1. International perspectives on drug treatment policy
March 2017

2. 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…

3. 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 ONDCP USA figures
All in million Euros, except Australia ($ million AUD); USA $USDm.
UK Other = social protection & gen public service

4. 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

5. 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

6. 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

7. 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).

8. 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

9. 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, doi: /j.addbeh

10. 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

11. Thank-you Professor Alison Ritter
Drug Policy Modelling Program, Director
National Drug and Alcohol Research Centre
UNSW, Sydney, NSW, 2052, Australia E:
T: + 61 (2)
DPMP Website:

12. 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

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

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

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

16. Methods of treatment funding
Foremost method of treatment funding:
Tax-based funding: 37%
Out-of-pocket payment: 25%
Social health insurance: 21%
Other: %
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).