 Good afternoon, my name is Peter Sharoschi and welcome from the Vienna International Center where we are sitting at the Commission on Narcotic Drugs 65th-61st session and Today we will discuss Stigma and how stigma affects the lives of people who use drugs and what this meeting can do about this problem So let's start with What words we should use because that's I think it's one of the key issues That somehow it defines who we are what words we use about people and One of the terms I think which is kind of controversial is is the term addiction and addict so can you tell me Judy like Why the international network of people who use drugs we are the executive director of Opposites the term of to use addicts I'm sure well the international network of people who use drugs have always had a problem With the addiction model and the language of disease the language of addiction which implies disease and the implication of a Disordered loss of control like this compulsion. So I think when you associate, you know Drug use and people use drugs with addiction You apply that language implies that we have no control over our lives That it's impossible to regulate or manage drug use which is not true. There are many who do So I think you know, we need to look at other words that we can use that Don't Increase the stigma of people who use drugs and imply that you know, we cannot make decisions about our own lives Or we lack agency or autonomy. So I think you know, it's important discussion To bring you know an addiction. It's not just about health. It's not about disease There are so many factors that we really need to look at and I think we miss out a lot on Reducing reducing drug use To a disease model to just a health framework What do you think about? Addiction itself because some people say it's a disease some people say it's a moral failure Some other say I think that that's just a social phenomena. So Sean Do you have any thoughts on that? Um My opinion is that the term addiction if you're going to use it at all has to be wider than drug use and we've seen some Researchers like Bruce Alexander talk about addiction in its various forms My problem comes when we use the term addict as a noun And we describe somebody as an addict because that comes with a whole set of presuppositions and ideas With it in terms of of addiction. I certainly don't think it's a disease I think it's part of the human condition We've seen a concerted effort by various international bodies to promote addiction as a disease under the guise of decreasing stigma in fact, you know, I always I always say would you have somebody who's got perhaps some sort of Bad habit around to your house Or would you rather have somebody who's been labelled as having some serious mental health disorder, you know And that question usually shows that that there's not reduced stigma Of course, there's a lot of stigma and there's a lot of stigma around mental health disorders Which shouldn't be there either but to claim that the disease model reduces stigma. I think it's just Dysingenious. I don't think it's an intelligent argument at all I think that it gives an excuse for paternalism for Putting people into coerced treatment or enforced treatment and I think that that there are a number of problems with it But most of all I don't think there's scientific data to support it The brain changes we see in so-called addiction are not that different to any other brain changes we see and the brain changes That's the way it works. So now I have a problem with with the pathologization of addiction Thank you and Actually, there are some governments who try to do something about stigma at this meeting including Canada who submitted a draft resolution on language and And the destigmatization of drug users and we have Donald MacPherson from Canada here. So don't I can you explain us? What is this resolution about? Well the government of Canada has put forward a resolution on Stigma and they're very committed to working towards reducing the stigma on That is society puts on an institutional institutional Settings put on people who use drugs And it's fascinating after after listening to to You too that that what's playing out in the debate about the resolution it's all about language and What's really interesting and I think it's really exciting at this time The language is shifting and the language has been stuck for a hundred years at least so so this Resolution which I think was put forward in good faith by Canada It had some very good wording in it It's become a focal point for exposing the debate on the old Stuck UN language that talks about drug abuse talks about drug abusers and more current contemporary language around problematic drug use people who use drugs the various Words that are being used for addiction now with substance use disorder drug dependency Addiction still gets used. So it's actually a really exciting time. I think in our field because there is language is critically important and the language is shifting and the resolution from Canada was an attempt to acknowledge the How how stigmatizing Concepts and language were to people who use drugs and created such barriers to all sorts of activities in the community so I Think now that this resolution has gone forward The language discussion is on and I don't think it's going to go away Do we see much opposition to this resolution and and who is opposing this? Yes, there's a significant amount of opposition to this resolution and a country with very fundamentalist views of What addiction is of punitive approaches of people who use drugs need to be sort of separated from society sort of treated Children and then youth have to be protected from drugs as if drugs have agency as if drugs Are going to come into their bedroom at night and infect them or something. It's it's a very very old-fashioned Non-evidence based Fear based view of drugs when in fact much of the discussion in the CND drugs are not the problem social condition to the problem social economic conditions Lack of community disconnection from community those are the problems, but this forum in particular Focuses on drugs as a problem, which is unfortunate and it would be great if we could get beyond that and maybe through this language discussion we can begin to open up some of those some of those Perspectives that that This is so much more about other things and drugs and we have to get beyond that So that the UN also has been discussing the issue of standardization of treatment and creating international standards for drug treatments and maybe the idea is not not very bad in itself, but the the UN UN office on drugs and crime and the WHO came out with a document this year on International standards and many organizations including input representing drug users is against That documents. Can you tell me what's the problem with that? Sure, so input You know we put input into these guidelines and then we were able to with other partners Mobilize a hundred eighty eights of society organizations and the issue wasn't the principles of the treatment guidelines We agree with developing these guidelines and I think the intention was to you know really define What treatment is and that it's not it shouldn't be compulsory, you know, some of the things that are happening in the name of drug treatment You know Torturous they're cruel Degrading in human treatment. So we definitely agree that these guidelines are needed But the problems that we had with these guidelines was again some of the stigmatizing language You know, they were supposed to be evidence-based and based on ethical standards But again, I think you know sometimes the intention behind things and the you know Maybe not looking at language enough and looking at models that we've gotten used to using such as the brain disease model that are non evidence-based increased stigma and you know falling into this idea that you know people who are drug dependent are not good employers are Not fit for parenting, you know These are some of the you know some of the language that we really need to start changing so that was one of the issues a second issue was not using the terms harm reduction because it is very You know political not some member states have a problem with it But we wanted to point out that these are supposed to be technical guidance. It shouldn't be You know subject to political biases So that was another issue that we had with it and also, you know broadening out harm reduction to look at, you know Safe injecting facilities and heroin assisted treatment Also, we thought that some of the guidelines weren't aligned with previous, you know technical guidance. So the WHO Technical guidance on key populations the injecting drug use the implementation tool obviously the comprehensive package that do mention harm reduction and Thirdly a major problem. We had with it also was the process So any WH document is supposed to go through a grade review review process Which is also supposed to involve community and have meaningful community input because at the end of the day These are the treatment guidelines are going to impact our lives. We know that they're the Intended authorship or for I guess primary audience sorry treatment providers, but in the day it affects our lives so You know, we should be meaningfully involved in reviewing the guidelines Yes, I think I come from a clinical kind of background on this and I think that and a data background and Some of the basic problems I have with it is is in particularly in the background section There's no referencing and and there's a lot of Statements there that are just not true There's no data to support them and then even in the treatment guidelines There's the promotion of short-term treatment detoxification without mentioning the risk of detoxification For certain people, you know, particularly opioid dependent people there's the promotion of Residential rehab Which there is not a single study anywhere in the world that shows that traditional models of residential rehab Outperforms spontaneous remission rates in substance use disorders not one study anywhere and certainly no well-controlled studies and You know, this is promoted and it shouldn't be in in a document that's supposed to be a scientific document On top of that a lot of the language is problematic as Judy has mentioned as well But I think it's it's almost a it's it's a document with multiple personalities and we can see in certain areas for example in the brief interventions and the This you know that that section on sort of more motivational approaches and brief interventions and screening The World Health Organization has referred to their assist tool, which is it's not a bad tool, you know But in other portions of the document it talks about the lifelong nature of substance use disorders or the ethnicity of them It compares them to other Health conditions which they very few comparisons with and we know from the data that the majority of substance use disorders If you want to use that criteria they resolve and they resolve spontaneously with our treatment That's not acknowledged anywhere in this document whatsoever and that to me is just unscientific and not clinical good practice Just to say a few things again, I don't have as much expertise as Judy and Sean in this area, but We're coming we're coming out of the dark ages not only in language, but only on thinking about what addiction is what treatment is and lapsing to the most expensive real residential treatment models that's Cover the fewest individuals in a society is is a it's very expensive type kinds of treatment. So There are you know, there are psychedelic therapies that are being developed with psilocybin with MDMA with LSD that are You know now being looked at for certain types of conditions including addiction so It's actually quite an exciting time But the doors have to open to new ways of thinking about what this phenomenon is. It's a really complex phenomenon treatment is is is works for some it's a complex process and We have to we have to that the document should be way better than it is given the state of knowledge If they had have had a really comprehensive Group of people looking at that they could have come up with a much better document But again, they elapsed to sort of the same old same old way of thinking and that's what the document tends to reflect Judy mentioned abuse in the name of treatment. So Can you tell us what kind of abusive forms of treatment and rehabs are around the world? Can we do a body? That's a difficult question So, I mean, you know some of the abuses that do happen in the name of treatment There are compulsory drug detention centers the government run They're very prolific or used quite very widely in Asia Particularly in China in terms of the numbers. I believe there's between like 200,000 to 500,000 people in compulsory drug detention What happens in there? You know people are picked up by the police They're put in these detention centers for anywhere up to six years So some of you know being detained in the name of treatment is sometimes a longer Sentence than being detained in prison So we assume that you know when things happen under the rubric of health or the you know regulatory powers of health Sometimes they're less we assume that they're less Abusive but that's not necessarily true and then within these centers not only is the their Deprivation of liberty or liberty, but there's also been physical and sexual abuse You know lack of Say treatment services for HIV hep C military drills so this whole gamut of Interventions that happen under the name of treatment, but I think you know also There's this growing trend towards that. There's you know in Latin America. There's these in Nepal There's private privately run rehab and they happen under the name of rehabilitation and unfortunately these type of measures get More funding and financing then, you know harm reduction approaches and you know evidence-based approaches So, you know, that's something that's usually problematic with Treatment and compulsory treatment. So, you know, we can't put we can't just assume that treatment or the health framework is necessarily always a good thing We always need to be interrogating, you know, what's happening Underneath that so you are from South Africa. So Can you tell us the situation there? Like are there also abusive forms of treatment and are there evidence-based programs available? So South Africa has had a long history with struggling with terms around harm reduction, for example We've had an extensive lobby against the term harm reduction organizations such as doctors for life have Had enough political power to stop us Using the accepted definitions of harm reduction and so our last national drug master plan had the description of a Localized version of harm reduction that focused purely on treatment Of people who who were using drugs and the presumption that all people who use drugs Were doing so in a way that that required treatment, which just wasn't true It's delayed the the rollout of opioid substitution therapies or opioid agonist therapies as I prefer to call them It's delayed the out the rollout of needle and syringe programs With the result that in certain cities, we've got a prevalence of hepatitis C of up to 93 percent 40 plus percent of HIV prevalence amongst people who inject drugs and all of this is preventable Fortunately the South African Policy landscape is changing for the first time ever last year. We had consultations between our central drug authority and People who most who are most impacted by drug policy in South Africa. We are seeing the World Health Organization basket of services as in their technical guidelines being introduced We still have a battle ahead of us because for example methadone is up to 30 times more expensive in South Africa And it's only available in the private sector for those that can afford it But we've had some successes in rolling out low-threshold programs And we've got one of the cities to find a low-threshold program, which is proving very very successful So we're hopeful that that the situation is going to change But where we do have a lot of abuses in the criminal justice system So people who get arrested for possession of drugs do not get any legal aid whatsoever They get automatically remanded or forced to sign an admission of guilt Which gives them a criminal record for the rest of their life making them virtually Unemployable for most sick formal sectors of the economy and and that's a form of subjugation of people and one of the points That I try and make is that in South Africa we've taken the resources that were used to police apartheid and And we've taken those resources and put them into the war on drugs And so we've got the military insert being used as an intervention in certain areas We've got a lot of police action We've got you know stop and searches and and a lot of people are ending up in jail you know because they simply happen to be in possession of a small amount of drugs for personal use and That becomes the perfect recruiting ground for gangsters and it increases the levels of marginalization and social exclusion Which drives drug use as we know so the the so-called solution is becoming the problem We activists are often criticized that we are always criticizing what we Rarely speak about the ideal word which or ideal system which we envision So my last round of question to all of you is that how would that ideal word look like and how would how would how would be people who use drugs treated in an in an ideal words and And drugs how would how would the government's treat drugs? Well, it's it's it's it's complicated, but it's really not in an ideal world drugs will be regulated We go through a process. That's what we do. We regulate drugs We regulate hundreds and hundreds and hundreds of drugs except for a very few that creates this huge market Underground market where the substances are full of toxins and you can't count on what you're getting and all that sort of stuff So ideally we would and that that is a major problem It has to happen in Canada the good example right now. We are having lots of harm reduction expanding treatment But it's not keeping up to the fact that the drug supply under prohibition is absolutely toxic That is a key driver of the overdose crisis in Canada So if people were using regulated drugs, there may be some overdoses there may be some problems for sure, but it There would not be the level of overdose deaths that we're seeing So to me all the treatment all the harm reduction in the world is not going to solve the problem if People are ingesting things that will kill them. They don't know the quality of so we have to start there And and of course we need good harm reduction good treatment good prevention all that sort of stuff But if people have to lapse to a toxic illegal market to get their supply of drugs there they're really It's it's hopeless Sorry to be so so hopeless I I hate using that word Um, no, I mean we definitely agree with you know the need to move towards regulation I'll just focus a bit more on the stigma and discrimination part I do think you know in terms of drug use it really has to be normalized and the fact that we don't normalize it creates Increasing stigma and discrimination so this vicious cycle of more marginalization which you know drives problems in people's lives And I think you know we really have to Start to realize that simply people have always used drugs and the you know these global architectures We used to control it has only happened in very recent times You know opiate use in China was very normalized for hundreds of years And there wasn't you know the level of problems until there was Western you know intervention kind of in that but Yes, I think you know we really need to start shifting our attitudes and yes, some people need You know assistance and access to medical services and social servers just as Everybody does and we all should have the right to that But I don't think we need to focus on you know drug use as the problem I've got two endpoints that I'd like to see The first is a world where people are most of the time able to make conscious informed decisions about the way In which they use drugs when they use drugs and which jokes they choose to use in a policy landscape That doesn't make those drugs more harmful or less beneficial That's the first one the second one is I'd like to see a world where drug policy isn't used as an excuse for the continued marginalization of people and exclusion of people and where the marginalization and Exclusion of people doesn't make drug use the most salient Option or the most important or the most meaningful option for people who use drugs where where they're able to participate fully in society And as a final point, I'd like to say we cannot achieve any of this as long as we've got the words evil Linked to addiction and to drug use as they are in the single conventions While we've got that language there We cannot hope to have a Constructive drug policy landscape because it's like building a house on a cesspool. It's gonna sink And I don't think I need to say more than that, but but really it's a big problem for me Thank you very much for joining me and thank you for those who watch this