1. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO: Normative guidance on and quality standards in drug demand reduction Dr Vladimir Poznyak Coordinator, Management of Substance Abuse Department of Mental Health and Substance Abuse

2. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Outline WHO and its core functions Examples of WHO guidelines/technical standards and requirements for their development WHO guidelines and quality standards on drug demand reduction Implementation and evaluation Recent developments and future plans

3. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO: three levels of operations

4. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO Core Functions 1.Providing leadership on matters critical to health and engaging in partnerships where joint action is needed (Leadership & Partnerships) 2.Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge (Research agenda & Knowledge management) 3.Setting norms and standards, and promoting and monitoring their implementation (Norms & Standards) 4.Articulating ethical and evidence-based policy options (Ethical and evidence-based policy) 5.Providing technical support, catalyzing change, and building sustainable institutional capacity (Technical support, Change & Capacity) 6.Monitoring the health situation and assessing health trends (Monitoring health)

5. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Examples of WHO standards in Public Health and Health Care Provision

6. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Examples of WHO Normative Guidance and Technical Tools on Drug Demand and Harm Reduction

7. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO Policy Frameworks for Norms and Standards related to Substance Use and Demand Reduction

8. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO HIV/AIDS 2011-2015 strategy and technical guides on HIV prevention, treatment and care for IDUs

9. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO Expert Committees on Drug Dependence (28 th and 30 th Reports, 1993,1998) Addressing the concepts of primary, secondary and tertiary prevention as well as harm reduction Definition and objectives of "treatment" in the context of drug demand reduction Principles of interventions and the management of drug-related conditions Quality assurance in treatment and monitoring of services

10. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Schedules for the assessment of standards of care in substance abuse treatment (WHO, 1993) A.Standards on access, availability and admission criteria B.Standards on Assessment C.Standards on Treatment Content, Provision, and Organization D.Standards on Discharge, Aftercare and Referral E.Standards on Outreach and Early Intervention F.Standards on Patient's Rights G.Standards on Physical Aspects of the Treatment Setting H.Standards on Staffing

11. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Standards in substance abuse treatment and grading of meeting them (WHO, 1993) Types of standards –Essential (E) –Advisable (ADV) –Not Indicated (NI) Grading of meeting the standard requirements –Adequately met (AM) –Inadequately met (IM) –Not met at all (NM) Invited suggestions on how to rectify the situation

12. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO regulations for guideline development (last update in 2010)

13. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Steps in developing WHO recommendations Guideline Development Group (GDG) Scoping documentsScoping questionsEvidence profiles Evidence, values, preferences and feasibility profiles Recommendations

14. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Quality of the Evidence Five factors should be considered: limitations, inconsistency, indirectness, imprecision, reporting bias Quality assessment No of studiesDesignLimitationsInconsistencyIndirectnessImprecisionOther Outcome 1 0

15. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Formulating WHO recommendations SUMMARY OF FINDINGS VALUES, PREFERENCES QUALITY FEASIBILITY ISSUES Recommendation and strength WHO reference documents, other sources including GDG input, WHO experience (explicitly stated and recorded)

16. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Categories of recommendation Strong Standard

17. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | UN ECOSOC (Economic and Social Council) Resolution (2004) "Invites the World Health Organization, in collaboration with the United Nations Office on Drugs and Crime, …to develop and publish minimum requirements and international guidelines on psychosocially assisted pharmacological treatment of persons dependent on opioids, taking into account regional initiatives in this field, in order to assist the Member States concerned" World Health Organization

18. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO Guidelines on pharmacotherapy of opioid dependence (WHO, 2009): selected system level recommendations Treatment of opioid dependence should be provided in the health care system There should be a treatment strategy / policy framework Psychosocially assisted pharmacological treatment should not be compulsory Treatment should be accessible to all those in need, including those in prison and other closed settings Essential pharmacological treatment consists of opioid agonist maintenance treatment and services for the management of opioid withdrawal

19. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Minimal requirements/standards in WHO Guidelines on pharmacotherapy of opioid dependence: minimal recommendations are suggested for adoption in all settings as a minimum standard; these should be considered the minimal requirements for the provision of treatment of opioid dependence best practice recommendations represent preferred strategies for achieving the optimal public health benefit in the provision of treatment for opioid dependence.

20. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Example of WHO recommendations for treatment programs for opioid dependence

21. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Example of WHO recommendations for pharmacotherapy options for opioid dependence

23. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO/UNODC Discussion Paper Principles of Drug Dependence Treatment (2008) Nine principles with: Description and justification Components Actions to promote the principle Components and actions to promote the principles are indicative of (minimal) requirements and standards for treatment

25. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels |

26. | Steps for implementation a WHO guideline Analyse local needs and priorities (look for additional data on actual practice) Identify all potential barriers and facilitating factors Determine available resources Design a strategy to support the adoption of recommendations and the make the overall context favorable to the proposed changes

27. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Evaluation of a WHO guideline The guideline should include parameters or outcome measures that can be monitored for the main recommendations. Ideally there should be baseline measures against which to assess performance in relation to the targets of change of the recommendations. Follow-up measurements can be taken once the guideline is implemented.

28. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | ATLAS on Substance Use Resources for prevention and treatment of substance use disorders (WHO, 2010) Based on results of the questionnaire survey of focal points identified in WHO Member States Information collected from 147 countries all over the world that represent 88% of the world population

29. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Availability of Guidelines on Pharmacological Treatment of Substance Use Disorders (WHO, 2010)

30. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | mhGAP Guidelines WHO mhGAP Evidence Resource Centre by priority conditions Intervention Guide Advocacy /information documents Policy/ planning documents Adaptation/ training material Journal publications Monitoring/ Evaluation tool Presentation and Dissemination Plan for mhGAP Guidelines

32. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Recent developments and future plans WHO training packages for: –mhGAP priority conditions, including Drug Use Disorders –Treatment of opioid dependence –Screening and brief interventions for substance use based on WHO ASSIST package. WHO guidelines on identification and management of substance use and Substance Use Disorders in pregnancy (including tobacco). Continued implementation of the WHO/UNODC Joint Programme on Drug Dependence Treatment and Care in selected low and middle income countries Further development of discussion papers produced in collaboration with UNODC – Principles of drug dependence treatment Position papers Development of international standards for primary prevention of drug use and drug use disorders (CICAD with involvement of WHO, EMCDDA, PAHO)

33. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Recent developments in normative guidance on demand reduction and future plans at global level WHO training packages for: –mhGAP priority conditions, including Drug Use Disorders –Treatment of opioid dependence –Screening and brief interventions for substance use based on WHO ASSIST package. Continued implementation of the WHO/UNODC Joint Programme on Drug Dependence Treatment and Care in selected low and middle income countries Monitoring prevention and treatment resources for substance use disorders –Global Information System based on the ATLAS-SU data collection tools (ATLAS-SU report), in collaboration with EMCDDA WHO guidelines on identification and management of substance use and Substance Use Disorders in pregnancy (including tobacco) Further development of discussion papers produced in collaboration with UNODC –Position papers with potential implications for standards/requirements Assessment of treatment systems for SUD (WHO SAIMS project) Development of international standards for primary prevention of drug use and drug use disorders (CICAD with involvement of WHO, EMCDDA, PAHO)

34. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | Some challenges in addressing demand reduction international standards Multisectoral scope of demand reduction systems often beyond the reach of governmental or professional regulations Huge differences in resources available for demand reduction in the countries Addressing different levels of health care –Primary health care as an important provider of demand reduction interventions –Secondary and tertiary levels of health care Differences in policy frameworks Issue of effectiveness and cost-effectiveness of programs and interventions Implementation, monitoring and evaluation

35. Building an EU consensus for minimum quality standards 15-17 June 2011, Brussels | WHO Department of Mental Health and Substance Abuse Management of Substance Abuse http://www.who.int/substance_abuse/