Cross posted from from the Stop the Drug War Chronicle Blog (12/18/08)
Ah, the Clockwork Orange brainwashing day. (For my preamble, click here. For coverage of day 1, click here.) There's nothing in my cranium. I've blocked it all out. A windowless auditorium and a set of presentations where the direction from the organizers to the presenters was "keep it tedious and repeat the information from the day before."
I sat for 9 hours or so waiting for some kind of stimulation that was not arriving. Supplied with powerpoint presentations of the most unimaginative kind, graphs and pie charts and tables, presenters made a great show of their learning and authority, but speakers had a complete inability to talk in either a compelling or dynamic fashion. Did no one on the organizing committee check to see if presentations would overlap? John Strang, National Addiction Center, United Kingdom, talked about methadone as Herb Kleber, Columbia University, USA, did the day before; a panel on brief interventions on which presenters both used the same WHO tool as a discussion point.
You can't blame the presenters. The organizers clearly had a concept in mind and that's where it stayed -- in someone's mind or in a folder in a cabinet hidden behind cleaning supplies that had been pilfered from the commissary.
The conference is presenters from university settings and addiction centers from the USA, Canada and the UK who have failed to adapt their presentations for their audience. I cannot imagine that Herb Kleber actually put any thought into what he presented. His secretary pulled a canned presentation from his presentation file in 'My Documents' and handed it to him at 4:00 pm on Friday afternoon. How does science on methadone translate into practice for someone who is dealing with an emerged heroin epidemic in Dar es Salaam? Yes methadone and buprenorphine is very effective but how do you deliver it to drug users in a country that has no history of addiction medicine, where methadone is not currently in the country, where users are not going to pay for medication and where the government is going to be looking over their shoulders for a reaction from the International Narcotics Control Board if they deviate from a clinic based system?
I might be the only person who really cared. Three quarters of the audience didn't show up today. After all, there is Christmas shopping to be gathered up and taken home. "From research to practice" is the tag after the colon in the description of the conference. The absent audience didn't get that on day 2 and maybe they knew it wasn't going to be delivered anyway.
Perhaps, however, none of this is the point. As Gilberto Gerra, Chief of Health and Human Development Section of UNODC indicated on the first day, UNODC is gathering steam to launch a big demand reduction initiative. However, to make it work, UNODC needs US buy-in. Therefore a US dominated event is a perfect sop to butter them up. It's a solid way of branding drug treatment as the demand reduction approach. The estimable John Strang choked nervously during his presentation when he mentioned 'harm reduction', lamely explaining that it's not a controversial term in Europe. European governments do see harm reduction as part of a health care continuum for drug users and hopefully can ensure that not only can they continue to fight for it through the UNGASS process but can see it assimilated into the new UNODC demand reduction initiative.
Thomas Barbor from the University of Connecticut School of Medicine delivered a fairly decent albeit guarded presentation on brief interventions. It would have been nice if he could have stretched out a little and talked in more detail about applications. Screening, Brief Intervention and Referral to Treatment (SBIRT) fits snugly into the harm reduction fold. It's aimed at non-problematic users in settings that are generally not used to discuss alcohol and drug use. Essentially, workers at needle exchange programs deliver brief interventions everyday but SBIRT takes it to emergency rooms and other venues and approaches a different audience. It's not a technique aimed at cessation of drug use and it's not necessarily targeted at people with problematic use although if those individuals are ferreted out, then they get the treatment referral. It was interesting watching Herb Kleber grapple with the concept (although it can't be new to him). He wanted to know what the sustained effect was on keeping use down after the intervention. However that's not the point. If use remains down, that's cool. But if the user can be more conscious of their use and not drink and drive for instance, then that's great.
Kleber wasn't the only one confused. I had dinner with a confused David Joranson from the University of Wisconsin. He's working with Scott Burris from Temple University and Dave Burrows from aidsprojects.com from the Land of Oz on providing access to pain medication to people in need. "So why are we lumped in with harm reduction?" was his plaintive cry. No reason that makes any sense, David, except when you get involved with providing pain medication to people who are suffering you come up against control mechanisms and fear. And when you provoke those feelings in authorities you get lumped in with all the other transgressors - the queers and the junkies and the sex workers - and life becomes a series of negotiations and compromises. Good people get hurt and great projects get unreasonably scrutinized because ideologues cannot get over their dogma and paranoia. Methadone and buprenorphine are essential medicines according to the WHO.
However, some funding for the pain medication issue has been applied to a short film that covers the health-oriented side (as opposed to the deviant side!) of opiate use. Called "The Two Faces of Opium" it shows the need for pain medicine and shows methadone as an addiction medicine. Unfortunately only about 25 people got to see this film as it was shown as an evening side event. I think the daytime audience would have benefited a great deal more from the film than the anything else on view today.
Allan Clear is executive director of the Harm Reduction Coalition.
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