Module 6 Effective drug prevention and treatment

Aims and learning objectives To define, understand and analyse the objectives and desired results of evidence-based drug prevention and drug dependence treatment, as part of a comprehensive health-based approach to drug use. Learning objectives: Participants will be able to: Understand the principles and potential results of drug prevention, and assess evidence for effectiveness Understand the objectives of different forms of drug dependence treatment Assess the cost-effectiveness of prevention and treatment interventions in resource poor settings

Introduction Despite increasing drug use, too few countries have national policies covering treatment & prevention, outlining measurable goals and strategies Drug policies mostly focusing on law enforcement, leading to serious health and social consequences for PWUD Call for drug use to be considered as a health issue, to be addressed by a strategy encompassing 3 components – prevention, treatment and harm reduction Lots of interventions have been developed, but not all have been effective Objective here: capturing the key objectives, characteristics and outcomes of evidence-based prevention and treatment interventions

Session 6.1: What we know about drug use 250 million people use drugs around the world – 1 in 20 people, and numbers are increasing Only 1 in 10 PWUD experience problems with their drug use or dependence Cannabis is the most widely used drug, followed by ATS, opioids, ecstasy & cocaine Between 8.5 and 21.5 million people inject drugs worldwide (mostly in East and Southeast Asia)

Session 6.2: Objectives of drug prevention A lot of prevention interventions developed in most countries, but not all have been effective – first issue is to define the objectives of these interventions Objective: Help people avoid or delay initiation of drug use. If a person is already using, avoid that their use becomes problematic But broader objective: Contribute to the positive engagement of people with their families, schools, workplace and community – build life skills and personal capacity in individuals & strengthen people’s ability to avoid drug problems Help people adjust their behaviour, capacities and well-being (ineffectiveness of “Just say no” campaigns)

Session 6.2: Risk and protective factors Objective one: reducing risk factors e.g. mental health problems, family abuse, growing up in marginalised communities, individuals torn by war and natural disasters Objective two: strengthening protective factors e.g. psychological and emotional well-being, strong attachment to caring families, schools and communities that are well resources and organised Conclusion: Often unrealistic to expect a reduction in the overall level of drug use. But interesting results if we seek to delay the onset of drug use, strengthen people’s ability to avoid drug problems, or increase their knowledge of risks

Session 6.3: Defining the different types of drug prevention Universal prevention Intervening on populations Broadest approach, targeting the general public, assuming that all members of the population are at equal risk of initiating drug use. Targets skills development, interaction with peers in social life Can be implemented in schools, communities, workplaces Mass media campaigns are costly and ineffective, accentuate stigma Well designed and funded campaigns targeting school children using interactive, skills-building approaches can have some impact

Session 6.3: Defining the different types of drug prevention Selective prevention Intervening on (vulnerable) groups Targets specific sub-populations whose risk of starting drug use or experiencing problematic use is higher than average (e.g. young offenders, school drop-outs, marginalised communities, etc.) Usually targets social risk factors making the group more vulnerable Interventions using multi-component, peer-led and interactive programmes focusing on teaching social and coping skills can have a positive effect in delaying drug use initiation and improving cognitive capabilities

Session 6.3: Defining the different types of drug prevention Indicated prevention Intervening on (vulnerable) individuals Targets high-risk individuals identified as at greater risk of experiencing problems with drug use (e.g. mental illness, social failure, hyperactivity, anti-social behaviour, etc.) Aim is not necessarily to prevent initiation of drug use but prevent the development of dependence or problematic use Most effective when the intervention seeks to address issues other than drug use by focusing on the social context and behavioural development of the person

Session 6.3: Defining the different types of drug prevention Environmental prevention Intervening on societies and systems Alters the immediate cultural, social, physical and economic environments in which people make their choices about drug use (e.g. what is expected or accepted in the community, national legal context, price, quality and availability of drugs) Can include taxation, advertising bans, retailer licencing and opening hours Examples: alcohol and tobacco, as well as regulated cannabis markets in some areas of the world

Session 6.3: Defining the different types of drug prevention The drug prevention cards Sort out the cards in the following categories: Universal prevention Selective prevention Indicative prevention Environmental prevention

Session 6.4: Minimum quality standards for prevention UNODC Minimum quality standards in drug prevention, 2013, promoting: the delivery of “an integrated range of interventions and policies based on scientific evidence in multiple settings, targeting relevant ages and levels of risks” A supportive policy and legal framework Scientific evidence and research Coordination of multiple sectors and levels Training of policy makers and practitioners A commitment to allocate adequate resources long-term

Session 6.4: Minimum quality standards for prevention EMCDDA Minimum quality standards on drug prevention – project cycle:

Session 6.5: Activity – The effectiveness & appropriateness of prevention interventions Split in groups of 4-5 people Study your drug prevention programme (see next slides) Respond to the questions below: What type of prevention programme is it? What do you think were the primary objectives? Do you think that the prevention programme was effective? Why? Would this programme be effective in your country? Would it be practically possible to implement in your country?

Session 6.5: Activity – 1st intervention: prevention campaign against NPS use in Romania “The difference between a user of illicit plants and a cow is that the cow knows what it uses. Drug use kills!”

Session 6.5: Activity – 2nd intervention: prevention campaign by NIDA in US schools

Session 6.5: Activity – 3rd intervention: UNODC video released on World Drugs Day 2013

Session 6.5: Activity – 4th intervention: Unplugged prevention programme in schools (international)

Session 6.5: The effectiveness and appropriateness of prevention interventions Issues to consider What are our objectives? Don’t be too ambitious! What is our target group? Which interventions will have the greatest impact? What is the best setting for messages to be delivered? You’ll need to take into account trust in the information provided, and the cost of the initiative What is the best intervention based on available resources? Avoid rushing into eye-catching campaigns that have little long-term impact!

Session 6.5: The effectiveness and appropriateness of prevention interventions Issues to consider Does the general policy/regulatory framework have an impact on my prevention intervention? The intervention should be enshrined in a public health approach to drug use Is the intervention based on evidence and research? And don’t forget to evaluate the effectiveness and cost- effectiveness of your intervention

Session 6.5: The effectiveness and appropriateness of prevention interventions A review of effectiveness Ineffectiveness of mass- media campaigns – except if delivered in coordination with community involvement interventions

Session 6.5: The effectiveness and appropriateness of prevention interventions A review of effectiveness School-based programmes that teach social and coping skills have better effects in delaying initiation than information provision only Interventions that seek to change the school environment are better than those trying to change individual behaviours as drug use is often related to school failure

Session 6.5: The effectiveness and appropriateness of prevention interventions A review of effectiveness Reducing criminal penalties for some drugs does not increase drug use, but significantly reduces health and social costs E.g. Portuguese decriminalisation model

Session 6.5: The effectiveness and appropriateness of prevention interventions A review of cost-effectiveness Investing in evidence-informed drug prevention reduces: the harms associated with drug use among individuals, their families and communities the costs to society: every dollar spent on good prevention programmes among youth can save up to 10 dollars (UNODC data)

Session 6.6: The availability of drug dependence treatment What treatments are available in your country/region? Who provides them? How much do they cost the patient? Does the patient have a choice of treatments? Are the existing treatments effective and appropriate?

Session 6.6: The availability of drug dependence treatment Definition: range of interventions (medical & psychological) that support people who have a problem with their drug use to stabilise or recover control over their consumption, or seek abstinence Need a comprehensive menu of services to suit the differing characteristics, needs, preferences and circumstances of each person Need to differentiate between occasional drug use and drug dependence (the 20/89 rule) Important gap between need and availability/quality of treatment services – only 1 in 6 people dependent receive treatment worldwide

Session 6.7: Defining the objectives of drug dependence treatment What are the key objectives of drug dependence treatment?

Session 6.7: Defining the objectives of drug dependence treatment Most people do not experience problems with their drug use and do not require treatment! Around 32% of people using tobacco become dependent Around 15% of people using alcohol become dependent Around 23% of people using heroin become dependent Around 15-16% of people using cocaine become dependent Around 11% of people using ATS become dependent Around 8% of people using cannabis become dependent Forcing people into treatment is not effective and constitutes a breach of the human rights of the patient

Session 6.7: Defining the objectives of drug dependence treatment Levels of control vs levels of harm

The objectives of drug treatment: what should we keep in mind? For the individual: achieve and maintain physical, psychological and social well-being through reducing risk-taking associated with drug use, reducing levels of use or complete abstinence (depends on the individual!). Good to provide stepping stones & stabilising strategies in the form of achievable interim goals to help structure progress For the family or community: that the person dependent on drugs is able to integrate and interact positively with those around them For the wider community: reduce health and social problems (rates of accidental death, HIV, hepatitis, drug dependence-related crime)

The objectives of drug treatment: what should we keep in mind? Who is the treatment for? With limited resources, focus on those whose use is most problematic What is the aim of the treatment? Mixture of maximising recovery from dependence and minimising the related crime, health and social problems What mix of interventions/services are needed? Plan for a menu of services and settings, focus on community-based, low-threshold services

Session 6.8: Minimum quality standards for drug dependence treatment UNODC “TREATNET”: comprehensive set of quality standards: Availability and accessibility Screening, assessment, diagnosis and treatment planning Evidence-based treatment Respect for human rights and dignity Targeting special sub-groups Treatment as an alternative to prison and in prison settings Community-based treatment Clinical governance Strategic planning and coordination

Session 6.8: Minimum quality standards for drug dependence treatment European Union minimum quality standards on demand reduction: Accessibility Physical environment (spacing, separate rooms, safety) Diagnosis Staff education and multi-disciplinary composition Assessment procedures Individualised treatment planning Informed consent Written client records Confidentiality of client data Routine cooperation with other agencies

Session 6.8: Minimum quality standards for drug dependence treatment African Union continental minimum quality standards: Complex but treatable Effective treatment attends to several needs of the individual, not just drug use (e.g. medical, social, legal, etc.) Medication often a core element of treatment (e.g. OST) Individual treatment plans must be evaluated and adapted frequently Key role of treatment to reduce social stigma and discrimination

Session 6.9: Key elements of an effective drug dependence treatment programme The tree of effective drug treatment Split into 4 groups Draw a tree with a trunk, roots and branches Roots: Underlying principles of drug dependence treatment Branches: key services needed for a comprehensive drug treatment programme Falling leaves: obstacles to evidence-based treatment

Session 6.9: Key elements of an effective drug dependence treatment programme Treatment methods: A menu of services Detoxification – first stage of drug treatment, often needs to be followed by long-term treatment OST – used to minimise the effects of withdrawal or move the patient to another means of administration Substitution treatment for stimulants – not widely available, but pilot projects ongoing Psychosocial treatment – counselling and other behavioural therapies including peer support Social support and rehabilitation – help people adjust to society and overcome many of the social problems associated with their drug use

Session 6.9: Key elements of an effective drug dependence treatment programme Treatment settings Need to deliver interventions in a range of environments: community based, residential, or in health services (e.g. drop-in centres or harm reduction facilities) Residential treatment – expensive and sometimes use unnecessary or unacceptable practices (too rigid? Coercive or abusive practices? Isolation?) Community-based treatment – more cost-effective, more capacity to deal with more patients, better integrated into health and social support services, make better use of community and family support, more robust reintegration Importance of prison-based treatment, based on the principle of continuity of care

Session 6.9: Key elements of an effective drug dependence treatment programme Respecting human rights and individual choice Any treatment programme must respect human rights and the principle of individual choice to enter treatment Treatment systems must need to be organised to encourage people to accept treatment but should not cross the line into coercion Any programme using torture, cruel and inhuman punishment, humiliation, forced labour, etc. is ineffective and inhumane and cannot be considered as ‘treatment’

Session 6.9: Key elements of an effective drug dependence treatment programme Ensuring cost-effectiveness Treatment is less expensive than alternatives (such as not treating or simply incarcerating PWUD) 1 dollar invested in treatment yields a return of 4 to 7 dollars in reduced drug-related crime, criminal justice costs and theft alone. When savings related to health are included, total savings can exceed costs by a ratio of 12 to 1 Treatment can reduce drug use by 40-60% and decrease criminal activity OST reduces criminal behaviour by as much as 50% among patients, as well as overdose deaths, risks of HIV infection, etc. Treatment improves prospects for employment

Session 6.10: Referrals to treatment: the limits of coercion Split into 4 groups Divide the flipchart paper into 2 in the length of the page, into 2 columns & think of methods to refer PWUD to treatment Accepable referrals/pressure Inacceptable referrals/pressure

Session 6.10: Referrals to treatment: the limits of coercion Self-referral by the individual Identification through general health and social service structures Identification through specialist drug advice centres and outreach services Identification through the criminal justice system (what is the limit of coercion?) Conclusion: any external pressures and conditions applied to people should respect due process, proportionality and the principle of self-determination

The IDPC Drug Policy Advocacy Training Toolkit is available here: http://idpc.net/publications/2013/06/training-toolkit-on-drug-policy-advocacy Contact us at contact@idpc.net