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.

This congressional resolution celebrating the 75th anniversary of the repeal of Prohibition shows the hypocrisy of the legislature continuing to support the drug war.

The state of Washington has come up with a youth angle on it's ever popular "rat for cash" program.You may now text message the crimestopper line and rat out the felon of your choice.Rewards for a con

This will probably get me labelled as a conspiracy nut, but it is a really interesting and well-documented subject.

Check out this blog post calling me a hippie and accusing me of overreacting to Obama’s rejection of marijuana legalization. This dude is cool though, I think, so it’s all good. But the whole thing misses the point of my post.

I never thought Obama was going to legalize marijuana. I was commenting on the absurdity of creating a whole Change.gov campaign and then using it to uphold the status quo. Obviously, Obama isn’t going to go change-crazy from day one, but this is a massively controversial issue, as evidenced by its #1 ranking on his site. Using Change.gov to reject popular and much-needed changes is ironic, and while I never expected anything more, I’m certainly not going to give him a pass just because his political posturing is painfully predictable.

Here’s a fun article interviewing college students in Massachusetts about their opinions on the new marijuana decriminalization policy. Unsurprisingly, most of them are all for it, but check out this remarkably candid response from an opponent:

Ed Finch, a 20-year-old sophomore from Franklin, voted against decriminalization for a couple of reasons. One was "purely financial," he said. His father is a Boston police officer who gets a lot of overtime when he has to go to court after a marijuana arrest, Finch said.

Yeah, I guess that’s pretty cool if the drug war is paying your tuition, bro. Imagine my surprise that none of the police officers who campaigned bitterly against decrim ever mentioned how much overtime the new law would cost them. It took a college student to concede the rank selfishness that drives police to defend marijuana prohibition.

Of course, it’s not just about money. It’s also about spite:

But his other reason is based on his own experience.

"I was frustrated with my stoner friends. They’re obnoxious, but I put up with them," Finch said.

Well, maybe we should pass a law that says Ed Finch’s friends watch too much Family Guy and never introduce him to any cute chicks.

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."

Allan Clear, after the nine hours took its toll

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.