TREATMENT CHALLENGES

1. TREATMENT CHALLENGES Dr.Thomas Legl President EURO –TC Director Kur- und Gesundheitszentrum Knappenhof/Austria Shaping the Future – A Multisectoral Challenge 52nd ICAA CONFERENCE ESTORIL, October 11th-16th 2009

2. BACKGROUND/GENERAL GUIDELINES WITHIN THE EU • Integrative Approach • Different Problems – Different Strategies • Punishment for Trafficking & Treatment for Dependant Persons • Counseling Consumers • Decriminalization vs. Legalization

3. EVIDENCE BASED RESEARCH • Level A: Consistent randomised controlled clinical trial cohort study, clinical decision rule validated in different populations. • Level B: Consistent retrospective cohort, exploratory cohort, ecological study, outcomes research, case control study . • Level C: Case series study . • Level D: Expert opinion without explicit critical appraisal, bench research or first principles

4. FINDINGS AND REALITIES • Time Factor most essential/cost cuttings • Treatment to be ready available/reality of long waiting lists • No single treatment appropriate for everyone /programmes predominately not flexible • Focus on multiple needs-co morbidity-social factor/ come-go-come back” effect • Continuous assessment/rare existence

5. Co-Morbidity - Flow Pattern Outpatient Facility Psychiatric Hospital High Co-Morbitity Low Co-Morbitity Specialised Residential Treatment High Co-Morbitity Substitution Programme Low Co-Morbitity

6. SUBSTIUTION TREATMENT • Around 600 000 patients receive treatment in Europe • Predominant option for opiod users • Methadone still most common with Buprenorphine coming up BEST PRACTICE • Long term basis and effective dosage • Psychosocial treatment • Excellent experience in combination with residential treatment

7. Substitution drugs • Very different legal situation within European countries • Methadone – Buprenorphine • Heroine maintenance – “perfect administration” • Matching treatment towards clients needs special target groups / Vienna experience

8. MATCHING TREATMENT TO THE PATIENTS NEEDS SPECIAL PROGRAMMES • Parents and Children • Dual Diagnosis • Adolescents • Gender Oriented Treatment • Ethnic Approach • Geriatric Communities

9. CHANGE IN CONSUMPTION PATTERNS WHAT IST THE ANSWER TO • Increasing consumption of cocaine • Increasing consumption of methamphetamines • Parallel -consumption of alcohol and stimulants in substitution programs

10. TYPES OF CONSUMERS • DROP OUT TYPE – long term use and social problems • SENSITIVE TYPE – female, successful • OBSESSIVE TYPE – male, frustrated with everyday live • SOCIALIZING TYPE – male, seeking social inclusion • LIFESTYLE TYPE - fun oriented party consumer Maik Just, Magdeburg 2006

11. IMPACT ON TREATMENT • Traditional Treatment setting, oriented towards opioid users only fits needs of small number of persons from first user group • Other types have no identification with treatment system, detest counseling and treatment together with opioid users mainly because of different social situation • As consequence often do not receive other treatment than individual therapy with private psychotherapists • Evidence based treatment principles highly ignored

12. Evidence based intervention and local necessities and strategies • DCD 2 –Democracy City and Drugs /European Project • Treatment challenges on local basis • Necessity to develop common guidelines on the European basis • Gap between knowledge ,local necessities and political realities • High motivation for common solutions

13. Liège • Main Topics: ▪ Increasing cocaine use ▪ Increasing number of pregnant women using drugs • Illegal drug users do not use possibilities for treatment • Boarder region with high drug trafficking • Challenges / needs to be done: ▪ Implementation of heroin assisted treatment ▪ Adequate residential treatment and aftercare ▪ Implementation of a consumption place ▪ Increase cooperation to reorganisation

14. Vienna • Main topics: ▪ treatment of addicted pregnant women & young mothers ▪ early treatment intervention of children with addiction background in the family ▪ treatment of older people, as well as other people dependent on other‘s help

15. Vienna • Challenges / needs to be done: ▪ implementation of case management ▪ work for a higher tolerance within the population ▪ Provide addicted persons during and after treatment (substitution) with a productive structure ▪ Special feature on education and job promotion for young persons Solutions for growing unemployment rate with early intervention system

16. 3. Leipzig • Main topics: ▪ Appropriate structure and possibilities for working activities as well as for leisure time rarely exist during outpatient treatment ▪ Insufficiant access to target groups ▪ Early intervention in general/somatic treatment facilities

17. Leipzig • Challenges / needs to be done: ▪ Provide sufficient psycho-social support for addicts in substitution treatment ▪ Optimise prescribing regulations for substitution drugs/train prescribers ▪ intensify work focused on women and families

18. 4. Central Bohemia Region (Czech Rep.) • Main Topics: ▪ High percentage of very young drug users ▪ Ethnic dimension-high prevalence of drug use in Roma community and other ethnic minorities ▪ Inadequate substitution treatment programmes offered by the towns-not practicable regulations (3 doctors cover population of 3000 adicts) High prevalence of pregnant drug using women

19. Central Bohemia Region • Challenges / needs to be done: ▪ Provide more staff specialised/trained in issues of drug treatment/therapy ▪ Provide short- and middle-term treatment, as well as sufficient aftercare ▪ Increase interest of politicians and raise financial contributions ▪ Set up a network of regional NGO‘s dealing with these issues

20. Stuttgart • Main Topics: • Not enough cooperation with primary health care • A rather well-working system for outpatient treatmet, but long waiting times • Many alcoholics can not be reached; substitution programs are missing their point

21. Stuttgart • Challenges / needs to be done: • Better Networking between stakeholders • Supporting early intervention, early warning systems also in terms of cost effectivness

22. TREATMENT MOTIVATION • Addiction treatment still has low retention rate – negative cost/outcome effects • Client participation in development of guidelines and planning of strategies • Unpleasant environment

23. ARE ISOLATED SETTINGS FOR DRUG/ALCOHOL ABUSERS STILL APPROPRIATE?

24. NEW STRATEGIES • Attachment to Primary Care Sytem –special education (general practicioners and substitution) • Common settings with other psychosomatic diseases /focus from symptom to wider perspective of psychosocial status

25. CHALLENGES • ADAPTING TREATMENT TO PATIENTS NEEDS • Needs emerge during therapy • Matching needs as they emerge • Treatment extended to different interventions at different times /relapse not failure • Making treatment attractive

26. KUR UND GESUNDHEITSZENTRUM KNAPPENHOF

27. THANK YOU FOR YOUR ATTENTION