At last, my final day in Vienna attending the United Nations' "Technical Seminar on Drug Addiction Prevention and Treatment: From Research to Practice" conference. (To read my scene-setting preamble from earlier this week, click here. Day 1 is here and day 2 is here.) It's a wind-down day for a conference that never wound up — the day when harm reduction was finally allowed to rear its head — so often unwelcome at any conference dominated, as this one is, by the United States, whose official governmental representatives are highly and categorically opposed to harm reduction. Harm Reduction appeared in that very earnest fashion whereby presenters say, "Here is the science. We need no more evidence. However, I can tell that you're not listening, so I'm going to tell you again that this all works, folks." It was also the day that I made a diplomatic faux pas (as we say in the language of diplomacy). More about that later. I missed the first couple of presenters as I was grappling with the sudden disappearance of Internet connectivity and was hoping that the coffee would kick in. The Viennese make good coffee although it's more of a utility tool than anything pleasurable, kind of like putting socks on in the morning. As I arrived, Dr. Shanti Ranganathan from TTK Ranganathan Treatment Centre in India had just finished her talk. I gather that she covered home detoxification and a camp for drug injectors (it could be fun to speculate how that camp would work). Speaking to a colleague later in the day, I learned that due to the rural nature of India, the approach to drug treatment there is very different from the way it's done in the northern hemisphere. It's very community oriented, and villages have a say-so in the process. I wish I'd caught more of Ranganathan's presentation, which was more along the lines of what I'd been hoping to get information about. How do you deliver drug services in resource poor countries? A gentleman behind me asked, "Haven't we overspecialized drug addiction treatment and shouldn't it be mainstreamed to take advantage of existing resources?" At last, a cri de coeur from the audience! Drug services including treatment, harm reduction, and diversion programs have all sprouted like varieties of weeds. They're somehow related, but the root system and the genetic coding are different. So how could countries and governments differentiate and choose among them? Or figure out how to construct the best array of services based upon what was on show? They couldn't, to my mind. After all, how could anyone possibly make sense of the patchwork quilt of treatment systems and social services in the north given that they don't necessarily make sense — or work — for drug users in their country of origin to begin with? It's as if we're displaying the leaning tower of Pisa or parading the Venus de Milo as models that they should aspire to, and then wondering why the resource poor world makes buildings that lean and statues that have no arms. One place I would not want to live is Sweden, where a random study of the kids at the youth program being trumpeted revealed that each youth suffered from an average of four mental disorders; the majority of parents had one. It must be good to have sane parents. Nothing like pathologizing the young, is there? The Dutch rolled into town with their admirably well-developed harm reduction knowledge and advocacy models. Dr. Wim van den Brink from the Academic Medical Centre at the University of Amsterdam in the Netherlands ran through the continuum of the stages of a drug user's drug taking career and discussed where, when, and which type of a wide range of interventions can and should occur. He included heroin maintenance in this list. (It is widely accepted that heroin maintenance is the fallback option for users who seek treatment but for whom methadone or buprenorphine has not worked. It's not usually a first line option. Outcomes are comparable to all other maintenance programs.) In van den Brink's view, drug-using patients should be able to talk over what their expectations are with their doctors and then negotiate their options. Fancy that. He was pretty much the first speaker who identified drug users as having a role in their own treatment. And he identified abstinence, maintenance, a safe high, and chaotic use as markers on a scale. That may be the first time in 20 years I've heard a clinician identify pleasure as part of the range of options. The legendary Dr. Franz Trautmann from the Netherlands Institute on Mental Health and Addiction ran through the evidence supporting harm reduction interventions including outreach, drop-in centers, and "drug consumption rooms" — the Dutch term for what we in the United States call safer injection facilities or medically supervised injection centers. (The panel facilitator, Gilberto Gerra, Chief of Health and Human Development Section of UNODC, chimed in to reassure everyone that drug consumption rooms do not violate international conventions). It was kind of a relief to hear Dr. Evgeny Krupitsky, head of a laboratory that conducts research on drug addiction at St. Petersburg State Pavlov Medical University, give a convoluted and amusingly wrong-headed talk about the desperate need for the Russians to make naltrexone the first-line response to drug addiction in Russia. (US rejection of harm reduction has its parallel in Russia's refusal to allow methadone.) Naltrexone is an opioid antagonist, which means you can't get high after you've taken it. The opioid receptors in the brain get too blocked up to let any more opioid in. However, as a form of treatment, it's just not very effective. So the Russians keep adding medications to the basic naltrexone dose, unwittingly creating an out of control medication pharmacopoeia for their patients. Monica Beg of UNODC had the task of informing everyone again that syringe exchange is effective in stopping the spread of HIV. Her PowerPoint showed the global distribution of exchange programs (probably limited to the UN-influenced world, to be fair) and did not cover the United States. "The science is clear. Syringe exchange works. The debate is over." Within UNODC there is no debate on the science but as mentioned in my original preamble, UNODC acts as the secretariat for the Commission on Narcotic Drugs (CND) and so when the member States of CND produce Political Declaration, those member states can completely ignore the science as is the case with the US and Russia. In fact, the HIV Prevention Unit deserve a medal for its work in pushing for support from within UNODC. And that's when I just had to speak. I pointed out that despite all of the evidence that needle exchange has been effective in the US (there are 200+ programs, with some of the larger ones federally funded; needle exchange has reversed the HIV epidemic in NYC, once the global epicenter of injection drug use and HIV; scientists at NIDA, NIH, CDC, NIAID are all on record as saying syringe exchange works), an article still appeared on CNN.com just this last July with David Murray, a supposed scientist for the Office of National Drug Control Policy, saying needle-exchange programs "do not succeed in its effort to control the contagion of disease." My point being that while the scientific debate may be over, the political debate continues in the US — not least in the way the US government has been disrupting the process leading up to this March's United Nations General Assembly Special Session on drugs. (While representatives to the UNGASS, plus numerous non-governmental agencies around the world have been calling for harm reduction to be recognized as an important part of demand reduction, US representatives have continued their war against it.) The chair responded to me by saying that there couldn't be a response to my point as it was a political question and inappropriate for this forum. And that science would win out. Stymied at not having a planned end point, I emotionally said that I was glad that this administration was now out. (Apparently it's taken as bad form to name names.) The interaction was filmed by an Iranian television crew that's covering the Iranian involvement in this meeting, which included Azarahksh Mokri of the Iranian National Center for Addiction Studies, who gave a wonderful presentation on how to introduce a methadone program into a country like Iran. He is a brilliant, charismatic speaker who was succint and on point throughout his talk. Christian Kroll of the UNODC HIV Unit, the last speaker before the closing, had that second returned from a UNAIDS Prgramme Coordinating Board meeting and was fired up from saying farewell to Peter Piot, the UNAIDS Executive Director and Under Secretary-General of the United Nations. Kroll ran through the history of the AIDS movement (accidently conflating Gay Men's Health Crisis and ACT-UP) and the importance of civil society input into the UN process. I kept waiting and waiting for the punch line. "Are you asking for more civil society input into UNODC?", I asked. Kroll's response: "Yes I am." Being practically the only representative from "civil society" at the meeting and definitely the only person that spoke, I can see his point. We then sang the Internationale and Mr. Kroll and I caught the subway home together. Allan Clear is executive director of the Harm Reduction Coalition.