1. Contact: michael.schaub@isgf.uzh.ch www.isgf.ch EQUS EQUS Conference - Brussels, June 16, 2011 Michael Schaub, Ambros Uchtenhagen Minimum Quality Standards in the field of Drug Demand Reduction Parallel Session A: Harm Reduction

2. Background information Harm reduction standards with high consensus Harm reduction standards with moderate consensus for discussion Harm reduction standards with low consensus dropped from the list Overview 2

3. BACKGROUND INFORMATION Country comparisons Availability of services 3

4. 4 Western & Southern Europe Austria, Belgium, Cyprus, France, Germany, Greece, Italy, Netherlands, Portugal, Spain, Switzerland Central & Eastern Europe Bulgaria, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia, Slovenia Northern Europe Denmark, Finland, Ireland, Sweden, United Kingdom Subdivision for country comparisons

5. Number completed per region 5 Harm Reduction Western & Southern Europe58 Central & Eastern Europe44 Northern Europe21 Total123

6. Availability of Services 6 Needle and syringe exchangeAll countries Supervised injection rooms *DE, ES, LU, NL, PL, NO, CH Outreach/street workAll countries Pill testing *BE, CZ, ES, FR, IT, NL, AT, PT, SI, UK, CH BBV testing & counselingAll countries VaccinationAll countries ReferralsAll countries Safer use counselingAll countries Safer sex counselingAll countries Sheltered housing *All countries but: BG, EE, RO Note. For the purpose of clarity, on the following slides only n of those services available in every country is displayed; n of the services marked with * is lower; Regional comparisons: for supervised injection rooms and pill testing no significance tests were cal- culated; the significance tests for sheltered housing included only countries, which offer this service

7. HARM REDUCTION Standards with high consensus (more than 80% agreement) 7

8. Structural Standards of Interventions 1. Accessibility: location 8 Evidence: Documents per country:Source: Lit review 11 Expert opinion 10 Expert consensus 8 Research project 11 Practice experience 17

9. Structural Standards of Interventions 1. Accessibility: location 9 n = 147 (service can easily be reached by public transport) - In my opinion, this standard should be a minimal standard in my country…

10. Structural Standards of Interventions 2. Staff qualification: minimum qualification 10 Evidence: Documents per country:Source: Lit review 12 Expert opinion 17 Expert consensus 12 Research project 10 Practice experience 22

11. Structural Standards of Interventions 2. Staff qualification: minimum qualification (e.g. at least half of staff has a diploma in nursing, social work, or psychology) 11 n = 133 - In my opinion, this standard should be a minimal standard in my country…

12. Outcome Standards at the System Level 3. Goal: reduced risk behaviour Evidence: Documents per country:Source: Lit review 25 Expert opinion 25 Expert consensus 25 Research project 15 Practice experience 26 12

13. Outcome Standards at the System Level 3. Goal: reduced risk behaviour n = 133 (reducing unsafe injections, unsafe drug use and unprotected sex) - In my opinion, this standard should be a minimal standard in my country… 13

14. Outcome Standards at the System Level 4. Goal: referrals Evidence: Documents per country:Source: Lit review 17 Expert opinion 19 Expert consensus 16 Research project 11 Practice experience 20 14

15. Outcome Standards at the System Level 4. Goal: referrals n = 130 (treatment services must be prepared to refer clients/patients to other health/social/treatment services if needed and agreed) - In my opinion, this standard should be a minimal standard in my country… 15

16. Outcome Standards at the System Level 5. Internal evaluation Evidence: Documents per country:Source: Lit review 9 Expert opinion 15 Expert consensus 12 Research project 8 Practice experience 11 16

17. Outcome Standards at the System Level 5. Internal evaluation n = 130 (services must regularly perform an internal evaluation of their activities and outcomes) - In my opinion, this standard should be a minimal standard in my country… 17

18. Outcome Standards at the System Level 6. External evaluation Evidence: Documents per country:Source: Lit review 11 Expert opinion 17 Expert consensus 13 Research project 9 Practice experience 11 18

19. Outcome Standards at the System Level 6. External evaluation n = 129 (services must regularly allow an evaluation of their activities and outcomes by an independent external evaluator) - In my opinion, this standard should be a minimal standard in my country… 19

20. Process Standards of Interventions 7. Assessment procedures: risk behaviour Evidence: Documents per country:Source: Lit review 15 Expert opinion 12 Expert consensus 8 Research project 9 Practice experience 15 20

21. Process Standards of Interventions 7. Assessment procedures: risk behaviour n = 125 (clients/patients risk behaviour is assessed) - In my opinion, this standard should be a minimal standard in my country… 21

22. Process Standards of Interventions 8. Informed consent Evidence: Documents per country:Source: Lit review 12 Expert opinion 13 Expert consensus14 Research project 6 Practice experience 11 22

23. Process Standards of Interventions 8. Informed consent n = 124 (clients/patients must receive information on available service options and agree with a proposed regime or plan before starting an intervention) - In my opinion, this standard should be a minimal standard in my country… 23

24. Process Standards of Interventions 9. Confidentiality of client data Evidence: Documents per country:Source: Lit review 18 Expert opinion 17 Expert consensus 17 Research project 10 Practice experience 19 24

25. Process Standards of Interventions 9. Confidentiality of client data n = 124 (client/patient records are confidential and exclusively accessible to staff involved in a clients/patients intervention or regime) - In my opinion, this standard should be a minimal standard in my country… 25

26. Process Standards of Interventions 10. Routine cooperation with other agencies Evidence: Documents per country:Source: Lit review 22 Expert opinion 23 Expert consensus 22 Research project 15 Practice experience 22 26

27. Process Standards of Interventions 10. Routine cooperation with other agencies n = 124 (whenever a service is not equipped to deal with all needs of a given client/patient, an appropriate other service is at hand for referral) - In my opinion, this standard should be a minimal standard in my country… 27

28. Process Standards of Interventions 11. Continued staff training Evidence: Documents per country:Source: Lit review 17 Expert opinion 18 Expert consensus 15 Research project 8 Practice experience 20 28

29. Process Standards of Interventions 11. Continued staff training n = 123 (staff is regularly updated on relevant new knowledge in their field of action) - In my opinion, this standard should be a minimal standard in my country… 29

30. HARM REDUCTION Standards with moderate consensus (50-80% agreement) 30

31. Evidence: 31 Documents per country: Structural Standards of Interventions 1. Accessibility: opening hours Source: Lit review 12 Expert opinion 12 Expert consensus 9 Research project 7 Practice experience 13

32. Structural Standards of Interventions 1. Accessibility: opening hours (adjusted to the needs of clients/patients, e.g. evenings & week-ends) n = 140 32 - In my opinion, this standard should be a minimal standard in my country…

33. Structural Standards of Interventions 1. Accessibility: opening hours (adjusted to the needs of clients/patients, e.g. evenings & week-ends) n = 140 33 - In my country, this standard is…

34. Structural Standards of Interventions 1. Accessibility: opening hours (adjusted to the needs of clients/patients, e.g. evenings & week-ends) 34 n = 61 r = 124 - …feasible, but meets problems – specification

35. Structural Standards of Interventions 1. Accessibility: opening hours (adjusted to the needs of clients/patients, e.g. evenings & week-ends) 35 Overall acceptability: tendency toward more No answer and less Yes-answers from Central & Eastern Europe Referrals: significantly less Yes-answers and more No answer from Central & Eastern Europe Regional differences:

36. Evidence: 36 Documents per country:Source: Lit review 7 Expert opinion 7 Expert consensus 3 Research project 4 Practice experience 10 Structural Standards of Interventions 2. Accessibility: costs to be paid by clients

37. n = 138 (exclusion of costs which limit the accessibility for poor clients/patients) - In my opinion, this standard should be a minimal standard in my country… 37

38. Structural Standards of Interventions 2. Accessibility: costs to be paid by clients n = 138 (exclusion of costs which limit the accessibility for poor clients/patients) - In my country, this standard is… 38

39. Structural Standards of Interventions 2. Accessibility: costs to be paid by clients (exclusion of costs which limit the accessibility for poor clients/patients) n = 37 r = 74 - …feasible, but meets problems – specification 39

40. Structural Standards of Interventions 2. Accessibility: costs to be paid by clients (exclusion of costs which limit the accessibility for poor clients/patients) No significant differences between investigated regions Regional differences: 40

41. Evidence: 41 Documents per country:Source: Lit review 9 Expert opinion 10 Expert consensus 7 Research project 9 Practice experience 8 Structural Standards of Interventions 3. Indication criteria: diagnosis

42. n = 137 (treatment indication is always made on the basis of a diagnosis or, if not possible, a detailed assessment of the current substance use) - In my opinion, this standard should be a minimal standard in my country… 42

43. Structural Standards of Interventions 3. Indication criteria: diagnosis n = 137 (treatment indication is always made on the basis of a diagnosis or, if not possible, a detailed assessment of the current substance use) - In my country, this standard is… 43

44. Structural Standards of Interventions 3. Indication criteria: diagnosis (treatment indication is always made on the basis of a diagnosis or, if not possible, a detailed assessment of the current substance use) - …feasible, but meets problems – specification 44

45. Structural Standards of Interventions 3. Indication criteria: diagnosis (treatment indication is always made on the basis of a diagnosis or, if not possible, a detailed assessment of the current substance use) No significant differences between investigated regions Overall acceptability: tendency towards more Yes- and less No- answers from Northern Europe Regional differences: 45

46. Evidence: 46 Documents per country:Source: Lit review 9 Expert opinion 13 Expert consensus 11 Research project 3 Practice experience 11 Structural Standards of Interventions 4. Indication criteria: age limits

47. (e.g. minimal age required for admittance) n = 135 - In my opinion, this standard should be a minimal standard in my country… 47

48. Structural Standards of Interventions 4. Indication criteria: age limits (e.g. minimal age required for admittance) n = 135 - In my country, this standard is… 48

49. Structural Standards of Interventions 4. Indication criteria: age limits (e.g. minimal age required for admittance) - …feasible, but meets problems – specification 49

50. Structural Standards of Interventions 4. Indication criteria: age limits (e.g. minimal age required for admittance) No significant differences between investigated regions Regional differences: 50

51. Evidence: 51 Documents per country:Source: Lit review 8 Expert opinion 7 Expert consensus 6 Research project 6 Practice experience 14 Structural Standards of Interventions 5. Staff composition: transdisciplinarity

52. n = 133 (e.g. service employs a multidisciplinary team composed of at least 3 professions) - In my opinion, this standard should be a minimal standard in my country… 52

53. Structural Standards of Interventions 5. Staff composition: transdisciplinarity n = 133 (e.g. service employs a multidisciplinary team composed of at least 3 professions) - In my country, this standard is… 53

54. Structural Standards of Interventions 5. Staff composition: transdisciplinarity (e.g. service employs a multidisciplinary team composed of at least 3 professions) n = 45 r = 74 - …feasible, but meets problems – specification 54

55. Structural Standards of Interventions 5. Staff composition: transdisciplinarity (e.g. service employs a multidisciplinary team composed of at least 3 professions) No significant differences between investigated regions Regional differences: 55

56. Evidence: 56 Documents per country: Outcome Standards at the System Level 6. Goal: reduced substance use Source: Lit review 12 Expert opinion 8 Expert consensus 8 Research project 8 Practice experience 13

57. Outcome Standards at the System Level 6. Goal: reduced substance use (reducing unsafe injections, unsafe drug use and unprotected sex) n = 133 - In my opinion, this standard should be a minimal standard in my country… 57

58. Outcome Standards at the System Level 6. Goal: reduced substance use (reducing unsafe injections, unsafe drug use and unprotected sex) n = 133 - In my country, this standard is… 58

59. Outcome Standards at the System Level 6. Goal: reduced substance use (reducing unsafe injections, unsafe drug use and unprotected sex) n = 47 r = 105 - …feasible, but meets problems – specification 59

60. Outcome Standards at the System Level 6. Goal: reduced substance use (reducing unsafe injections, unsafe drug use and unprotected sex) Vaccination: tendency towards less Yes- and more No-answers from Central & Eastern Europe, especially when compared with Northern Europe Sheltered housing: significantly more No answer and less Yes- answers from Central & Eastern Europe Significantly less Already implemented-answers from Central & Eastern Europe, especially when compared with Western & Southern Europe Regional differences: 60

61. Evidence: 61 Documents per country: Outcome Standards at the System Level 7. Cost-effectiveness ratio Source: Lit review 5 Expert opinion 4 Expert consensus 3 Research project 3 Practice experience 2

62. 62 Outcome Standards at the System Level 7. Cost-effectiveness ratio n = 129 (positive outcomes like e.g. number of abstinent clients/patients in relation to service costs) - In my opinion, this standard should be a minimal standard in my country…

63. 63 Outcome Standards at the System Level 7. Cost-effectiveness ratio n = 129 (positive outcomes like e.g. number of abstinent clients/patients in relation to service costs) - In my country, this standard is…

64. 64 Outcome Standards at the System Level 7. Cost-effectiveness ratio (positive outcomes like e.g. number of abstinent clients/patients in relation to service costs) n = 52 r = 85 - …feasible, but meets problems – specification

65. 65 Outcome Standards at the System Level 7. Cost-effectiveness ratio (positive outcomes like e.g. number of abstinent clients/patients in relation to service costs) Overall acceptability: tendency towards less Yes- and more No- answers from Western & Southern Europe, especially when compared to Northern Europe Needle-syringe exchange, safer use counseling, safer sex counseling, sheltered housing: significantly less Yes- and more No-answers from Western & Southern Europe Regional differences:

66. Evidence: 66 Documents per country: Outcome Standards at the System Level 8. Cost-benefit ratio Source: Lit review 3 Expert opinion 3 Expert consensus 3 Research project 3 Practice experience 2

67. Outcome Standards at the System Level 8. Cost-benefit ratio (tangible benefits like e.g. years of increased life expectancy in relation to service costs) n = 128 - In my opinion, this standard should be a minimal standard in my country… 67

68. Outcome Standards at the System Level 8. Cost-benefit ratio (tangible benefits like e.g. years of increased life expectancy in relation to service costs) n = 128 - In my country, this standard is… 68

69. Outcome Standards at the System Level 8. Cost-benefit ratio (tangible benefits like e.g. years of increased life expectancy in relation to service costs) n = 48 r = 78 - …feasible, but meets problems – specification 69

70. Outcome Standards at the System Level 8. Cost-benefit ratio (tangible benefits like e.g. years of increased life expectancy in relation to service costs) Overall acceptability, needle-syringe exchange, outreach/street work, vaccination, referrals, safer use & safer sex counseling, sheltered housing: significantly more No-answers from Western & Southern Europe Significantly more Feasible, but meets problems-answers from Northern Europe Regional differences: 70

71. Evidence: 71 Documents per country: Process Standards of Interventions 9. Assessment procedures: complete needs assessment and priorisation Source: Lit review 9 Expert opinion 11 Expert consensus 9 Research project 8 Practice experience 13

72. Process Standards of Interventions 9. Assessment procedures (1) complete needs assessment and priorisation (e.g. 1. harm reduction of intravenous drug use and, 2. reduction of used syringes in public spaces etc.) 72 n = 127 - In my opinion, this standard should be a minimal standard in my country…

73. Process Standards of Interventions 9. Assessment procedures (1) complete needs assessment and priorisation (e.g. 1. harm reduction of intravenous drug use and, 2. reduction of used syringes in public spaces etc.) 73 n = 127 - In my country, this standard is…

74. Process Standards of Interventions 9. Assessment procedures (1) complete needs assessment and priorisation (e.g. 1. harm reduction of intravenous drug use and, 2. reduction of used syringes in public spaces etc.) 74 n = 36 r = 60 - …feasible, but meets problems – specification

75. Process Standards of Interventions 9. Assessment procedures (1) complete needs assessment and priorisation (e.g. 1. harm reduction of intravenous drug use and, 2. reduction of used syringes in public spaces etc.) 75 Acceptability: no significant differences between investigated regions Significantly more Not feasible at all-answers from Central & Eastern Europe, especially when compared to Western & Southern Europe Regional differences:

76. Evidence: 76 Documents per country: Process Standards of Interventions 10. Assessment procedures: client/patient status Source: Lit review 16 Expert opinion 17 Expert consensus 14 Research project 10 Practice experience 16

77. Process Standards of Interventions 10. Assessment procedures: client/patient status (the clients/patients health status is assessed) n = 126 - In my opinion, this standard should be a minimal standard in my country… 77

78. Process Standards of Interventions 10. Assessment procedures: client/patient status (the clients/patients health status is assessed) n = 126 - In my country, this standard is… 78

79. Process Standards of Interventions 10. Assessment procedures: client/patient status (the clients/patients health status is assessed) n = 32 r = 55 - …feasible, but meets problems – specification 79

80. Process Standards of Interventions 10. Assessment procedures: client/patient status (the clients/patients health status is assessed) Acceptability for vaccination: significantly more Yes- and less No- answers from Western & Southern Europe, especially when compared to Northern Europe Significantly more Not feasible at all-answers from Central & Eastern Europe Regional differences: 80

81. Evidence: 81 Documents per country: Process Standards of Interventions 11. Individualised treatment planning Source: Lit review 13 Expert opinion 15 Expert consensus 10 Research project 9 Practice experience 16

82. 82 Process Standards of Interventions 11. Individualised treatment planning (intervention regime and intervention plans, if applicable, are tailored individually to the needs of the client/patient) n = 125 - In my opinion, this standard should be a minimal standard in my country…

83. 83 Process Standards of Interventions 11. Individualised treatment planning (intervention regime and intervention plans, if applicable, are tailored individually to the needs of the client/patient) n = 125 - In my country, this standard is…

84. 84 Process Standards of Interventions 11. Individualised treatment planning (intervention regime and intervention plans, if applicable, are tailored individually to the needs of the client/patient) n = 42 r = 74 - …feasible, but meets problems – specification

85. 85 Process Standards of Interventions 11. Individualised treatment planning (intervention regime and intervention plans, if applicable, are tailored individually to the needs of the client/patient) No significant differences between investigated countries Regional differences:

86. Evidence: 86 Documents per country: Process Standards of Interventions 12. Written client records Source: Lit review 12 Expert opinion 11 Expert consensus 7 Research project 7 Practice experience 13

87. Process Standards of Interventions 12. Written client records (assessment results, intervention plan, interventions, expected changes and unexpected events are documented complete and up to date for each client/patient in a client/patient record) n = 124 - In my opinion, this standard should be a minimal standard in my country… 87

88. Process Standards of Interventions 12. Written client records (assessment results, intervention plan, interventions, expected changes and unexpected events are documented complete and up to date for each client/patient in a client/patient record) n = 124 - In my country, this standard is… 88

89. Process Standards of Interventions 12. Written client records (assessment results, intervention plan, interventions, expected changes and unexpected events are documented complete and up to date for each client/patient in a client/patient record) n = 32 r = 58 - …feasible, but meets problems – specification 89

90. Process Standards of Interventions 12. Written client records (assessment results, intervention plan, interventions, expected changes and unexpected events are documented complete and up to date for each client/patient in a client/patient record) No significant differences between countries found Referrals: tendency towards less Yes- and more No-answers from Central & Eastern Europe, especially when compared with Northern Europe Regional differences: 90

91. Evidence: 91 Documents per country: Process Standards of Interventions 13. Neighbourhood/community consultation Source: Lit review 9 Expert opinion12 Expert consensus 10 Research project 7 Practice experience 8

92. Process Standards of Interventions 13. Neighbourhood/community consultation (avoiding nuisance and conflict with other people around the service) n = 123 - In my opinion, this standard should be a minimal standard in my country… 92

93. Process Standards of Interventions 13. Neighbourhood/community consultation (avoiding nuisance and conflict with other people around the service) n = 123 - In my country, this standard is… 93

94. Process Standards of Interventions 13. Neighbourhood/community consultation (avoiding nuisance and conflict with other people around the service) n = 42 r = 86 - …feasible, but meets problems – specification 94

95. Process Standards of Interventions 13. Neighbourhood/community consultation (avoiding nuisance and conflict with other people around the service) Acceptability: no significant differences between investigated regions Significantly more Not feasible at all-answers from Central & Eastern Europe Regional differences: 95

96. HARM REDUCTION Standards with low consensus (less than 50% agreement) 96

97. Structural Standards of Interventions 1. Indication criteria: age limits 97 n = 135 (e.g. minimum age required for admittance) - In my opinion, this standard should be a minimal standard in my country…

98. Questions? Discussion Contact: www.isgf.ch 98