International perspectives on drug treatment policy March 2017

Drug Policy (alcohol, tobacco and other drugs) Drug policy as a balance of 3 pillars: Supply reduction Domestic policing, border control, source country control, regulation of supply for licit drugs Harm reduction Reducing harm without reducing use, eg NSP, plastic glassware Demand reduction Preventing commencement of use Providing treatment & support Investment mix? Predominantly supply reduction…

Comparisons: Drug budgets (illicit) Country Australia USA (federal only) UK (EMCDDA) Sweden (Ramstedt, 2006) France (EMCDDA) Asian/SEA countries Yr 2010 2015 2002 2013 NA Law Enforcement 65% 51.9% 64.9% 73.0% 39.0% Treatment 22% 43.4% 11.7% 25.0% 44.3% Prevention 9% 4.6% 0.1% 1.4% 13.4% Harm Reduction 2% -  - 0.15% Other 23.3%2   2.6% TOTAL (in millions)1 1,701 28,883 8,436 739 2,056 Sources: Ritter et al, 2014; EMCDDA http://www.emcdda.europa.eu/countries/public-expenditure; ONDCP USA figures All in million Euros, except Australia ($ million AUD); USA $USDm. UK Other = social protection & gen public service

Spending enough on treatment? Met need of treatment (= of all those diagnosed) hovers at 5-20% of people with diagnosis (AUD lowest) Met demand for treatment (= of all those seeking/wanting treatment) is higher, but still poor: Country Drug type % met demand USA All substances 15% to 31.4% Mojtabai & Crum, 2013; Sareen, et al. 2013 Canada Opioids 26% Popova et al Australia 34% Ritter et al, 2014 England Alcohol 5.6% Drummond et al, 2004 Scotland 8.2% Drummond et al., 2009 Illicit drugs 60% PHE report, 2017

Systems of care – four features Alcohol and other drugs combined Disease management perspective vs episodic Integrated with health care or separate systems Treatment purchasing/commissioning

1. Alcohol and drugs combined? Alcohol & drugs combined or separated out? Most countries have a dedicated govt unit for AOD treatment (combined 66%) A small # of country’s have a separate drug treatment govt unit (7%) Most countries offer predominantly combined/integrated care EG: AUS all combined care, including OST

2. Disease management vs episodic Most nations currently have ‘episodic’ model Researchers and practitioners calling for disease management framework Difficult to shift systems that are reliant on “episodes of care” One barrier – approaches to funding EG: In Australia, no capitation/managed care arrangements (fund holder responsible for care to a person over the course of her/his life).

3. Integrated with health or separate systems? No clear data to summarise international experience Depends on view of the “problem” (as disease, delinquency, or social problem) If ‘delinquency’ = control If ‘disease’ = health care If social problem = social care Nations shift (depending on their history of drug policy) between these three ‘attitudes’ to what the problem is, which then reflects treatment service systems Within nations, much local diversity, and driven by providers and funding systems EG: Australia: government specialist AOD embedded fully within health care system; non-government providers split between social-welfare and healthcare

4. Purchasing arrangements How treatment is funded & purchased drives significant treatment policies: EG Health vs social-welfare Disease management or episodic Treatment settings: hospital, community, NGO Workforce, service quality & sustainability implications Analysis of treatment purchasing/funding arrangements Conceptual schema: Ways in which providers are chosen Ways in which services are paid Ways in which price is managed Ref: Ritter, A., Hull, P., Berends, L., Chalmers, J & Lancaster, K. (2016) A conceptual schema for government purchasing arrangements for Australian alcohol and other drug treatment. Addictive Behaviors, 60, 228-234 doi: 10.1016/j.addbeh.2016.04.017

Summary of purchasing mechanisms Ways in which providers are chosen Australian arrangements Aligned with…. 1. Competitive (open, targeted, panel) Widely used for NGOs Social-welfare 2. Historical / negotiated Widely used for hospitals Health 3. Accredited providers Rarely used Ways in which services are paid for 5. Block grant Widely used 6. Fee-for-service Used in primary heath care settings Health – GPs 7. Payment for activity Used in public hospitals (ABF) Health – hospitals 8. Payment for outcome Not used in Australia, research evidence not positive 9. Capitation Not currently used in Australia … Ways in which price is managed 10. Fixed price  Only in one Aus state 11. Negotiated price Social welfare

Thank-you Professor Alison Ritter Drug Policy Modelling Program, Director National Drug and Alcohol Research Centre UNSW, Sydney, NSW, 2052, Australia E: alison.ritter@unsw.edu.au T: + 61 (2) 9385 0236 DPMP Website: http://www.dpmp.unsw.edu.au

Treatment settings Internationally recognised treatment settings (n=4): Specialist AOD treatment settings General health services Mental health services Primary health care services Focus on health care systems, not social-welfare systems

Alcohol Use Disorders: WHO ATLAS on Substance Use (2010)

Drug Use Disorders: WHO ATLAS on Substance Use (2010)

Pharmacological interventions Countries with clinical guidelines for pharmacological interventions with SUD (WHO ATLAS, 2010)

Methods of treatment funding Foremost method of treatment funding: Tax-based funding: 37% Out-of-pocket payment: 25% Social health insurance: 21% Other: 8.6% Varies by world region: eg in Europe 43% tax-based funding and 48% social health insurance (cf Africa and Americas, with 41% out-of-pocket funding).