Topic : Treatment – October 2020
The Civil Society Forum on Drugs in the EU (the ‘CSFD’) welcomes the opportunity to contribute with this submission to the 3rd intersessional meeting of the 63rd session of the Commission on Narcotic Drugs (CND), which took place from 19 to 21 October 2020. This contribution will focus on Thematic session 1 and, in particular, on the topic of treatment.
The information contained in this submission has been sourced in from the experience and research of CSFD members that have worked for years in the field of treatment. While the submission inevitably reflects a European perspective, the recommendations aim to have a global scope, as all people are equally entitled to the right to health, and to evidence-based treatment interventions.
Promote the public health perspective
Drug dependence should be conceived as a public health problem and, as such, it should be embedded in the health structures and responses. The UNGASS 2016 document, which states that addiction is basically and foremost a public health issue, was signed by all 193 member states of the UN. Nevertheless, for the majority of the countries that signed the UNGASS 2016 document, treatment remains the prerogative of the justice system and thus depends of the Ministry of Justice or that of Homeland Security.
Drug dependence and other addictive disorders are a matter of public health, and drug- related services should be therefore considered essential and on par with other public healthcare services. Ensuring the continuity of treatment services is particularly needed in times of COVID. However, health systems initially regarded as solid have not been able to provide professionals with basic equipment and support, and some countries have even stopped funding services for people who use drugs. Moreover, CSFD members reported that harm reduction services that had been operating for decades in various countries of the EU were compelled to close down.
Additionally, considering drug dependence from a public health perspective will support efforts to eliminate stigma, which constitutes one of the biggest obstacles for entering and adhering to treatment, particularly amongst women.
We call on the EU to urge UN Member States to treat drug dependence under the public health perspective and to acknowledge these services as essential and put them on par with other public healthcare services.
Need to assess the magnitude of the problem and provide sufficient resources
The COVID pandemic has underlined the necessity and the shortage in many countries of a widespread and available network of services for people who use drugs. To ensure that drug treatment will not continue to fall short of the needs in the near future, it is imperative to have a clear picture of the magnitude of the problem. Public authorities should not only take into account the most problematic profile of users but they also should widen the scope of treatment programmes and accurately estimate the treatment needs of people whose profiles are usually not considered. A clearer picture should lead to higher funding from national budgets, which would support offering additional vacancies and help reduce the waiting lists (which in some cases can go up to ten months).
During this decade there have been remarkable improvements in the design of treatment programmes, which are nowadays more complete and integrate more psychosocial aspects. Nevertheless, these are scarcely funded, which results in a problematic implementation.
Furthermore, in view of the economic crisis, governments are now inclined to develop services that are cheaper, although not always as professionalized and with the same level of quality. Treatment programmes should continue to be based on technical criteria. Decision-makers need to be convinced of the necessity to implement high-quality treatment services (outpatient and residential), and to provide the funding required to operate them.
We urge the EU to call on UN Member States to carry out realistic assessments of the need for treatment, taking into account the necessities of all profiles of users. More funding should be allocated for the provision of treatment services, where the quality of treatment should be prioritized.
Need to strengthen the continuum of care logic
Many treatment services are delivered by professionalized civil society groups. While there are remarkable differences between countries, the organizations that provide these evidence-based services should be integrated into each country’s healthcare system with the aim of improving the quality of services. This is key to ensuring the ongoing quality of treatment programmes.
Treatment services should be an integral part of the continuum of care in any national health system as part of their mission to help people to improve their quality of life (with an emphasis on health). In some countries, the reality is that certain treatment modalities, such as professionalized therapeutic communities are sometimes marginalized and undervalued. This needs to change.
Furthermore, treatment interventions may precede or be followed by other processes, including harm reduction programmes, and reintegration services, across a continuum of care. For this reason, it is essential to implement a coordinated networking system between the different resources involved. In addition, it is also necessary to coordinate with other parties involved (justice system, employment bureaus, housing and health services, support services for victims of abuse, gender-based violence, etc.) in order to establish an appropriate technical coordination with these networks.
Isolating harm reduction and drug treatment services from each other is an artificial approach that in some cases can be counterproductive, and that is derived in part from the HIV control model implemented years ago. In reality, people who use drugs need a continuum of care that monitors their health status (including the control of infectious diseases), but that is based on the respect of their mental health, quality of life and human rights. All of these areas are united within each individual and should all be interconnected. The split between harm reduction services and drug treatment services also stands in the way of offering effective drug treatment. When examining solid examples such as those in the Netherlands, we can conclude that drug treatment also includes a continuum of methods, and means to control drug dependence and achieve abstinence can occupy different positions on this continuum. The needs of each individual are different, depending on their situations, levels of substance use, and motivation. While harm reduction services endeavour to mitigate the risks that arise from drug use (including the transmission of HIV and other diseases), detoxification and rehabilitation objectives are typically left out. In addition, since drug treatment programmes are often considered as being solely abstinence-oriented, they are not included in the World Health Organization’s Harm Reduction package[i].
Opioid substitution therapy
Regarding opioid substitution therapy and other evidence-based drug-dependence treatment, guidance from UNODC, UNAIDS, WHO, INPUD[ii] and other partners emphasises that it can lead to improved health and well-being among people who use drugs; and emphasises the following four principles:
- Retention in therapy: The use of illegal drugs while in OST should never be a reason for excluding a client from the programme. This could indicate the need for a clinical adjustment of the treatment. However, the medication dosage must never be adjusted as a reward or punishment.
- Safety: The OST programme should ensure the safety of clients and staff and medications should be kept in a secure location at all times. Clear information should be given to clients on the rules and regulations within the centre.
- Openness and flexibility: Rules and regulations surrounding entry and retention in OST should not be overly burdensome for clients. Long waiting times, limited dispensing hours and compulsory urine testing are not recommended. Offering same-day treatment upon registration is a good practice.
- Respect: High-quality care that is non-stigmatizing and non-discriminatory is a cornerstone of effective and principled treatment.
Recovery is an important concept regarding the treatment of drug dependence. It means not merely reducing or eliminating the use of drugs, it also translates into becoming an active member of society[iii]. It is important to strengthen each individual’s “recovery capital”, understood as the sum of internal and external resources that can be drawn to start and sustain recovery[iv]. The treatment process enables individuals to recover and strengthen the various skills and abilities that form their ‘recovery capital’ at many levels. Each person’s emotional skills are especially addressed, as well as their social capital, and the impact of recovery on their relationships and social groups. Lastly, collective recovery capital is also considered, including the impact of recovery in the social context, especially cost/benefit balance[v].
In the last ten years, several research studies have focused on the relevance of recovery (fundamentally, recovery capital and social recovery) as the basis of treatment for addictive behaviours. However, these studies utilise general intervention designs, without considering individual situations and special needs. The evolution of recovery- oriented programmes up to present interventions has been heterogeneous in model, techniques, and perspectives[vi].
The COVID pandemic has resulted in higher unemployment which will make even more difficult for clients to achieve social reintegration. Treatment organizations therefore, should diligently and methodically redesign their re-entry programmes to adapt to this new reality. At the same time, political pressure must be applied to request the passing of laws that make it easier for people to reintegrate upon completion of treatment.
Indeed, recovery perspectives should be included in national healthcare systems. It is crucial to invest in research that takes into account the particularities of drug dependence and the essential factors of recovery and to design recovery-oriented programmes to ensure greater effectiveness of treatment programmes.
We urge the EU to call on UN Member States to fully integrate organizations that provide evidence-based treatment into each country health-care systems.
The continuum of care logic between drug-related services (prevention, harm reduction and reintegration services) should be strengthened and better coordinated with other health and social services. Particular efforts should be made to bridge the gap between treatment and harm reduction services in order to ensure more effective interventions. We recommend to call for the respect of the four main principles in the provision of opioid substitution therapy. Last but not least, we recommend to include the recovery perspective in national healthcare system and to promote recovery-oriented research.
Need to take into account all profiles of users
There is a clear need to advance in the design and implementation of programmes for drug dependence for all profiles of users. For instance, while, treatment programmes for adult opioids users are more or less ensured in Europe, little advancement has been made concerning the design and implementation of programmes for people with different profiles of drug dependence. According to the EMCDDA, the complexity of the drug market makes it more and more difficult to address the different patterns of use, especially with the poly drug use becoming commonplace, especially among youngsters[vii]. This should be reflected in treatment modalities and programmes.
Furthermore, outreach programmes’ availability has increased significantly in the last decade but it has targeted the same profiles, i.e. opioids users, cocaine users, or people with dual pathology, among others. There is lack of adaptation to different profiles. Undoubtedly additional research is very much needed.
Treatment programmes targeting a wide range of users’ profiles should be researched, developed and implemented, including such profiles as:
- Young people and their families
- Chronic users
- Homeless people
- Aging population
- Women (including particular services for women with dependent children, women who experience gender-based violence, etc.)
- LGBTQI+ community
- People with disabilities
- Migrants and refugees
In the past, these collectives had been left aside because no treatment programme was offered to them or because they had dropped due to the inadequacy of programmes.
Transversal aspects of treatment
Needless to say, all programmes should be evidence-based, and put the people at the centre of interventions. It is imperative to involve people in treatment in the design and implementation of the process. If a successful recovery is to be achieved, it is essential that each individual be respected in their dignity as a human being, and that they be not passive recipients of treatment, but a protagonist of their own therapeutic programme.
Moreover, treatment programmes should include an intersectional perspective (taking into account different race, gender, sexual orientation, etc.) as well as a gender perspective. There is much work to be done to mainstream the gender perspective in all areas of treatment programmes (irrespective of their being mixed or gender-specific). Women are much less likely to enter or adhere to programmes that do not respect or take women’s needs into account. Concrete ways of achieving include updating the design of programmes, ensuring that treatment infrastructures guarantee the security and privacy of women, and implementing therapeutic activities that address gender-based needs effectively[viii].
Another quite innovative perspective is the children’s rights perspective in treatment programs. In other words, how children’s rights are affected by the provision of drug related services to their parents, and the crucial role they play in the recovery process and the implementation of these services.
This would require professional teams to be trained in general perspectives (intersectional, gender, children’s rights, etc.) and in specificities of intervention (mental health, gender, gerontology, etc.)
Moreover, there is a pressing need for better evaluation and monitoring that translate into the ongoing improvement of treatment programs. Private providers, generally less monitored than their public counterparts, should be similarly assessed.
We recommend that the EU calls for greater research, design and implementation of treatment programs aiming to target a wide range of users’ profiles, particularly those who have not been given a great deal of attention until now.
Evidence-based and person-centred treatment and the involvement of people in treatment should be the founding basis of treatment services. Furthermore, intersectorial, gender and children right’s perspectives should be transversally implemented by trained professionals in treatment. In order to improve treatment services, the EU should encourage and call for greater evaluation and monitoring.
Ensure treatment in prison settings
As pointed out by the European Monitoring Centre for Drugs and Drug Addictions “encouraging drug-dependent offenders to engage with treatment can be an appropriate alternative to imprisonment”[ix]. WHO further states that countries should affirm and strengthen the principle of providing treatment, education and rehabilitation as an alternative to conviction and punishment for drug related offences[x]. Moreover, in light of the COVID situation, alternatives measures to imprisonment should be incremented in order to reduce overcrowding and more resources should be invested to ensure a better coordination of the continuum of care[xi].
In prison, two important principles should be respected. Firstly, the equivalence of care, which entails that prison settings should offer basic prevention, treatment and harm reduction services that have proved effective in improving self-care and reducing recidivism. On that basis, countries should ensure that evidence-based treatments, including OST and other pharmacological treatments are provided in prison settings. Currently, only fifty-four countries across the world provide OST for people with drug dependence in prison[xii].
Secondly, continuity of care between community and prison upon admission and after release is key to ensuring the effectiveness of prison-based drug treatment programmes. Technical Guidance from the Global Fund to Fight AIDS, TB and Malaria states that people dependent on opioids should be supported upon release from prison as they are at particularly high risk of HIV and overdose, in the weeks following their release. In preparation for release they should be linked with peer- led civil-society organisations that can offer trusted support to people with a history of drug use. All prisoners, including people receiving OST and people with a history of injecting drugs should be given information on the risk of overdose after a period of reduced use or abstinence from opioids[xiii].
We call on the EU to promote evidence-based and genuinely voluntary treatment within the framework of alternatives to incarceration, provided it is appropriate under medical criteria, and dispensed by professional staff.
Moreover, the EU should point to the obligation to respect the principle of equivalence of care in prisons, by calling on Member States to ensure evidence- based treatments, including OST and other pharmacological treatments in prison. Additionally, continuity of care after release must be ensured to reduce the risk of overdose, and to increase the effectiveness of prison-based drug treatment programmes.
Lessons learned from COVID
The emergence of COVID poses a huge challenge for the continuity of treatment services, which have to implement new safety, treatment, and admission protocols. The field of treatment has been particularly innovative. As identified by EMCDDA’s European Drug Report, the innovations include introducing more flexibility in substitution treatment prescribing, and greater use of e-health, amongst others. The flexibility of prescription has been acknowledged and welcomed by people using the services and has even resulted in the request to preserve and expand it in the future[xiv]. We recommend that the impact of those changes in treatment delivery, and for the people who use those services, is monitored and evaluated, and we request to proceed to change the intervention modalities according to evidence. In any case, the guidelines should always guarantee the safety in take-home prescriptions for people with drug dependence, avoid unsafe storage of medications, and at the same time prevent diversions.
In addition, access to treatment can play an important role in COVID prevention. A recent study from Norway shows that people who use drugs who are in treatment are much more likely to know about symptoms of COVID, and are more familiar with Covid-19 services[xv].
We call on the EU to promote the monitoring and evaluation of new practices in the field of treatment, as they have emerged due to the irruption of COVID, and to commit to adapt those intervention modalities according to evidence.
All in all, treatment is not considered a priority in the international and national political agendas. And it should be. As noted by the 2019 Ministerial Declaration, treatment services are falling short of meeting expectations and needs. And meeting these needs does not solely mean to provide accommodation places in treatment programmes, but also to adapt these programmes to people’s specific profiles and to respond to new trends with evidence-based interventions. Programmes should be improved on an ongoing basis and enrol professionals capable of working with a broad perspective of recovery that connect all social and health services, under the overall perspective of public health, with treatment services fully integrated in national healthcare networks. Research, innovation, funding and political will could prove decisive in improving and strengthening treatment services. Treatment should definitely be in the political agenda.
We call on the EU to include treatment aspects in the EU and international drug political agenda.
The Civil Society Forum on Drugs in the EU (CSFD) is an expert group of the European Commission that was created in 2007 on the basis of the Commission Green Paper on the role of civil society in drugs policy in the EU. Its purpose is to provide a broad platform for a structured dialogue between the Commission and European civil society which supports drug policy formulation and implementation through practical advice. The CSFD is consistent with the EU Strategy on Drugs 2013-2020 and the new Action Plan on Drugs 2017-2020 both of which require the active and meaningful participation and involvement of civil society in the development and implementation of drug policies at national, EU and international level. Its membership comprises 45 CSOs from across Europe and representing a variety of fields of drug policy, and a variety of stances within those fields. Below is the list of CSFD members for the period 2018-2020:
- ABD – Associació Benestar i
- AFEW International
- Ana Liffey Drug Project
- APDES – Agência Piaget para o Desenvolvimento
- APH – Association Proyecto Hombre
- ARAS – Romanian Association Against AIDS
- Citywide Drugs Crisis Compaign
- De Regenboog Groep
- Dianova International
- Diogenis Drug Policy Dialogue
- EAPC – European Association for Palliative Care
- EATG – European AIDS Treatment Group
- ECAD – European Cities Network for Drug Free Societies
- EFSU – European Forum for Urban Security
- EuroTC – European Treatment Centres for Drug Addiction
- EUSPR – European Society for Prevention Research
- FAD – Fundación de Ayuda contra la Drogadicción
- Federation Addiction
- FEDITO BXL
- Forum Droghe
- FUNDACIÓN ATENEA
- GAT – Grupo de Ativistas em Tratamentos
- HRI – Harm Reduction International
- IDPC – International Drug Policy Consortium
- INPUD – International Network of People who use Drugs
- IREFREA – Instituto Europeo de Estudios en Prevención
- MAT – Magyar Addiktológiai Társaság
- Médicos del Mundo España
- PARSEC Consortium
- Polish Drug Policy Network
- Prekursor Foundation for Social Policy
- Proslavi Oporavak
- Romanian Harm Reduction Network
- Rights Reporter Foundation
- San Patrignano
- SDF – Scottish Drugs Forum
- WFAD – World Federation Against Drugs
- YODA – Youth Organisations for Drug Action
 Scottish NGO “We Are with You” conducted in August 2020 an informative survey of their clients and there was overwhelming feedback from people on OST about the benefits of the new flexible arrangements. 70% did not want to go back to the old style restrictive ODT approach.
[i] AFEW network & AIDS Foundations East and West. Needs and gaps in treatment and rehabilitation for people who use drugs in selected countries of EECA. 2018. http://www.afew.org/wp- content/uploads/2018/06/Rehabilitation_AFEW-Report_ENG.pdf
[ii] United Nations Office on Drugs and Crime, International Network of People Who Use Drugs, Joint United Nations Programme on HIV/AIDS, United Nations Development Programme, United Nations Population Fund, World Health Organization, United States Agency for International Development. Implementing comprehensive HIV and HCV programmes with people who inject drugs: practical guidance for collaborative interventions. Vienna: United Nations Office on Drugs and Crime; 2017.
[iii] Moos, R.H.; Finney, J.W. (2011). Commentary on Lopez-Quintero. Remission and relapse—The Yin- Yang of addictive disorders: Commentary. Addiction, 106, 670–671
[iv] Granfield, R.; Cloud, W. (2001). Social Context and “Natural Recovery”: The Role of Social Capital in the Resolution of Drug-Associated Problems. Subst Use Misuse, 36, 1543–1570.
[v] MacGregor, S. (2012). Addiction recovery: A movement for social change and personal growth in the UK, by David Best, Brighton. Drugs Educ. Prev. Policy, 19, 351–352.
[vi] Molina, A., Saiz, J., Gil, F., Cuenca, M. L., & Goldsby, T. (2020). Psychosocial Intervention in European Addictive Behaviour Recovery Programmes: A Qualitative Study. Healthcare, 8(3), 268. MDPI AG. Retrieved from http://dx.doi.org/10.3390/healthcare8030268.
[vii] European Monitoring Center for Drugs and Drug Addictions. European Drug Report 2020 – Key issues. https://www.emcdda.europa.eu/system/files/publications/13238/TD0420439ENN.pdf
[viii] Hansen, G. (2018). La perspectiva de género en los programas y servicios de drogodependencia. Revista Infonova (35) 35-49.
[ix] European Monitoring Center for Drugs and Drug Addictions, Health and social responses to drug problems. 2017. https://www.emcdda.europa.eu/system/files/publications/6343/TI_PUBPDF_TD0117699ENN_PDFWEB_20171009153649.pdf
[x] World Health Organization. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. 2016 update. July 2016. https://www.who.int/hiv/pub/guidelines/keypopulations-2016/en/
[xi] International Drug Policy Consortium. Sustainable measures to prevent and address COVID-19 in European prisons. June 2020
[xii] Global State of Harm Reduction: 2019 updates. Harm Reduction International. https://www.hri.global/global-state-of-harm-reduction-2019
[xiii] The Global Fund to Fight AIDS, TB and Malaria, Technical Brief: Addressing HIV and TB in Prisons, Pre-Trial Detention and Other Closed Settings; June 2017, Geneva
[xiv] Polish Drug Policy Network advocates in the parliament for opioid addiction treatment with prescription-based substitution. 1st October 2020. http://www.politykanarkotykowa.pl/english/polish- drug-policy-network-advocates-in-the-parliament-for-opioid-addiction-treatment-with-prescription- based-substitution/
[xv] Drug and Alcohol Dependence.COVID-19 survey among people who use drugs in three cities in Norway. Published 18th September 2020. https://www.xmol.com/paper/1307737129743519744?recommendPaper=1255936330455474176