Part Two- Drug Policy and Public Health MODULE 11- REDUCING HARMS FROM SUBSTANCE USE HOW TO DEVELOP A PUBLIC HEALTH PLAN OF ACTION Pan American Health Organization

Learning Objectives Upon completion of this module you will be able to: Conduct a situation assessment at the local level Develop a public health response to substance use problems in your community This module describes how to develop a public health plan of action for reducing harms from substance use at the local and national levels. It is divided into two sections: 1) How to conduct a Situation Assessment at the local level 2) How to develop a public health response Pan American Health Organization

What is Needed to Implement Effective Policies and Programs at National/Local Level An assessment of policy needs from a public health perspective Clear statement of objectives linked to specific policies and programs Organizational capacity/support (qualified staff, funding), NGOs, governments, and other stakeholders Implementation monitoring with objective indicators of progress The following ingredients are needed to develop a plan and implement effective policies and programs at national or local level: An assessment of policy needs from a public health perspective. Such an assessment should contain a clear statement of objectives based on credible supporting data. The objectives should be linked to specific policies and programs. The assessment should also address organizational capacity (such as qualified staff) and funding support or needs), based on information gathered from stakeholders, governments, and other stakeholders in the community, including drug users themselves. Finally, the plan should provide for implementation monitoring with objective indicators of progress, such as percentage reductions in crime, treatment services, HIV infection, violence, and self-reported drug use in school students. These ingredients are typically part of a Rapid Situation Assessment. Pan American Health Organization

Basic Components of a Rapid Situation Assessment Assessment of context Assessment of drug use Assessment of resources Assessment of intervention methods and policies The basic components of a Rapid Situation Assessment are: an assessment of context, an assessment of drug use, an assessment of resources, and an assessment of intervention methods and policies. These components will each be described in detail. Pan American Health Organization

Assessment of Context Impact of structural, social and cultural factors on drug use Risk factors Geographic location, a rapid socioeconomic development, growing unemployment, etc. Protective factors Religion, family, etc. Policy and legislative context Specialized drug policy, criminal justice system, etc. Context refers to the structural, social and cultural factors that have an impact on drug use, and which need to be addressed in any policy response. Context includes both risk factors and protective factors. Risk factors for substance misuse include such factors as geographic location, rapid socioeconomic development and growing unemployment. For example, the favellas of Rio de Janeiro have all of these risk factors, and are locations where drug trafficking, drug availability and drug use are prevalent. Protective factors, on the other hand, are conditions that reduce the likelihood of drug use. A stable neighborhood, strong family ties and religious values are factors that protect children from exposure to drugs. All these factors should be taken into account in a Rapid Situation Assessment of the policy context. An important starting point for any assessment of context are the policy and legislative documents that structure the management of substance-related problems by the government authorities in the community, including specialized drug laws and general health policy documents. Pan American Health Organization

Assessment of Drug Use The nature and extent of drug use The development of its impact and prevalence Social characteristics of users Geographic location Places of drug use The second component of a Rapid Situation Assessment is an evaluation of drug use in the community. This assessment should focus on the following points: The nature and extent of drug use, The long-term and recent trends in its impact and prevalence, Social characteristics of users, and Geographic location of drug use and drug trafficking. Pan American Health Organization

Assessment of Drug Use cont. Review routine records and statistics from treatment programs, primary care clinics, emergency rooms, HIV clinics, criminal justice agencies, etc. Consult hospital records, drug-related death reports, arrests and drug seizure data Conduct surveys or obtain survey data The context of the policy environment and the extent of drug use in the community can be assessed by assembling relevant information from primary and secondary sources. It is first important to ascertain to what extent substance abuse has become problematic, and if so, whether the existing policy structure as adequate to deal with it. Secondary analysis of existing data consists of reviewing routine records and statistics from agencies that provide services to drug abusers: treatment programs, primary care clinics, emergency rooms, HIV clinics, social services, criminal justice agencies. Data collected for other purposes are typically available to the public. These include hospital records, drug-related death reports, arrests and drug seizure data can also be consulted. Often school surveys are available, and in some cases national and regional population surveys have been conducted. Research reports are sometimes available from academic institutions and government agencies including the results of general population (household) surveys and school surveys. Pan American Health Organization

The Value of Epidemiological Population Surveys Epidemiological data collection methods can be used to monitor: Information on drug-specific patterns of use and current use trends. Knowledge of the characteristics of drug use. Perceived effects of substance use on the economy. The emergence of new drugs Epidemiological data collection methods are an extremely valuable basis for planning. They can be used to monitor information on drug-specific patterns of use and current use trends, knowledge of the characteristics of drug use, perceived effects of substance use on the economy and the emergence of new drugs. Pan American Health Organization

Other Secondary Sources Review prescription data Research reports (academic and ad hoc, published and unpublished) including general population (household) surveys, school surveys, etc. Ephemera (including media and newspaper reports, etc.) Qualitative data from key informants and drug users Other existing sources of information should also be consulted. If prescription drug diversion is part of the problem, data can be obtained from prescription and dispensing monitoring systems. Other secondary sources include policy and legislative documents (specialized drug policy, general health policy documents, etc.) and ephemera such as media and newspaper reports. Often it is useful to interview key informants from the various sectors concerned with substance misuse using qualitative methods like focus groups, including the police, public health officials, prison authorities, health care providers, physicians and nurses in emergency departments, mental health professionals, and school officials. Another valuable source of information is drug addicts in treatment centers, in prisons or other correctional institutions. Once all of these data have been assembled, they can be used to develop an assessment report describing the main substance-related problems and issues. Pan American Health Organization

Assessment of Resources Identify existing resources, such as specialized and public aid agencies, funds and qualified personnel who are available to help in the fight against drug abuse. Number of prevention, treatment and rehabilitation programs. Coordination of these activities; financial resources An assessment of the available resources will include the identification of existing resources, such as specialized and public aid agencies, funds and qualified personnel who are available to help in the fight against drug abuse. It will also consider the number of prevention, treatment and rehabilitation programs and the financial resources available for coordination of these activities. Pan American Health Organization

Assessment of Intervention Methods and Policies Statement of objectives A description of the activities that the government or lead agency will pursue to meet these objectives The final component of a Rapid Situation Assessment leading to a plan of action is the assessment of intervention methods and policies. This should begin with a clear statement of objectives. These will flow from the assessment of context, drug problems, and resources. Communities and civil society should be engaged in a discussion on what aspects of the drug problem are of most concern. Priorities might focus on reducing organized crime and violence, the impact of drug use on families and communities, or the transmission of HIV or drug use by students, street children, or indigenous populations. There could be a combination of objectives covering these as well as other priorities. These and other considerations will determine which activities the government or lead agency will pursue to meet the objectives. As reviewed in Modules 5-9 of this course, there is growing evidence worldwide regarding effective and ineffective intervention options, and this evidence can be used to decide which activities and programs would be most effective in achieving their objectives. For example, there is clear evidence of the impact of drug dependence treatment on reducing street crime, and of the effect of harm reduction programs on HIV infections. Clearly, the range and extent of activities will be constrained by available resources. The key messages of the 2001 WHO report on mental health that were adapted and applied to disorders caused by psychoactive drugs can be used to select areas of focus. Other useful sources include PAHO’s Strategy for Substance Abuse Reduction. Pan American Health Organization

Seven Steps for a Comprehensive Plan of Action Provide treatment in primary care Screening and brief intervention Identifying drug users before dependence develops Referring dependent users to specialized care Utilize existing health and social care services This and the next slides provide seven steps for a comprehensive plan of action, based on the global mental health report recommendations of 2001. The first step is to provide treatment in primary care. This refers to the inclusion of screening and brief intervention procedures in primary care settings so that drug users can be identified before they develop drug dependence, and drug users with drug dependence can be referred to specialized treatment. Existing health and social care services are in an excellent position to recognize symptoms of harmful drug use and dependent drug use Pan American Health Organization

Seven Steps for a Comprehensive Plan of Action Make psychotropic medicine available Treat drug-use disorders Treat overdose and withdrawal symptoms The second option for a comprehensive drug strategy is to make psychotropic medicine available for treating drug-use disorders. For opiates, methadone and buprenorphine are part of the WHO essential drug list and can be made affordable. Other psychotropic medicines can be used for treating both overdose and withdrawal symptoms to several commonly used psychoactive drugs. Pan American Health Organization

Seven Steps for a Comprehensive Plan of Action Provide care in the community Community-based ambulatory programs Outreach services The third activity suggested for consideration in any policy reform strategy is to provide care in the community. There is a tendency to favor expensive hospital-based residential programs despite evidence that community-based ambulatory programs are equally effective for most patients. Outreach services should also be part of any comprehensive system of care. Pan American Health Organization

Seven Steps for a Comprehensive Plan of Action Educate the public Use of media or social networks Increase knowledge about drug-use disorders and appropriate service options Increase support for policy reforms and community management of drug users The fourth activity is to educate the public about drug-use disorders and where to find services. A valuable investment of resources is public education through the media or social networks. The more the public knows about drug use disorders and the appropriate service options, the more they will be able to support both policy reforms and the management of drug users in the community. Pan American Health Organization

Seven Steps for a Comprehensive Plan of Action Engage communities, families, and users in program development and policy reform Inclusion of civil society groups Source of information, expertise, and experience Deliver services to support recovering drug users Strengthened political support for appropriate policies Better-informed policy-making Widened support for policy implementation The next activity is to engage communities, families and users in program development and policy reform. The term ‘civil society’ encompasses numerous groups, including people and communities most affected by drug policy such as drug users, people living with HIV, faith groups, and indigenous people and their communities. Civil society groups and organizations can play a key role in all sectors of public policy-making and represent a valuable source of information, experience and expertise. For example, policies and programs designed to reduce the spread of HIV have proved to be most effective when developed in partnership with people and communities most affected by the epidemic. In the field of drug policy, civil society organizations, including those that represent families and drug users, can play a major role in delivering services that support drug users in recovery. Other benefits of engagement with civil society are the strengthening political support for appropriate policies; formulating better-informed policy; widening support for policy implementation. Pan American Health Organization

Seven Steps for a Comprehensive Plan of Action Establish evidence-based policies, programs, and laws Promote health care Provide for harm-reduction services Protect human rights Offer alternatives to prison The sixth activity option is to establish policies, programs and legislation that promote health care, provide for harm reduction services, protect human rights and offer alternatives to prison. Current supply-led drug policies have had little impact on the scale of the global drug market and have led to a number of negative consequences. A shift of focus from criminalizing and punishing drug users to promoting human rights, public health and socio-economic development could bring better results and be more consistent with other areas of social and health policy. Drug laws need to strike a balance between responding to the illegal market and facilitating the delivery of health and social care programs targeted at dependent drug users. Drug laws or their enforcement should be designed so that the delivery of public health (such as efforts to prevent HIV infection) and social reintegration programs (such as drug dependence treatment) are not impeded. New or revised drug laws should draw a clear distinction between the different actors operating in the market, i.e., high-level drug traffickers, drug users, small dealers and couriers. Appropriate responses should be developed for each of these groups. For example, alternatives to imprisonment, such as fines, or referral to treatment and care services, should be designed for low-level drug dealers and dependent drug users.   Pan American Health Organization

Seven Steps for a Comprehensive Plan of Action Develop human resources Creation of a workforce of health care workers who are educated and informed about drug use and the associated problems Use of organizations such as WHO and PAHO The final activity suggested for any policy reform strategy is to develop human resources to create a workforce of health care workers who are educated and informed about drug use and the associated problems. This can be done by taking advantage of the various training opportunities provided by WHO, PAHO and other organizations. Pan American Health Organization

How to Address the Challenges to Implementation Reduce Stigma and Discrimination Respect, protect and promote human rights Build coalitions Develop key messages Educate the community Build support at all levels There will be significant challenges to the successful implementation of any policy response to substance-related problems. The first and most important is the stigma and discrimination against drug users and misperceptions of the public and policy makers of the nature of their problems and effectiveness of various solutions. Respecting, protecting and promoting human rights should be the basis of all the work in health, as health itself is a universal human right. The key ingredients of successful implementation are building community coalitions, developing key messages to the public, educating the community about the nature, extent and need for a public health response to drug problems, and building support at all levels, including government, NGOs, faith groups, health care providers, the criminal justice system and school officials. Pan American Health Organization

FINAL ASSIGNMENT How would you develop a plan of action for your country? How would you develop a plan of action for your country? Pan American Health Organization