PRINCIPLES OF DRUG DEPENDENCE TREATMENT.

This paper outlines nine key principles for the development of services for the treatment of drug use disorders. It is recognized that in some circumstances resources will be rather limited and priorities in resource allocation need to be set. It is important that in such situations, a response to drug use disorders is developed as “building blocks” on which more diverse and sophisticated interventions can be developed and incorporated in the treatment system as further resources become available. Depending on human and financial resources available and the quality level of the existing health system in each country, the actions suggested by the present document may be progressively and gradually implemented, taking into account the outlined components for each principle as a general framework.

PRINCIPLE 1: AVAILABILITY AND ACCESSIBILITY OF DRUG DEPENDENCE TREATMENT.

Description and Justification

Drug dependence and it's associated social and health problems can be treated effectively in the majority of cases if people have access to a continuum of available and affordable treatment and rehabilitation services in a timely manner. To this end, all barriers limiting accessibility to treatment services need to be minimized for people to have access to the treatment that best fits their needs.

Components

Many factors contribute to treatment accessibility:

1. Geographical accessibility, distribution, and linkages.

• Health care system and public health networks, in cooperation with social services and the broader community, can provide essential prevention and treatment services and support for people with drug use disorders in their communities. Social services and other institutions (e.g. schools, civil society organizations, and self-help groups) can serve as points of the first contact for potential patients and help them access treatment.
• In a comprehensive treatment system a large scale, distributed network of treatment facilities that can respond to various needs of individuals seeking treatment permits an adequate response in each community.
• The basic prevention and treatment services for drug use disorders need to be within the reach of people with different levels of income.
• Within a continuum of care, people with drug dependence should have access to treatment services through multiple entry points.
• Outreach services, as part of a continuum of care, are needed to reach the ‘hidden’ populations most affected by drug use, often non-motivated to treatment or relapsing after a treatment program. Outreach services are particularly important to attract problematic drug users early and to establish contact with the population of people with severe disorders who may not seek treatment because of stigma and marginalization.

2.Timeliness and flexibility of opening hours. Same-day admission or short waiting time for structured services, as well as a provision of immediate intermediate services, including patient information. A wide range of opening hours will facilitate access to services for individuals with employment or family responsibilities.

3.Legal framework. Requirements to register drug addicts in official records, if associated with the risk of sanctions, may discourage patients from attending treatment programmes, thus reducing accessibility.

4.Availability of low threshold services. Flexibility in the organization of treatment services will improve access by a larger range of individuals in need. This includes the availability of services with a low threshold for patient admission and the removal of unnecessarily selective criteria.

5.Affordability. Payment for treatment and rehabilitation services may constitute a significant barrier for patients in many cases without sources of income. Insurance coverage or inclusion of drug dependence care in the public health care system is therefore key to promote access for those most in need.

6.Cultural relevance and user-friendliness. Current knowledge indicates that a treatment climate that is culturally sensitive, preferably multi-professional, team orientated, and that encourages patient participation and involvement in treatment facilitates patient access and retention in treatment, and ultimately improved treatment outcomes.

7.Responsiveness to multiple needs and diversification of settings. The availability of specialized services and residential settings to care for the more complex cases, e.g., patients with drug dependence and associated somatic or psychiatric disorders is essential to increase accessibility.

8. Criminal justice system responses play a significant role in improving access for individuals affected by drug dependence to treatment services: law enforcement officials, courts and prisons may closely collaborate with the health system to encourage drug-dependent individuals to enter treatment.

9.Gender-sensitiveness of services. Services tailored to gender-specific treatment needs can improve accessibility by responding to differential stigmatization, child care needs, and issues in pregnancy.

Actions to promote this principle

Ensure that:
1. the system of services permeates both urban and rural areas and builds upon the primary health care system. Key components include proactive outreach, low-threshold, early identification and brief intervention in primary health and social care services, basic drug dependence treatment services, and referral to treatment services from the criminal justice system.
2. legal frameworks guarantee protection from potential sanctions for those seeking treatment.
3. there are a functional referral and counter-referral mechanisms between different services in the system as well as to and from other agencies, facilitating a continuum of care.
4. the number of people on waiting lists and waiting times are minimized, and that intermediate responses are available.
5. staff attitudes are welcoming and non-judgmental.
6. services take into account and respect cultural norms.
7. patients’ perspectives are taken into account in service design and development.
8. eventual service costs to patients are affordable and waved if necessary.
9. services for women in primary health care and facilities for children of parents with drug dependence are built in close relationship with drug dependence treatment programs.