Contact: EQUS Contact: EQUS Conference - Brussels, June 15, 2011 Ambros Uchtenhagen, Michael Schaub European quality standards in drug demand reduction: Project Overview

2 The main tasks

1.To establish an expert group 2.To identify, map and review existing quality standards and benchmarks (in prevention, early detection and early intervention, treatment, harm reduction and social rehabilitation) and to provide a gap analysis 3.Set up a consultation and consensus building mechanism 4.To develop a design for a framework of minimal quality standards and benchmarks (structure, key aspects, type and level of specification). This design should also reflect on potential risks, uncertainties and other factors 5.To present options and suggestions for minimal quality standards and benchmarks as a discussion basis between experts and policy makers 6.To prepare for the Commission a final report consisting of options on EU minimum quality standards and benchmarks in the field of drug demand reduction The main tasks of EQUS project 3

4 Prevention –Separate expert group of EU project –Coordinated at John Moore University, Liverpool –Special advisors and consultants Treatment / rehabilitation –European core group –Collaborating partners –International partners (USA, CA, AU) –Coordinated at ISGF, Zurich University Harm reduction –European core group –Special advisors and consultants –International contributions from Kent University The expert group: project partners

5 Inventory of existing quality standards & benchmarks (in Member States and internationally)

3 separate inventories for quality standards in – Prevention interventions and systems – Treatment & rehabilitation interventions, services and systems – Harm reduction interventions, services and systems Identification of relevant documents – Detailed instructions on inclusion and exclusion criteria – Identification of reference documents Establishing national lists of included and excluded documents Extracting contents from included documents – Using prepared structured templates (in English) – No translation of integral documents from national language into English – Supervision by senior scientists Inventories: general procedures 6

In the field of drug prevention, the development of minimum quality standards has taken a different approach. In 2009, the Commission provided funding for a project titled 'European Drug Prevention Quality Standards' This project was carried out by the Prevention Standards Partnership, led by the UK Liverpool John Moores University, and completed in November This project systematically reviewed drug prevention programmes and interventions in the EU and at international level and developed a set of process quality standards in the field of drug prevention. The experience and information produced through this project has been adapted for the development of the EQUS project. See Inventories: drug prevention 7

Include published documents providing information on quality standards on specific interventions, on specific settings of intervention delivery, and of regional / national intervention networks Exclude – unpublished grey literature, documents on local standards and documents without declaration of their origin – standards/guidelines not focusing exclusively on the drugs field (e.g. general standards in health or social care) – International documents if not made relevant at national level Priority is given to - official documents (e.g. by health authorities, professional associations, major service providers, insurances) - research reviews / reports, indicating the grade of evidence for the findings EQUS: document search criteria 8

General descriptors – Template ID: country code, document nr, template nr, author,date – Publication details – Mandating body (stakeholder) – Legal status of document – Methods used for identifying standards and benchmarks Specific descriptors – Specifications of interventions, services, systems – Specific structural, process and outcome standards – Grading of evidence per standard EQUS: template structure 9

A highest degree of evidence: meta-analysis or review of randomised controlled studies (RCT) B very high degree of evidence: review from multiple RTC with convergent results C high degree of evidence; results from single RCT and controlled clinical studies D moderate degree of evidence: prospective comparative longitudinal studies without control design E low degree of evidence: single intervention/service follow-up studies, case studies F very low degree of evidence: non-systematic observations Z not known EQUS: grading of evidence (developed from Atkins 2004) 10

It should be a national document It should have an evidence grade A or B for treatment/rehabilitation, evidence grade A or B or C for harm reduction It should be based on systematic literature search or expert consensus On the basis of these criteria, 29 documents for treatment/rehabilitation and 9 documents for harm reduction were identified as reference documents EQUS: Criteria for reference documents 11

349 relevant documents were included in the electronic masterfile – 259 documents on quality standards for treatment / rehabilitation, from 28 countries – 90 documents on quality standards for harm reduction, from 18 countries The inventory 12

General information – Majority of documents are national and from public origin at all 3 levels, for all interventions and settings – Interventions cover all types of target populations and of substances Specific information – Broad range of structural, process and outcome standards are well covered at all 3 levels – Clear deficit in documents for benchmarks – Basis of standards : expert consensus, expert opinion and literature review prevail on all 3 levels – Interventions : best covered are psychosocial and substitution interventions – Settings : best covered are outpatient services – Limited availability of evidence grades across all standards and levels Main findings from inventory: Treatment / rehabilitation 13

General information – Majority of documents at national level and of public origin – Broad range of interventions, of target populations and of substances is covered, but few documents only for safe injection rooms and pill testing – Settings: few documents on office-based, pharmacy-based and club- based interventions Specific information – Structural, process and outcome standards are covered at all 3 levels – Overall limited availability of evidence grades, but frequent indication of recommended or mandatory standards Main findings from inventory: harm reduction 14

15 Model-design for a framework of EU minimal quality standards

Types of quality standards 16 Level 1: interventions Level 2: services Level 3: systems Structural standards Setting standards Resource standards Legal/ethical adequacy standards Process standards Implementation standards Procedural standards Cooperation / networking standards Outcome standards Effectivity standards Effectiveness standards Coverage standards Benchmarks Cost-benefit ratioCost-utilisation ratio Cost- effectiveness ratio

Counselling and early interventions Psychosocial interventions Substitution maintenance Heroin-assisted treatment Detoxification Vocational rehabilitation Other rehabilitation Level 1: Treatment interventions 17

Needle exchange program Supervised injection room Outreach work / street work Pill testing Blood borne virus infection testing Vaccination Referral to other services if needed Safer sex education Safer use education Sheltered housing Level 1: Harm reduction interventions 18

For treatment/rehabilitation Out-patient services for ambulatory treatment In-patient services for residential treatment Prison-based services for intramural treatment Office-based services for treatment in private practice Teams specialised in addiction treatment Teams not specialised in addiction treatment For harm reduction Same as those in treatment / rehabilitation Additional categories are pharmacies and clubs Level 2: Types of services 19

Prepare comprehensive lists of available quality standards from inventory (separate for structural, process and outcome standards, for treatment/rehabilitation and harm reduction) Identify degree of consensus through stakeholder surveys Information basis provided to stakeholders – List of countries mentioning each standard in how many documents – For each standard the number of documents labelling it as mandatory – Source of each standard – Evidence grade for each standard Minimum quality standards are identified through high level of consensus in stakeholder surveys (>80%) How to identify minimum quality standards 20

Main gaps of quality standards in inventory 21 Level 1: interventions Level 2: services Level 3: systems Structural standards Setting standards Resource standards Legal/ethical adequacy standards Process standards Implementation standards Procedural standards Cooperation / networking standards Outcome standards Effectivity standards Effectiveness standards Coverage standards Benchmarks Cost-benefit ratioCost-utilisation ratio Cost- effectiveness ratio

22 Framework for a consultation & consensus building mechanism

Stakeholder survey: –Definition of stakeholders to be involved in the consensus building process –Results of stakeholder and expert consultation (including perceived obstacles, resource implications, legal implications) Proposals for next steps –Detailed gap analysis for the research agenda –Recommendations for future updating of standards Implementation by National Authorities. –Identification and discussion of implementation obstacles –Options for implementation strategies (local / regional conferences, interactive internet consultations, guidance and incentives for services) Consensus building process 23