Treatment system-based data collection: an integrated approach to monitoring

1. Expert meeting: Implementation of the treatment strategy EMCDDA Lisbon , 24-26 June 2013 Treatment system-based data collection: an integrated approach to monitoring

2. This meeting as part of a process • Treatment working Group (2007) • Cross-unit project on treatment 2010-2012: • Consultant project treatment system maps • Expert meeting on facility surveys • Treatment strategy (2012) • New Cross-unit project on implementation of treatment strategy 2013-2015

3. Late 60s and 70s: changing youth cultures (cannabis, amphetamines, LSD) and small heroin sub-cultures • Mid 70s: Increased heroin availability, peaking during mid-80s into the 90s in western EU and later in eastern EU (epidemics)

4. Specialised providers (often psychiatry-led) • Abstinence-oriented treatment approach • Often detox, residential treatment (e.g. boom of therapeutic communities) • Stepwise reintegration (TCs then aftercare)

5. Heroin epidemics associated with serious health and social consequences: • HIV epidemics among injectors, mortality, open drug scenes, etc. •  Need to better understand the drug situation to develop data-driven responses

6. Urgent information needs in the late 80s and 90s • Understanding and assessing the nature, patterns and extent of drug use at city level, then at Member State level • Development of epidemiological indicators, including the treatment demand indicator • Remember: Heroin predominant drug, predominantly specialist outpatient and inpatient structures, relatively ‘short’ treatments

7. Change of paradigm: “ 2 game changers” mid 90s onwards • 1st: New policy priority: A public health approach! • Increase access and availability of drug treatment • Diversification of providers, • Expansion of outpatient, low-threshold treatment services • Ranging from specialised to non-specialised providers (e.g. general practitioners)

8. Year of OST introduction in Member States Sources: EMCDDA SB 2011 HSR 1

9. Emphasis on greater access and availability of opioid substitution treatment (e.g. methadone, buprenorphine) Maintenance treatment -> drug addiction: chronic, relapsing disorder ‘Life-long treatment’

10. Treatment has evolved in Europe: • The 1980s-1990s: • Opioid substitution develops into the major response to opioid use: • Strong evidence base;; • 10-fold increase (1993-2013) • Diversification of medications and treatment regimes; • High coverage through involvement of office- based doctors (GPs) or other primary care system 50% of estimated problem opioid users reached; • The 2000’s - … • Closing of “treatment gap” between community and prison; • Ageing populations of opioid users; • Decline of heroin epidemic; • Specialised drug treatment facilities register more demands for stimulants and other non-opioid treatment.

11. Treatment data collection as well … • 2001  TDI established as main drug treatment monitoring system in Europe • 2003/4  first ST on treatment responses • - Use of additional data sources: Substitution ‘registries’, prescriptions databases; health insurance/reimbursement statistics; sales data • 2008 ‘new’ ST 24 - to determine how many are in treatment • 2012  treatment systems aproach • Current technological innovations may allow improved monitoring • - EHRs (electronic health records) & hospital admission data (ICD-codes)

13. Treatment system maps • Based on generic model and using already available data • Developed on basis of reported facility types at national level • Follow the broader ‘treatment’ definition of the TDI • Describe structure of national treatment system • Help to improve knowledge of reporting gaps • Provide the basis for estimating treatment coverage • [provide sampling frame for facility survey]

15. Low threshold Specialist Outpatient Primary and general health care Criminal justice Specialist inpatient

16. A system-based approach… combined with indicators of needs (prevalence rates, treatment demands, expert opinion on treatment needs) and characteristics of services (e.g. facility survey)…

17. Helps to identify whether available services match the needs (nationally, sub-nationally) and improve system organization Allows to identify gaps in service provision (especially between regions) and highlight monitoring gaps Estimate service utilisation and coverage at population level Measure performance longitudinally and resource allocation as well as continuity of care (inter-agency collaboration and protocols), access to services (equity), quality, etc. Improve communication of findings and monitoring in an integrated framework

18. Treatment prevalence • Project launched in 2005, assessment of feasibility and several pilots conducted • Aim: to have insight into number and characteristics of the population staying in treatment (and entering treatment) during a year • Rationale: - large part of treated population stay in treatment longer than one year (long time clients, often opioid users in OST); • - large part of treatment resources for those clients • Method: TDI network as starting point; most countries able to provide TOTAL number on the same facilities providing TDI data

19. Facility survey

21. Facility survey • Section A - Administrative information • Section B - Target population and client information • Section C – Staffing and Quality Management • Section D – Facility Services

22. Treatment prevalence Dagmar