Co-operation between drug treatment centres and the Probation System in Catalonia. Josep M Suelves Direcció General de Salut Pública

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1 Approaches to Drugs and Alcohol Abuse in Prisons & Probation Co-operation between drug treatment centres and the Probation System in Catalonia Josep M Suelves Direcció General de Salut Pública

2 CATALONIA Surface: km2 Inhabitants: 7,611,711 Density: inh/km births per deaths per ,3 % foreigners Health expenditure per capita: 1,255

3 Estimates of the annual prevalence of problem opioid use (among population aged 15 64) Source: EMCDDA Annual Report 2010

4 AIDS incidence by year of diagnosis among injecting drug users by country, cases per million, 1998 to New cases per million population Belgium Bulgaria Czech Republic Denmark 2005 Germany Estonia 2008 Ireland Greece Spain France Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden United Kingdom Croatia Turkey Norway Source: EMCDDA Statistical Bulletin 2010

5 Proportion of prison population receiving opioid substitution treatment Source: EMCDDA Annual Report 2010

6 Offenders on probation ordered to follow drug treatment. Catalonia, 2010 Residential; 151 Outpatient; 892

7 Last year prevalence of cocaine use among young adults (aged 15 34) in Europe, Australia, Canada and the USA Source: EMCDDA Annual Report 2010

8 Last 12 months prevalence of cannabis use among all adults, young and younger adults, measured by national population surveys Source: EMCDDA Statistical Bulletin 2010

9 Trends in last year prevalence of cannabis use among young adults (aged 15 34) Source: EMCDDA Annual Report 2010

10 Drug users admitted into treatment: cases referred by court/probation/police (%). Catalonia, Heroin Cocaine Cannabis Alcohol

11 A reasonably good relationship Confusion about legal status Duration of treatment Residential treatment Abstinence Confidentiality Urine drug tests

12 Average adult alcohol consumption in 48 European countries (2005) Source: WHO/Europe European Status Report on Alcohol and Health 2010

13 Mortality from liver cirrhosis among men in 27 European countries, 2005 Source: WHO/Europe European Status Report on Alcohol and Health 2010

14 Mortality due to all road traffic accidents among males in European countries (n=30), 2005 Source: WHO/Europe European Status Report on Alcohol and Health 2010

15 Road crashes have a major impact on Public Health Each year people die from road crashes in the WHO European Region (Peden et al., 2004). The nonfatal consequences are also severe: more than 2 million injured people require hospital admission and millions more require medical attention, with a large proportion permanently disabled (UNECE, 2006). Road traffic injuries in the Region result in an annual loss of 3.6 million years of healthy life due to premature death or disability (disability-adjusted life-years). The loss of national productivity is an economic threat, resulting in high societal costs equivalent to about 2% of gross domestic product. For the European Region, this translates into hundred of billions of euros, including health service costs to treat and rehabilitate injured people.

16 EU transport ministers have commited to try to cut annual road deaths by 50% between 2001 and Deaths from road crashes in 2005 Source: ETSC. Raising Compliance with Road Safety Law. 1st Road Safety PIN Report.

17 The traffic injury pyramid Catalonia 1 Mort 12 Ingressos hospitalaris 281 Han patit lesions que han requerit tractament o han afectat les activitats quotidianes Source: based on SCT, CMBD-HA, and l ESCA-2006

18 Road injuries are not accidental

19 Road injuries are not accidental

20 Road injuries are not accidental...by chance??

21 Injury causation model

22 The Haddon matrix Factors Host Agent Environment Phases (person) (vehicle) (physical and socioeconomic) Pre-crash Alcohol use Braking capacity Design and maintenance of the roadway Enforcement of speed limits Enforcement of BAC limits Crash Safety belt use Speed, size & crash tolerance of vehicle Breakaway poles Enforcement of restraint use laws Post-crash Bystander care Integrity of fuel system Emergency and trauma systems

23 Legal actions in Spain ~1990: Maximum BAC allowed changes from 0.8 to 0,5 g/l (0,3 g/l for novice and professional driovers). Fines from 300 to 600 euros, and 3 months suspension of driving license. Some cases may be treated as criminal offences. 2006: Driving license demerit system implemented. Intoxicated drivers loose 6 points (starting with 12) 2008 Drivers found with a BAC over 1,2 g/l (or refusing a breath test) may be sentenced to prison (6-12 months) or probation. Driving license will be suspended for 1-4 years. Drivers without a licence can be imprisoned.

24 Traffic injury mortality in Catalonia, Font: Servei Català de Trànsit. Anuari estadístic d accidents a Catalunya Source: Servei Català de Trànsit. Anuari estadístic d accidents a Catalunya 2009

25 How are alcohol-related road injuries evolving? Source: ETSC. Raising Compliance with Road Safety Law. 1st Road Safety PIN Report.

26 Positive alcohol tests among drivers dead from road injuries. Catalonia Source: Servei Català de Trànsit

27 Population in prison and on probation in Catalonia, Source: Departament de Justícia

28 Cases on probation x 100,000 inhabitants. Catalonia, Source: Departament de Justícia

29 Population on probation in Catalonia, Source: Departament de Justícia

30 Drug users admitted into treatment: cases referred by court/probation/police (%). Catalonia, Heroin Cocaine Cannabis Alcohol

31 Populations at risk: DUI offenders Some characteristics of repeat DUI offenders (Nochajski & Stasiewicz, 2006): Males No clear evidence on age distribution More likely to persist in DUI behaviour More likely to have been involved in crashes and to have more traffic violations Some studies have found higher BAC levels among recidivists. Among recidivists with low BAC levels, other drugs may be involved Alcohol dependence is more frequent. Higher prevalence of psychiatric symptoms/disorders (antisocial personality, depression )

32 Reducing recidivism among DUI offenders Interventions to prevent recidivism (Nochajski & Stasiewicz, 2006): Sanctions become less effective as time between arrest and punishment increases. punishment increases. License revocation/suspension is a common consequence of DUI conviction. It may require too much time to be effective. Convicts may continue driving without a license. Fines may be effective... when they are paid. When combined with effective rehabilitation programmes (conventional treatment, brief interventions), sanctions seem to be more effective.

33 Treatment for alcohol dependence among DUI offenders? An increasing number of raffic offenders under probation. Prevalence of alcohol dependence is unknown, but expected to be high. Some acceptable screening instruments are available and have been tested in similar populations, including AUDIT, CAGE, MAST, and more specific instruments. Professionals working in probation services may screen and refer cases. Treatment facilities are available.

34 Domains and item content of AUDIT

35 Interpreting AUDIT scores Total score =>8-10 Hazardous alcohol drinking (or alcohol disorder). 25.9% of all DUI offenders assessed. Items 4 to 6 >0 Early stages of dependence. 30.4% of all DUI offenders assessed Total score > 20 Alcohol dependence, specialised alcohol treatment may be necessary 3.7% of all DUI offenders assesed.

36 DUI offenders on probation in Catalonia (n=114) Mean AUDIT score 7.9; range Alcohol breath analysis when arrested: mean value 1.00 g/l; range % report to be complete abstainers 48.2% report not >2 drinks/day 37.7% report never drinking >6 drinks in a single ocassion

37

38 21,9%

39 DUI offenders on probation. Consensus guidelines in Catalonia Offenders should be advised to contact a drug treatment centre if any of the following criteria are met: AUDIT score >= 15 Alcohol breath analysis when arrested >= 1,2 mg/l (BAC>=2.4 g/l) An alcohol disorder is suspected

40 To be continued Not self-perceived as a crime Prevention vs rehabilitation Side effects Emphasis on education Substance use (and other mental) disorders neglected Administrative and other legal actions overlapped A very large population Stakeholdersnot considered

41 Thanks for your attention!

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