PRINCIPLES OF DRUG DEPENDENCE TREATMENT. part 3

PRINCIPLE 3: EVIDENCE-INFORMED DRUG DEPENDENCE TREATMENT.

Description and Justification -

Evidence-based good practice and accumulated scientific knowledge on the nature of drug dependence should guide interventions and investments in drug dependence treatment. The high quality of standards required for approval of pharmacological or psychosocial interventions in all the other medical disciplines should be applied to the field of drug dependence.

Components -

•  There is a range of evidence-based pharmacological and psychosocial interventions relevant to different stages in the addiction career and treatment process. No single treatment is appropriate for all patients and differentiated and targeted treatment interventions to respond best to the specific needs of each clinical condition. For example, moderate cases may be handled in primary care settings (e.g. general practitioners with relevant training), while more severely affected patients, especially those with co-morbidities, may require multidisciplinary interventions, including psychiatric evaluation and care.

• Sufficient duration. In treating complex chronic diseases and preventing relapse, long-lasting treatment programmes have been found the most effective strategy and may be necessary for the more severe forms of drug dependence. It is therefore key for treatment services to develop approaches to facilitate long term patient retention in treatment.

•  The integration of psychosocial and pharmacological treatment methods can improve the outcome and should be proposed to the patients as part of a comprehensive approach. A holistic treatment orientation, treating the whole person, rather than the addiction only, has been shown to have better results in terms of relapse prevention.

•  Multidisciplinary teams including medical doctors, psychiatrists, psychologists, social workers, counsellors, and nurses can respond best to the needs of patients, also due to the multi-factorial nature of drug dependence. Treatment and care for physical conditions (liver disease, infections, pain, etc) and concomitant psychiatric disorders utilizing both medications and psychosocial interventions may significantly improve the treatment outcomes.

•  Brief interventions. Individuals with experimental and occasional substance use can benefit from screening and brief interventions, which are an effective and economical prevention option, also at the early stages of substance use disorders.

•  Outreach and low-threshold interventions can reach patients not motivated to engage in structured forms of treatment. These interventions offer a comprehensive package of measures to prevent the health and social consequences of drug dependence and have demonstrated effectiveness in preventing the transmission of HIV/AIDS and other blood-borne infections.

•  Basic services offering the essential support to stop or reduce drug use need to be distributed and widely available thorough the territory, including detoxification, psychosocially assisted opioid agonist pharmacotherapy of opioid dependence, counselling, rehabilitation strategies and social support.

•  Medically supervised withdrawal is required for patients who are heavy dependent users of certain substances (such as opioids, sedative/hypnotic substances, and alcohol) and are likely to experience withdrawal complications. Detoxification is a preparatory step to start long lasting drug-free oriented programs.

Maintenance medications with proven efficacy and effectiveness in preventing relapse and stabilizing drug dependent patients are available only for opioid dependence. These medications belong to two main groups: long-acting opioid agonists and antagonists. Opioid agonist pharmacotherapy is one of the most effective treatment options for opioid dependence when methadone or buprenorphine are administered at a individualized dosage for a period of several months to years. Alternatively, a defined group of opioid dependent patients who are detoxified and highly motivated can be prescribed an antagonist medication (naltrexone) as part of continuing relapse prevention treatment.

•  Psychological and social interventions have demonstrated to be effective in rehabilitation and relapse prevention, both in out-patient and residential settings. Psychotherapies such as cognitive behavioural therapy, motivational interviewing and contingency management, have shown promising results. Social support interventions like employment programmes, vocational training and legal advice and support have been demonstrated to be effective in facilitating social inclusion.

•  Self-help support groups complement formal treatment options and can support standardized psychosocial interventions.

•  Socio-cultural relevance. Evidence-based treatment methodologies and strategies need to be adapted to the diverse regional, national and local circumstances, taking into account both cultural and economic factors.

•  Knowledge transfer and ongoing clinical research implemented in different settings and regions is key to permanently improve the treatment programs available to patients.

•  Training of treatment professionals from early on in their careers, including within university curricula and continuing education is essential to disseminate evidence-based methodologies.

Actions to promote this principle -

Ensure that:-

1. available resources are invested in evidence-based interventions

2. a comprehensive treatment system offers a wide range of evidence-based and integrated pharmacological and psychosocial interventions, aimed at treating the whole person. The range includes interventions of diverse intensity, from outreach, low-threshold and brief interventions to long-term, structured treatment
3. the duration of treatment interventions is determined by individual needs, and there are no pre-set limits to the duration of treatment
4. whenever possible, services are staffed by multidisciplinary teams adequately trained in the delivery of evidence-based interventions
5. basic services including detoxification, psychosocially assisted opioid agonist maintenance pharmacotherapy for opioid dependence, counselling, and social support are available thorough the territory
6. more complex cases, including patients with concomitant severe somatic and psychiatric disorders receive adequate care, possibly through referral to specialized services
7. psychosocial interventions have demonstrated to be effective in rehabilitation and relapse prevention, both in out-patient and residential settings, in particular cognitive behavioural therapy, motivational interviewing and contingency management, employment and vocational training, counselling and legal advice.
8. interventions are adapted for relevance to the socio-cultural environment in which they are applied, constantly updated in accordance to research developments and diversified research is conducted in all regions of the world.