A position paper developed by the Civil Society Forum on Drugs (CSFD), an expert group of the European Commission
Membership of the CSFD comprises 45 civil society organisations coming from across Europe and representing a variety of fields of drug policy, and a variety of stances within those fields. Its purpose is to provide a broad platform for a structured dialogue between the Commission and the European civil society which supports drug policy formulation and implementation through practical advice. The CSFD welcomes the inclusion of the issues faced by people who use drugs, including mental health concerns, within the political agenda as it is a topic needing dire attention which has previously been overlooked.
The complexities of the relationship between mental health conditions and drug-related harms are clear. Determinants of mental health conditions include inequality, marginalisation, discrimination, stigmatisation, violence, homelessness and adverse childhood experiences, and exist at broader social, economic and commercial levels. People who use drugs are often already vulnerable to these factors because of their drug use.
In addition to this, both drug-related harms and mental health conditions disproportionately affect stigmatised and marginalised communities. Women present to services with more severe mental health problems than men, which have developed over shorter periods of drug dependence. Young people may turn to substances as self-medication, in an attempt to relieve anxiety, depression and other challenges related to youth angst, which can lead to severe mental health problems if their conditions are not addressed promptly. Yet, both of these sub-populations have unequal access to specific services tailored to their needs. Additionally, ethnic minorities and indigenous groups who are already subject to multiple intersecting vulnerabilities and disproportionately impacted by drug control efforts are often also excluded within current systems of service provision.
The term “dual pathology” is often used in the context of people with a mental health condition who use drugs and implies a disease with a known biological cause. Mental health conditions can be determined by the interaction between an individual and their social environment and not necessarily by their brain biochemistry. The use of the term “pathology” promotes a predominantly pharmacological approach and can lead to increased (over)medicalisation. “Comorbidity”, in turn, describes the co-occurrence of two conditions (in this context, a mental health condition and substance use). The CSFD members agree that the term “comorbidity” should be used as a replacement for “dual pathology”, as it highlights the complexity of the relationship between both conditions while promoting a more integrated, holistic, and person-centred approach. It also emphasises that dependence and high-risk drug use are not always associated with mental health problems.
Because of the complicated relationship between mental health conditions and drug use, often it is difficult to detect whether mental issues were triggered by continued substance use (alcohol included), or, as is reported with increasing frequency, whether drug use or even dependence have root causes in preexisting emotional distress and psychological vulnerability. People with comorbidities require access to high quality interventions because of the complexity and intersectionality of the issues they experience and the risks they face. At the same time, often individuals experiencing comorbidities are misdiagnosed and provided with inappropriate or inadequate medical care. An adequate diagnosis is crucial to developing an individual treatment plan, adjusted to the needs of each person. Treatment of comorbidities must be comprehensive, adapted to the individual’s characteristics (profile, needs, and expectations, interaction with their community, environment, etc.) and grounded in an intersectional, gender-sensitive and human rights-based perspective.
A person-centred approach is particularly important given the specific needs of individuals experiencing this comorbidity who are also part of the vulnerable groups mentioned above. The WHO reports rising rates of adolescents presenting with poor mental health or mental health conditions. Globally, one in seven 10-19 year-olds experience a mental health disorder, while suicide is the fourth leading cause of death among 15-29 year-olds. This deterioration in mental health can lead to an increased risk of developing a comorbidity later in life, hence it is essential to ensure adequate care for young people who may be at risk of developing a comorbidity.
Barriers to Care
The current system of mental health care prioritises specialised, large mental health institutions and promotes inpatient care as the primary method of intervention. A pharmacological approach is often predominant in treatment methods. Many countries across the EU demonstrate insufficient funding for mental health services and ineffective, biased distribution of available resources within the system.
Often community-based options for service provision are overlooked. The lack of resources and strain on the system lead to insufficient implementation of integrated, person-centred approaches. This is especially evident in the context of opioid agonist treatment (OAT). While OАT programmes have been shown to be universally effective, some eligibility criteria can be extremely hard to meet, creating barriers to retention in the programme for people who use opioids and experiencing mental health issues. Furthermore, there are considerable challenges for clients of OAT programmes to access treatment in a psychiatric ward, such as if their condition requires stabilisation in a mental health area other than for drug dependence, i.e. depression, psychosis, etc. A lack of resources can mean that even facilities which are equipped to treat comorbidities have difficulty with OAT administration.
- Ensuring availability of mental health care services for people who use drugs not only in the context of drug dependence treatment. In particular, staying vigilant to the risk of over-medicalisation of people with comorbidities.
- Improving accessibility of care through the development of outpatient, community-based service options, offering mental health care and substance use services at primary health care level.
- Given the biopsychosocial nature of comorbidities of mental health and substance use, approaches to address them should be multifaceted and include not only medical and psychiatric measures but also social, family, and community-based interventions. Hence, medication should be accompanied by other therapeutic strategies that rely on the ‘psychosocial’ component.
- Continuum of care should be ensured through scaling-up reintegration services by creating opportunities for social and vocational reintegration, through day centres and psychosocial follow-up services, in order to give individuals the tools they need when they leave the treatment program.
- Public authorities must guarantee the long-term sustainability of reintegration services, particularly in the residential sector, contrary to the current increasing incidents of underfunding.
- It is vital to invest in services, research and innovation in the field of mental health and drug use, and harm reduction, prevention, treatment and recovery within a biopsychosocial approach. It is essential to support the development of specific programmes within drug dependence services and including an intersectional, gendered perspective.
- Continuous monitoring and evaluation of the effectiveness of interventions should be ensured.
- Using evidence-based techniques, avoiding overmedicalization and promoting the training and education in individual skills and coping mechanisms that increase people’s level of autonomy.
- Public authorities must also ensure that deteriorating mental health among youth is addressed as a matter of priority to lessen the risk of the development of comorbidities later in life.
- Revision of educational curricula for specialists in mental health and substance use services to ensure the inclusion of person-centred and gendered perspectives.
- Person-centred, biopsychosocial approaches (incl. minimisation of over-medicalisation) should be promoted through training and establishment of multidisciplinary teams able to address a range of problems.
- Awareness-raising campaigns to reduce stigma and improve health literacy should be developed.