to include
38:12questions around alcohol or drug use in,
38:15let's say, broader epidemiological
38:17studies or assessments being done.
38:20And you said for planning of the
38:23health response.
38:25And obviously if there is a recognizable
38:29problem around substance use,
38:31which many of the emergencies that
38:33are currently in,
38:34you know think Ukraine,
38:36think Afghanistan,
38:37these are regions and populations that
38:40already free and increasing conflict
38:43now at high rates of substance use.
38:46So that will be really important then
38:49to take that into the preparation
38:52phase as kind of humanitarian
38:54actors are looking at financing,
38:56but also translations and
38:59adjustments of existing documents,
39:01capacity building.
39:02And maybe to mention that there is
39:05the on the World Health Organization,
39:07the NH Gap Manual on mental Health
39:09and substance use.
39:10There is a version especially
39:12available for humanitarian settings.
39:15Also considerations around
39:17medication access and what's on The
39:20Who list of essential medicines,
39:23how can that be made available in
39:25terms of procurement and so on.
39:27And here again kind of some medications
39:29that are in the essential list of
39:33medicines especially for treatment
39:35of alcohol use disorders,
39:37but also methadone,
39:38pranophine are of course there
39:40and as such as also naloxone for
39:44opioid overdose reverses.
39:45And then in line with what I said
39:48before about acute emergencies
39:49and protracted emergencies in the
39:52deliverer or the implementation phase,
39:54in acute emergencies the focus will
39:57be on life saving interventions
39:59and then in protracted emergencies,
40:02all of the above.
40:03But we are moving and again a number
40:05of tools are available more to
40:08community based treatment formats
40:09as they are being implemented in
40:12other low resource settings and
40:17obviously in the deliver Phase,
40:19I mean there will be some challenges
40:21that will have to be addressed.
40:23Like you know, competing priorities,
40:26massive massive resource constraints
40:28like we see now every day on the
40:31news from current emergencies
40:33taking place but also stigma.
40:36Populations are mobile sometimes go back and
40:41forth disruptions and staffing and so on.
40:44So all of what you know you you
40:46may be also see in other clinical
40:49services times 20 in many ways will
40:51be what will be the challenges of
40:55delivering anything around substance
40:57use care in humanitarian settings?
41:00And then also for the evaluation
41:02of such services,
41:03existing kind of in standard documents
41:07on health and humanitarian settings
41:09such as a sphere handbook provide some
41:12common indicators which then different
41:15humanitarian actors can work with.
41:17So that's the little bit,
41:18the framework that we will be
41:20coming up with in order to provide
41:23guidance on the how to do,
41:25how to act as humanitarian
41:28organizations so that substance
41:31use in humanitarian emergencies
41:34becomes part of the response and not
41:37somehow the left behind that child.
41:40And obviously all of this will need to
41:43be further evaluated and implemented.
41:45So now maybe for the last five minutes
41:49or so and I'll just share with you
41:52a little bit what UNODC is actually
41:54doing in different ways of our
41:57programming around and in our case as
42:00the mandate is more around drug use
42:02and drug use disorders in humanitarian.
42:08So you saw already before the slide how we
42:11have done a rapid assessment in Uganda.
42:14We've done similar ones in Pakistan and Peru.
42:17We have hosted an expert
42:19group meeting during COVID.
42:20So that was all online and in 2020,
42:23with over 100 experts from all
42:26around the world, including some I
42:28think also from your university,
42:31we have done a resource mapping
42:33what's available,
42:33what tools can be adjusted,
42:35which mention interventions related
42:38to substance use disorders among
42:41populations in displacement.
42:42We have done this Delphi survey to
42:46identify priorities together with experts.
42:49As mentioned in my introduction,
42:51we are coordinating at the level of
42:54the Interagency standing committee
42:56and with different humanitarian
42:58organizations like the big NGOs and so on.
43:00And UNHCR our partners in the UN and
43:05have now set up a sub group which is
43:07specifically on substance use disorder
43:11treatment and developing training materials.
43:14And we're and hopefully coming out
43:16next year in the first quarter was a
43:19handbook on addressing substance use
43:21in humanitarian emergencies and we do
43:23a lot of learning by doing in the real world.
43:26So I've said it I think
43:27twice on this handbook.
43:29You know, any studies you are doing,
43:31any research you're involved in
43:33really we would be very interested
43:36to learn and take into account or
43:39also any comments that came to your
43:42mind as you heard me present now
43:44and this is the draft outline of
43:46the handbook that we will be having.
43:48So you will,
43:48you will see a lot of the elements
43:51of what I just presented to you,
43:54prevention and treatment is there
43:56kind of information on epidemiology,
43:58on the response frameworks and
44:01we will end with recommendations
44:04for policy and policymakers.
44:06What I'm showing you here is the
44:09outline of the training materials
44:10that we are developing with the
44:13interagency spending committee.
44:15Maybe one of the things also that
44:17was notable during my presentation
44:19is that we're often speaking about
44:22pyramids and levels and so on.
44:24So and also the training materials
44:25will go in this direction.
44:27So we will have very basic training
44:30materials for all community workers.
44:33So that for example includes elements
44:36such as understanding about substance
44:38use disorders as health disorders,
44:40basic psychosocial skills,
44:42but also the identification and Emergency
44:46Management of overdose for example.
44:48We're promoting and supporting
44:50community based recovery support and
44:53then at the basic intervention level.
44:55So that would be where health community
45:00workers would already be the target group.
45:04So this would have already more also
45:06on screening and brief interventions.
45:08And then the advanced intervention
45:10level here would be so-called
45:12specialized health workers,
45:14but not specialized in substance use,
45:16but those that can implement the NH gap
45:20packages for non specialized healthcare
45:23settings developed by WHO and partners.
45:28So ending with a few photos,
45:31we have pre pre 2020 and reality
45:35done a study with the World Health
45:38Organization and demonstrated the
45:41feasibility of take home naloxone
45:44already in low income countries.
45:46Ukraine was pre
45:482020 part of this study,
45:49but even now in 2023,
45:52we could continue with trainings on
45:55opioid overdose management and in Ukraine.
45:59And just also this year we have been at
46:01the border between Ecuador and Colombia.
46:04And we have worked kind of with
46:06humanitarian and protection
46:08organizations there and provided
46:10training similar to the outline I
46:12showed you before on substance use
46:15screening and brief interventions
46:17and how they could eventually
46:19integrate that in their ongoing work.
46:22Also not only since this year,
46:25but I've just been this year to Afghanistan.
46:27But our office is together with
46:30the World Health Organization
46:32supporting drug treatment services
46:34in Afghanistan and they're very,
46:37very challenging circumstances continuing
46:39even to provide low threshold services,
46:43basic mess about no maintenance treatment,
46:46residential services,
46:47including residential treatment
46:49services for women.
46:52This thing is more kind of in
46:55terms of information in West Africa
46:57where unfortunately also a lot of
46:59humanitarian emergencies are ongoing.
47:01We have done a mapping of the
47:03infrastructure and the capacity of
47:05treatment services in different
47:07countries in that region.
47:09And already since last year and before
47:12our colleagues from the prevention teams,
47:15I've been working with these
47:17family programs that I mentioned
47:19before in different settings like
47:21in Bangladesh refugee camps,
47:24also in Afghanistan on family skills
47:27programs and maybe this more a way forward.
47:30We have a program on elements
47:32of family therapy,
47:34especially for adolescents with
47:36substance use problems and that we will
47:38take as of next year also to Ukraine.
47:41So now really,
47:43really coming to an end and I think
47:45we're OK in time, which is great.
47:47So I can hear from you any take
47:49home message from APP.
47:51I mean,
47:51I think you've heard it before and
47:54we just published a small editorial
47:56or so in this regard.
47:58I mean we're really arguing that
48:00it's time to move beyond asking
48:03whether it's feasible or necessary
48:05to provide substance use services
48:08to displace populations and rather
48:10start beginning to promote their
48:12adoption as essential components of
48:15the humanitarian response and then evaluate,
48:18learn from that and take it further.
48:21So and before we close,
48:23there are two last things I think
48:25one you don't have,
48:25we will not have time for,
48:27but I'll show you afterwards or maybe
48:29case you don't have any questions.
48:32First,
48:32I would like to thank really the
48:35donors of UNODCS Global Projects
48:36and the work of the Prevention,
48:38treatment and rehabilitation section
48:40as well as all the host countries,
48:44civil society organizations,
48:45people with lift and living
48:48experience who we have worked with
48:50and who are sharing their wisdom and
48:53knowledge so that we can develop this
48:56technical guidance which hopefully
48:58will be available more soon.
49:00And this is a little film film about life,
49:03about much of the work we're doing,
49:04but I will just share you the
49:07YouTube link so that rather we
49:09have a little bit of time to talk.
49:11And with that,
49:13I am again very thankful that I
49:16have the opportunity to talk to
49:19you and would love to hear from
49:22you what you recommend to us,
49:23what else to include in our guidance,
49:26what may be is missing necessary and
49:29what may be from your research has
49:33emerged as additional essential elements.
49:35Thank you so much and over to you, Mark.