Education and training on substance use disorders

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1 Educatio ad traii o substace use disorders Recommedatios for future atioal Dru Policies P-PG /Res-Edu (2013) 4 By the Worki Group o establishi educatio ad traii prorammes i the field of addictios Co-operatio Group to Combat Dru Abuse ad Illicit trafficki i Drus

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3 3 Frech Editio: Educatio et formatio aux troubles liés à l usae de substaces Recommadatios pour de futures politiques atioales e matière de droues The opiios expressed i this work are the resposibility of the authors ad do ot ecessarily reflect the official policy of the Coucil of Europe. All rihts reserved. No part of this publicatio may be traslated, reproduced or trasmitted, i ay form or by ay meas, electroic (CD-Rom, Iteret, etc.) or mechaical, icludi photocopyi, recordi or ay iformatio storae or retrieval system, without prior permissio i writi from the Pompidou Group Coucil of Europe, May 2014 Prited i Germay

4 4 The Authors Richard Muscat is Professor of Behavioural Neurosciece, Departmet of Biomedical Scieces at the Uiversity of Malta. Withi the Pompidou Group he is the vice-chair of the Permaet Correspodets ad the Bureau. He furished the framework for the paper toether with Ree Stamm, while Ambros Uchtehae added to the text ad provided most of the examples ad refereces. The Expert Group listed below provided valuable iput throuhout the preparatio of the mauscript. Ree Stamm is Deputy Head of the Dru Sectio at the Swiss Federal Office of Public Health. He was maily ivolved i the developmet of a atioal policy for educatio ad traii o substace use disorders. Ambros Uchtehae MD, PhD is Professor Emeritus of Social Psychiatry, Uiversity of Zurich, fouder ad chairperso of the Swiss Research Istitute for Public Health. The Expert Group Mr Roma Gabrhelik, Czech Republic Professor Amie Beyamia, Frace Professor Mierva Melpomei Malliori, Greece Dr Ramzi Haddad, Lebao Mr Valerij Dobrovolskij, Lithuaia Dr Liljaa Ijatova, the Former Yuoslav Republic of Macedoia Professor Jallal Toufiq, Morocco

5 5 The Pompidou Group The Co-operatio Group to Combat Dru Abuse ad Illicit Trafficki i Drus (Pompidou Group) is a iter-overmetal body formed i Sice 1980 it has carried out its activities withi the framework of the Coucil of Europe. 35 coutries are ow members of this Europea multidiscipliary forum, which allows policy-makers, professioals ad experts to exchae iformatio ad ideas o a whole rae of dru misuse ad trafficki problems. Its missio is to cotribute to the developmet of multidiscipliary, iovative, effective ad evidece-based dru policies i its member states. It seeks to lik policy, practice ad sciece. Throuh the setti up i 1982 of its roup of experts i epidemioloy of dru problems, the Pompidou Group was a precursor for the developmet of dru research ad moitori of dru problems i Europe. The multi-city study, which aimed to assess, iterpret ad compare dru use treds i Europe, is oe of its major achievemets. Other siificat cotributios iclude the piloti of a rae of idicators (Treatmet Demad Idicator) ad methodoloical approaches, such as a methodoloy for school surveys, which ave rise to the ESPAD (Europea School Survey Project o Alcohol ad other Drus 1 ). The research platform has superseded the roup of experts i epidemioloy, active betwee 1982 ad There has bee a chae of fuctio from developi data collectio ad moitori methodoloies to assessi the impact of research o policy. This started with the holdi i 2004 of the Strateic Coferece o liki research, policy ad practice Lessos leared, challees ahead, which idetified the lack of exchae of kowlede as a major ap. 1 See Pompidou Group list of documets ad publicatios at the ed of this publicatio

6 6 The research platform s primary role was to better support the use of research evidece i policy ad practice, thus facilitati the developmet of evidece-based policy. Moreover, it also sialled the latest issues that arose from dru research i the social ad biomedical fields ad promoted iteractio betwee research disciplies such as these ad psycholoical dru research. Reports o these subjects have bee published ad ca be viewed i the appedix. Followi the madate by the miisters for the Pompidou Group work proramme at the Miisterial Coferece i November 2010, the research platform has ow bee superseded by expert roups related to specific topics i particular coheret policies. The activities per se follow o from a iitial request from Greece duri a Mediterraea Network meeti to address the issue of educatio ad traii i the field of addictios. The outcome i part is the paper herei ad the eleve relevat recommedatios that have come to the fore followi the discussios by the expert roup.

7 7 Cotets The Authors 4 The Pompidou Group 5 Cotets 7 1. Backroud 9 2. The strateic objectives Iteratioal leal ad political framework Scietific justificatio of educatio ad traii i the field of addictio Premises for a eeral cocept The eeral model for educatio ad traii Characteristics of addictoloy traii prorammes Implemetatio of policy ad prorammes Summary ad recommedatios 49 Refereces 50 Appedix I Text of the resolutio adopted duri the 57th Sessio of CND 55 Appedix II List of Pompidou Group publicatios 58

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9 P-PG /Res-Edu (2013) 4 Backroud The problem Substace use disorders (SUDs) are prevetable ad treatable medical coditios that have a major impact o public health as well as the social ad ecoomic well-bei of the idividual ad society at lare. Related morbidity ad mortality rates are very hih worldwide ad addictive substaces rak hih i the Global Health Risks report of the World Health Oraisatio (WHO 2009a). The size of the problem is evidet from the best estimates of persos sufferi i the EU from alcohol depedece (14.6 millio), opioid depedece (1 millio) ad caabis depedece (1.6 millio) (Wittche et al. 2011). The scope of the problems resulti from SUDs is ot met by a appropriate availability of prorammes ad services; coverae of the populatio i eed with alcohol ad dru use disorder treatmet services is low. Oly 10% of opioid- depedet people worldwide have access to care, ad this miority is spread across the 40% of coutries that provide treatmet services for ijecti dru users (WHO 2010). Eve i coutries with hih resources, the quality of services is frequetly deficiet (McLella et al. 2003, Haase et al. 2004). As i other medical fields, the efficiecy ad effectiveess of itervetios deped o the availability of competet staff. Professioal competece stems from research-based educatio ad traii as well as empathic patiet-friedly attitudes ad respodi to the idividual eeds ad expectatios of patiets. I the case of substace use disorders this icludes ecouraemet ad empowermet of patiets to take care of themselves (Oliver et al. 2004). Cooperatio with self-help efforts improves the outcomes (Humphreys ad Moos 2007). Such competeces ca be leared. Most people with substace use problems are ot see by specialists, but i eeral practice, by family doctors, i social services, i hospitals ad emerecy rooms. These staffs also eeds adequate uderstadi of substace use ad substace

10 10 use disorders i order to recoise them ad provide helpful advice, brief itervetios ad referral for treatmet (Caer et al. 2013). This is aother type of competece, but equally importat, ad it too ca be leared. Cosequetly, there is a rowi body of evidece to support the arumet that all health care providers should demostrate such competeces. Despite the emeri cosesus, ot all the uidelies ad traii prorammes are satisfactory i relatio to outcome evaluatio (Uchtehae et al. 2005). Moreover, the existi literature describi such SUD curricula has bee criticised for its lack of systematic assessmet data to support specific educatioal approaches ad evaluatio. 1.2 A Europea deficit Traii i the addictio field i differet coutries coveri the Europea reio has demostrated that commo stadards o addictio traii based o evidece are required. I-ThETA 2 looked ito this very aspect ad has reported that where traii exists, at best, it is ot coordiated at atioal level, ad at worst, there are oly a few traii possibilities offered by NGOs. The traii i addictio is rarely iterated ito official traii structures, leavi the addictio field i the maris of the traii system that exists for the mai disciplies cocered (psychiatry, psycholoy, social work ad ursi care) (Uchtehae et al. 2008). Moreover, taki ito accout the differet leislative frameworks that over dru policy ad the atioal cultures that exist i relatio to the represetatio of the dru pheomeo, it traspires that to date, o miimum stadards are i place with respect to traii i the addictio field. A recet EU project to idetify miimum quality stadards i dru demad reductio (EQUS) established lists of miimum stadards o the basis of relevat atioal ad iteratioal uidelies ad other publicatios, ad submitted the lists to a exteded umber of stakeholders olie ad duri a Europea Coferece. This cosesus buildi process resulted i defiite lists of stadards that received 80% of cosesus or more. At the same time, a major deficit i implemeti the accepted stadards at atioal level became obvious. Implemeti shared quality stadards i dru policy ad itervetios will iclude major efforts i educatio ad traii (Uchtehae & Schaub 2012). Similar deficits i addictoloy traii are described i the USA (Isaacso et al. 2000, Rasyidi, Wilkis ad Daovich 2012). 2 I-ThETA: Iteratioal Thik Tak Educatio ad Traii o Addictio

11 The madate of the worki roup o addictoloy prorammes This roup was set up followi a appeal for the creatio of a addictoloy diploma to meet the traii eeds of medical ad paramedical staff i Europe ad the Mediterraea Reio. This appeal was lauched by the Permaet Correspodet from Greece duri a MedNET meeti i Jue It was suested that this issue of traii o addictios be addressed ot oly by the MedNET member coutries but also by other member coutries of the Pompidou Group that would be iterested i the topic. Duri the first meeti of the worki roup i October 2011 i which the issue of the differet coutries existi addictoloy prorammes was discussed, it was evidet that ot all coutries were i a positio to satisfy the ecessary requiremets for those ivolved i the field of addictio. As a result, the outcome of the meeti provided the impetus for the preparatio of the terms of referece for which the issue of educatio ad traii i relatio to dru policy was formulated. This work proposal was accepted by the MedNET committee i Brussels i November This expert roup followed this work proposal / terms of referece, which was submitted to the Pompidou Group Permaet Correspodets for acceptace. Accordi to the proposal, the roup is to prepare a framework that icorporates the objective of educatio ad traii ito the maistream of policy ad practice (see terms of referece P-PG/Res/Educatio (PG 2011)).

12 12 2 The strateic objectives Taki ito accout the differet leislative frameworks that over dru policy, diverse atioal cultures ad the resultat represetatio of the dru pheomeo, the existi traii systems ad the state of proress coceri addictio traii, it soo became apparet that the roup was ot i a positio to simply draft recommedatios for a traii proramme. Therefore, the worki roup areed o three strateic objectives. 2.1 Iteratio of addictoloy prorammes at atioal level The first objective is to put the topic of educatio ad traii o the aeda of each atioal dru policy ad to iterate such prorammes i the maistream of their educatioal systems. It is a lo-term objective, but it should uaratee the sustaiability of the results. 2.2 Comprehesive cocept for atioal traii policy The secod objective is to develop a eeral cocept that describes the differet elemets take ito accout duri the formulatio of a atioal traii policy. This documet, which emphasises the differet strateic challees, should serve as a referece framework for atioal policymakers for the formulatio of those policies. This documet should allow for a flexible ad lo-term traii policy that takes ito accout the differet atioal cotexts.

13 Iteratio of addictoloy prorammes at EU level Fially, the third objective is to ecourae the EU to iclude the topic of addictio traii i the ew EU stratey o drus, possibly o the basis of the documet drafted by the worki roup. To date, the worki roup o the itroductio of educatio ad traii i the addictio field has maaed, throuh Professor Mei Malliori, Permaet Correspodet for Greece, to ifluece the ew EU Dru stratey adopted o 11 December 2012, which icludes i the last poit 28.8: Esure ad reiforce traii of professioals ivolved with dru related issues, both i the demad as well as the supply reductio field (EU 2012).

14 14 3 Iteratioal leal ad political framework 3.1 Leal basis: UN covetios The Sile Covetio of 1961 ures siatories i article 38 to take all practicable measures for the prevetio of abuse of drus ad for the early idetificatio, treatmet, educatio, after-care, rehabilitatio ad social reiteratio of the persos ivolved (UN 1961). With respect to havi adequate traied staff to do the ecessary skilled job i the area of addictios, the Uited Natios 1971 Covetio, amely article 20, states the followi (UN 1971): 1. The Parties shall take all practicable measures for the prevetio of abuse of psychotropic substaces ad for the early idetificatio, treatmet, educatio, after-care, rehabilitatio ad social reiteratio of the persos ivolved, ad shall co-ordiate their efforts to these eds. 2. The Parties shall as far as possible promote the traii of persoel i the treatmet, after-care, rehabilitatio ad social reiteratio of abusers of psychotropic substaces. 3. The Parties shall assist persos whose work so requires to ai a uderstadi of the problems of abuse of psychotropic substaces ad of its prevetio, ad shall also promote such uderstadi amo the eeral public if there is a risk that abuse of such substaces will become widespread. The UN Covetio o the Rihts of the Child seeks to protect childre from the use of psychoactive substaces (UN 1988) ad the Covetio o the Rihts of Persos with Disabilities (UN 2006) icludes the riht to health amo a umber of other rihts.

15 Ethical basis: huma rihts (Coucil of Europe) A traii ad educatio policy also has to be based o the respect of huma rihts. Hece, the key elemet here is the Covetio for the Protectio of Huma Rihts ad Fudametal Freedoms, as put forward by the Coucil of Europe i 1951 (CE 1951). The covetio outlies, i a umber of articles, core issues that aim to protect the idividual by the rule of law; these iclude the riht to life, the prohibitio of ihuma or deradi treatmet, slavery ad compulsory labour, as well as discrimiatio i a umber of domais (Articles, 2, 3, 4, ad 14). Moreover, the Covetio o Huma Rihts ad Biomedicie, itroduced by the Coucil of Europe i 1997, seeks to protect the diity ad idetity of all huma beis ad respect the rihts ad freedoms with reard to the applicatio of bioloy ad medicie. This also etails equitable access to health care i additio to free ad iformed coset (CE 1997). These covetios thus provide the ratioale for the developmet of educatioal resources that will provide users of psychoactive substaces the service they require as a riht ad ot merely as a afterthouht. Cosequetly, providi such services, be they primary, secodary or tertiary care, requires traied persoel at the differet levels of expertise to esure that each service is covered by staff with the relevat competeces. 3.3 Rihts to health stadards (Uiversal Declaratio of Huma Rihts, Coveat o Ecoomic, Social ad Cultural Rihts, WHO) The Uiversal Declaratio of Huma Rihts (UN 1948) cotais, amo a umber of relevat coditios, the riht of equal access to medical care ad social services (art. 25/1), Article 12 of the Coveat o Ecoomic, Social ad Cultural Rihts states (UN 1976): 1. The States Parties to the preset Coveat recoize the riht of everyoe to the ejoymet of the hihest attaiable stadard of physical ad metal health. 2. The steps to be take by the States Parties to the preset Coveat to achieve the full realizatio of this riht shall iclude those ecessary for:

16 16 (a) The provisio for the reductio of the stillbirth-rate ad of ifat mortality ad for the healthy developmet of the child; (b) The improvemet of all aspects of evirometal ad idustrial hyiee; (c) The prevetio, treatmet ad cotrol of epidemic, edemic, occupatioal ad other diseases; (d) The creatio of coditios which would assure to all medical service ad medical attetio i the evet of sickess. The rihts to health stadards ad the idiscrimiate access to health ad social care caot be achieved i practice without appropriate shared educatio ad traii of the professioals ivolved. However, a report by the Iteratioal Uio for Health Promotio ad Educatio for the Europea Commissio metioed that traii aloe produces a relatively small retur o ivestmet, ad efforts should be directed at oraisatioal chaes that facilitate reater use of evidece-based care which will promote populatio health whether the itervetios cocered are prevetive or curative. There is also a eed, i may coutries, to re-orietate medical ad urse traii to produce a reater emphasis o prevetio. The World Health Report 2006 is dedicated to the problems ad priciples of workforce developmet i health services. I additio to appropriate traii ad cotiui educatio it metios other ecessities. I Chapter 2 o uret health eeds it eumerates some of the mai problems as follows (WHO 2006): Iappropriate or iadequate traii, with curricula that are ot eeds-based Poor access to iformatio ad kowlede resources Ueve distributio of workers at differet levels of service delivery, from atioal proramme officers throuh to health facility persoel Poor policies ad practices for huma resources developmet (poor career structures, worki coditios ad remueratio) Lack of supportive supervisio Lack of iteratio of services with the private sector The WHO Pla of Actio for the period states: the oal i all coutries is to build hih-performi workforces for atioal health systems to respod to curret ad emeri challees. This meas that every coutry should have implemeted atioal strateic plas ad should be plai for the future, drawi o robust atioal capacity. Globally, a full rae of evidece-based uidelies should iform ood practice for health workers (WHO 2006).

17 4 17 Scietific justificatio of educatio ad traii i the field of addictio 4.1 The role of research evidece Educatio ad traii is ot a oal i itself. It is istrumetal for achievi ood outcomes i prevetio ad treatmet. This implies reviewi ad cotiuously updati the results of research evidece o the effectiveess ad efficacy of approaches, methods ad prorammes used i prevetio ad treatmet, as a basis for promisi ood practice. However, every coutry will have to make choices amo the various approaches ad prorammes, accordi to the type ad prevalece of dru problems ad to the availability ad structure of health ad social services. Therefore, educatio ad traii has to cosider two tasks: to qualify the workforce o the basis of available research evidece, ad to tailor approaches ad prorammes to the available resources. 4.2 Reviews of evidece The body of scietific kowlede i dru prevetio ad treatmet has icreased cosiderably over the last decades. At the same time, prevetive ad therapeutic methods have bee diversified. Research results are at times cotroversial, depedi o the variability of taret populatios, methodoloical procedures ad iterpretatio of fidis. Riorous stadards had to be developed for aalysi studies ad for establishi meta-aalytical methods, compari multiple studies i a systematic review. Iteratioally, two oraisatios have bee established i order to review ad aalyse evaluatio studies selected for their riorous methodoloy: the Cochrae Collaboratio ad the Campbell Collaboratio (liks uder Refereces below).

18 18 The Cochrae Collaboratio has its focus o evaluatio of medical treatmets, while the Campbell Collaboratio has its focus o social itervetios. Both oraisatios make their reviews available i their respective olie libraries. A rowi umber of reviews cover pharmacoloical ad psychosocial treatmets i addictio ad their outcomes. Not all issues i prevetio ad treatmet have bee studied or are eve able to be studied with the most riorous comparative methodoloy, the radomised cotrolled trials (RCT). A radi scheme of evidece (GRADE worki roup 2004) helps to classify research results accordi to their scietific value ad thereby facilitates the iclusio of a rae of methodoloical differet studies ito a overall review that ca be used as a uidelie for ood practice. Oe example is the WHO iteratioal uidelies o psychosocially assisted pharmacoloical treatmets of opioid depedece; its recommedatios differ i streth ad the evidece behid the recommedatios is also raded. A further differetiatio is made by formulati miimal requiremets (WHO 2009b). May uidelies are ot or ot oly based o scietific evidece, but o expert opiio ad experiece. This is ope to bias ad criticism. I order to miimise these disadvataes, strict methods have also bee developed for cosesus buildi amo experts, allowi for a qualified represetatio of cliical experiece. Oe example is the quality stadards for dru prevetio, o the basis of the AGREE II methodoloy (AGREE II 2009). 4.3 Cosesus o miimum stadards for itervetios (EQUS project) A attempt to provide miimum quality stadards i demad reductio has bee made by the EU. I effect, as a result of the EQUS project, i which the issue of quality was put at the forefrot, a fial list of proposed miimum stadards was made i which 33 stadards were idetified for prevetio, 22 stadards for treatmet ad rehabilitatio ad 16 stadards for harm reductio. Uder prevetio, P6 ad P23, treatmet/rehabilitatio, TR6, TRs15 ad TRil5, ad harm reductio, HR2 ad HR11, relate to adequately qualified staff to ru the services i questio (Uchtehae & Schaub 2011). The EU is expected to provide fuds for facilitati the implemetatio of these miimum quality stadards i 2013, as these as yet are ot i place.

19 5 19 Premises for a eeral cocept 5.1 Uderstadi substace use disorders ad care optios There is o uiform uderstadi of addictive behaviour. Various paradims apply here: the use of psychotropic substaces ca be uderstood as self-medicatio for symptom relief (Khatzia 1997), as a special variatio of self-maipulatio, tailori use to a desired state of mid, or as istrumetal for self-ehacemet, optimisi fuctio ad output (Harris 2007). Or else, substace use is uderstood as a lifestyle pheomeo, i the sese of cosumerism or of a expressio of sub-cultural idetity. O the other side of the coi, addictio ca be uderstood as a brai disease, with repetitive substace use resulti i structural brai chaes (Lesher 1997), or o a vulerability-stress model focusi o the impact of eetic ad evirometal factors o the brai chaes (Volkow et al. 2004). All these paradims are backed up by some research evidece ad have a impact o the choice of therapeutic optios. Efforts to build a overall uderstadi i a comprehesive theory of addictio have bee made, brii the various elemets toether i a sythetic framework (West 2006). Also, the various addictio trajectories i cotemporary societies ad their cosequeces have bee aalysed (Raikhel ad Garriott 2013). Fially, it is also apparet that co-morbidity with other psychiatric disorders is commo i addictio, with some two-thirds of the cases havi such a co-morbid coditio. Uderstadi addictio as a chroic relapsi disorder has cosequeces for itervetio strateies (McLella et al. 2000) as well as for commuity perceptio ad acceptace, for policy-maki ad for the access to care. However, evidece o spotaeous recovery from dru depedece ecouraes itervetios focusi o facilitati self-help potetials (Kliema ad Sobell 2007), ad lessos ca be leared for successful treatmet approaches.

20 20 This meas, i essece, that addictive behaviour is ot homoeeous with reard to causal factors, risk costellatios ad recovery potetial. Each idividual case has to be cosidered for its idividual eeds ad resposiveess. Educatio ad traii must eable professioals to uderstad this diversity without udue bias, ad to provide a broader view of pathways ito ad out of dru related coditios. 5.2 Adaptability of the cocept to atioal cotexts A traii ad educatio policy should be a iteral part of a atioal dru policy as exemplified i the ew EU Drus Stratey At its best, it is fixed i the atioal leislatio, as for example i Switzerlad. The traii of professioals resposible for dru addictio issues is a key elemet of professioalizatio i this field. A traii ad educatio policy should be adapted to the leislative ad structural cotext of each coutry. The questio of, for istace, whether a traii system should cotribute to create a ew professio (addictoloist) or whether it should ive ew tools to the professios already ivolved to add ew abilities i addictio, is a atioal political decisio. Cosequetly, a traii policy should be based o the aalysis of the specific atioal cotext ad traii eeds i a ive coutry. 5.3 Addressi all cocered actors i prevetio ad treatmet Prevetive efforts as well as early recoitio ad itervetios, support for treatmet ad rehabilitatio prorammes, ad acceptace of addicts as cadidates for re-iteratio ito the labour market ad ito society at lare caot take place without a comprehesive approach ivolvi all types of actors. A atioal traii policy should therefore address four taret audieces: the professioals who are dedicated full time to depedet patiets (specialists i addictio or addictoloists), the professioals who are occasioally cocered with depedet patiets (e.. primary care physicias, emerecy services practitioers, social workers, urses at a eeral hospital, police officers, teachers, priso staff),

21 21 alo with volutary workers ad peers from civil society ad the Church, for example, as well as members of society i eeral. This approach reflects the idea that addictio affects essetially the whole of society, ad it caot be deleated to specialist professioals aloe. 5.4 Treatmet diversity ad treatmet eeds Each society ad culture may have its ow mixture of addictive behaviours, with some bei more iflueced by alcohol ad others by illeal drus or tobacco. The epidemioloy data provide iformatio about which problem oe miht wish to address first, ad this will have a ifluece o which traii stratey will be chose. At preset, priorities i prevetio ad treatmet approaches are also determied by traditioal attitudes ad ideoloical prefereces. This ca be see especially i the preferece of prevetio, treatmet, harm reductio or repressio. I Europe however, such differeces are i the process of bei replaced by a more uiform policy, as proposed by the EU dru strateies ad dru actio plas. A aalysis of the situatio is provided by EMCDDA, based o iformatio from the atioal focal poits, i its aual reports (EMCDDA 2012). The eed for prevetive itervetios depeds larely o epidemioloical data (icidece ad prevalece of addictive behaviours, type of populatios at risk) ad o qualitative kowlede about attitudes i the taret populatios. Such idicators help to formulate priorities for future types of prevetio (uiversal, tareted or idicated prevetio). The type ad extet of treatmet eeds also deped o the specific situatio at atioal level. They ca be approximated by compari epidemioloical ad treatmet data, but also by taki police data, waiti list data, ad iformatio from key iformats ito cosideratio. I eeral, the broader the spectrum of prevetive ad therapeutic approaches, the more likely the persos with addictive behaviours will be reached ad will fid a acceptable treatmet. The eed for harm reductio approaches is maily determied by documeted eative cosequeces of dru use ad abuse i a coutry. Both health ad social cosequeces are to be cosidered here.

22 22 It is recommedable to shape educatio ad traii i respose to atioal priorities ad itervetio eeds. 5.5 A cotiui model of itervetios Treatmet approaches ad prorammes, as well as prevetio prorammes, have bee developed i most coutries i respose to eeds, without systematic plai at the atioal level, ad they had to establish themselves i the framework of a competitive market. Ievitably, this situatio has cotributed to ideoloical ad practical fihts. The best kow examples are the cotroversies betwee abstiece-orieted ad aoist maiteace treatmets of opioid depedece, betwee recovery-orieted ad harm reductio approaches, betwee prorammes aimi at total abstiece ad those aimi at reductio ad chae i cosumptio style ad extet. Icreasily, research results support a cocept of complemetarity of approaches rather tha exclusiveess. The diversity of persos eai i addictive behaviours calls for a diversity of approaches, ad the leadi questio is o loer Which approach is best? but rather What is ood for whom? The result is a cocept of a iterated service system. A ood example is the British model of a iterated system for dru services, issued by the Beckley Foudatio (Steves et al. 2006). It covers the whole rae from low threshold harm reductio approaches to structured treatmet prorammes ad stresses the eed for coordiatio. Educatioal prorammes will eed to be coceived o the above premise. 5.6 A step-by-step procedure A starti poit for developi a atioal policy for educatio ad traii could be a aalysis of the preset situatio ad the idetificatio of priority eeds. The ext step is a cocept of appropriate itervetios respodi to priority eeds, with a preferece for well-documeted ad evaluated approaches. Experimetatio ad careful evaluatio of experimets could be helpful i order to deal with specific challees.

23 Problems with addictive behaviours will chae over time: ew substaces, ew cosumptio patters ad prefereces, ad ew taret populatios may surface. Prevetive ad therapeutic resposes must be ope to adaptatios i order to meet the ew problems, ad educatio ad traii must prepare all actors accordily. 23

24 24 6 The eeral model for educatio ad traii 6.1 Why a eeral model? These premises all come to the same coclusio: o sile educatio ad traii proramme will be adequate for the specific problems i the various coutries. Therefore, the worki roup decided ot to preset a fixed traii proramme but rather to develop a eeral model to establish a lo-term traii ad educatio policy that emphasises the differet elemets to be cosidered ad that ca be used as a referece for establishi such a policy i each coutry. 6.2 The hierarchy model of taret roups ad educatioal level The eeral model emphasises that all taret roups should be addressed but at differet levels of kowlede ad skills, starti at the bottom with a eeral uderstadi of the addictio pheomeo by importat actors i society such as politicias, policymakers, jouralists, etc., up to addictio specialists who eed full kowlede of ad competeces o prevetio, treatmet ad harm reductio. Other cocered professioals who occasioally meet depedet patiets i their specific fuctio, for istace urses at a eeral hospital, social workers i a oraisatio for uemployed people, or church volutaries worki i a oraisatio for homeless people, eed to receive appropriate traii. WHO has for a lo time stressed the importace of well-traied eeralists (o-specialists) i health care (WHO 1996). The eeral model does ot mea that each taret roup should be addressed at the same time. Each atioal policy will defie its ow priorities. The eeral model provides a overview ad framework.

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