EMCDDA PAPERS Residential treatment for drug use in Europe

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1 ISSN EMCDDA PAPERS Residetial treatmet for drug use i Europe Cotets: Summary (p. 2) I Itroductio (p. 2) I Historical perspective of residetial treatmet for drug users (p. 4) I Extet ad ature of residetial treatmet (p. 6) I Treatmet elemets i residetial programmes (p. 10) I Residetial treatmet cliets (p. 16) I Orgaisatioal structure of residetial treatmet (p. 19) I Coclusios (p. 23) I Refereces (p. 25) I Appedixes (p. 29) Abstract: Today, i most Europea coutries, residetial treatmet programmes form a importat elemet of the rage of treatmet ad rehabilitatio optios for drug users. The aim of this paper is to provide a Europe-wide overview of the history ad availability of residetial drug treatmet withi wider atioal drug treatmet systems. To help with this, the paper describes the history ad availability of residetial treatmet i Europe ad develops a categorisatio of the broad rage of available models ad treatmet approaches applied i residetial settigs. Coutries differ i the level of residetial treatmet provisio. Over two-thirds of the reported facilities i Europe are cocetrated i just six coutries, each reportig over 100 facilities. A descriptio is provided of the characteristics of residetial treatmet (ipatiet) cliets, as well as discussio of orgaisatioal ad quality assurace issues relevat to residetial treatmet ad how these matters are dealt with across Europe. Keywords residetial treatmet drug use drug treatmet systems Recommeded citatio: Europea Moitorig Cetre for Drugs ad Drug Addictio (2014), Residetial treatmet for drug use i Europe, EMCDDA Papers, Publicatios Office of the Europea Uio, Luxembourg. 1 / 31

2 I Summary Residetial treatmet comprises the provisio of a rage of treatmet delivery models or programmes of therapeutic (ad other) activities for drug users, withi the cotext of residetial accommodatio, i either the commuity or a hospital settig. The mai therapeutic approaches used iclude the 12-step/ Miesota model, therapeutic commuity ad cogitive behavioural (or other) therapy-based itervetios. I Europe, treds i the developmet of residetial drug treatmet closely mirror broader social treds i istitutioal care. This has icluded a iitial psychiatric phase followed by a more liberal social therapy phase i the secod half of the 1970s, ivolvig the family ad social eviromet of drug users; the grass-roots iitiatives by self-help groups were followed by a period of professioalisatio of therapeutic staff ad quality maagemet. The 1970s ad 1980s saw a expasio i residetial care, followed by a cotractio i favour of commuity-based outpatiet treatmet; ad the objectives of drug treatmet chaged from a sole focus o abstiece to itegratig the reductio of harm. I the history of residetial drug treatmet, each coutry retais its ow story of the emergece of drug use problems. A large part of the earlier sociopolitical debates reflected atioal culture ad values ad determied chages i atioal health systems ad fudig streams. However, the HIV/AIDS crisis of the 1980s had a profoud impact o the residetial treatmet respose to drug addictio across may Europea coutries, leadig to the scalig up of more varied treatmet offers withi a itegrated system of resposes to drugs. Today, i most Europea coutries, residetial treatmet programmes form a importat elemet of the rage of treatmet ad rehabilitatio optios for drug users. Coutries differ, however, i the level of residetial treatmet provisio. Over two-thirds of the reported facilities i Europe are cocetrated i just six coutries, each reportig over 100 facilities, with Italy reportig the highest umber (708 residetial facilities). There is also variatio i the treatmet approaches used to treat drug-usig cliets i residetial settigs i Europe today. Although i 15 coutries the approach/priciples of the therapeutic commuity were idetified as predomiat employed by all or most of the residetial programmes i their territory a combied cliical practice, rather tha fidelity to oe treatmet approach, is widely accepted. Although, historically, residetial treatmet programmes have bee exclusively drug free, curret data idicate the growig importace of providig medicatio to substitute for illicit opioid use. The best available iformatio source to describe the profile of drug cliets eterig residetial treatmet i Europe is the treatmet demad idicator (TDI). I the 22 Europea coutries providig data, aroud drug cliets etered ipatiet treatmet i 2011, with those eterig ipatiet cetres represetig oly aroud 11 % of all reported drug cliets i Europe. This suggests that, o average, aroud oe perso commeces ipatiet treatmet for every 10 people startig specialist outpatiet treatmet. However, substatial iter-coutry differeces exist. Typically, ipatiet cliets are male ad i their early 30s. Compared with outpatiet treatmet etrats, they live i more disadvataged social coditios (low educatio, ustable livig coditios ad uemploymet). Just uder half of ipatiet cliets eter treatmet for problems related to primary use of opioids (maily heroi). I most Europea coutries, fudig for residetial treatmet is provided by govermets, typically i the cotext of a joit fudig arragemet either betwee differet levels of the govermet or i tadem with health isurace. I a umber of coutries, drug users make some persoal cotributio to residetial treatmet. To aid quality assurace ad improved processes i residetial treatmet, a cosiderable umber of Member States ote the existece ad use of evidece-based cliical guidelies ad service stadards. I 1. Itroductio I Backgroud ad aims Latest estimates suggest that, while almost three-quarters of a millio problem opioid users are receivig opioid substitutio treatmet i Europe, at least a quarter of a millio drug users are receivig other forms of treatmet, icludig a rage of approaches i residetial settigs. Most people receivig specialist treatmet for drug problems may ot eed to access residetial treatmet. Their eeds ca be met appropriately by commuity drug treatmet services, which have icreased i availability ad effectiveess over the past decade. However, outpatiet treatmet ad rehabilitatio may ot always be the most appropriate optio, particularly for a select group of drug-depedet cliets who eed the safety ad structure that residetial treatmet ca provide. Hece, residetial drug treatmet is a sizeable ad ecessary elemet i the rage of treatmet optios available to drug users. While measurig ad improvig drug treatmet provisio ad outcome i opioid substitutio treatmet have bee high o the research ageda i recet years, the extet ad ature of residetial treatmet has received less research attetio. Addressig this iformatio gap is likely to beefit fudig 2 / 31

3 bodies, which eed to uderstad the ature of residetial programmes ad the extet of services offered i order to make treatmet more effective ad cost-effective with respect to the rage ad amout of services offered. Cliets ad their families too ca use such iformatio to gai isights about the ature of treatmet ad the approaches that may be used erroeous cliet expectatios about treatmet ca lead to higher rates of dropout, cliet perceptios of failure ad iefficiet use of treatmet resources. Although such argumets apply to all forms of treatmet, they are particularly relevat to residetial treatmet because of the high cost of this treatmet provisio. There is a wide rage of differet types of residetial treatmet, ad residetial treatmet is advacig ad curretly developig its evidece base. To aid compariso, it is importat to establish commo factors ad models amog this variety. Traditioally, residetial programmes have bee delivered over a umber of moths, up to a year, to allow successful achievemet of treatmet goals. I the curret ufavourable ecoomic coditios, it is particularly relevat to examie whether ad how the patter of residetial treatmet provisio is chagig ad how providers are respodig to ew demads ad opportuities i terms ot oly of treatmet duratio, but also of programme cotet ad itesity. The aim of this publicatio is to provide a Europe-wide overview of the history ad availability of residetial drug treatmet withi wider atioal drug treatmet systems. To facilitate this, this paper develops a categorisatio of the broad rage of available models applied i residetial settigs. Fially, it describes the characteristics of residetial treatmet cliets, as well as presetig ad discussig key features of the orgaisatioal issues aroud this type of treatmet. This publicatio is descriptive i ature ad does ot attempt to cosider the effectiveess of residetial programmes for drug users. A assessmet of the evidece base, with a focus o therapeutic commuities, ad a evaluatio of therapeutic commuities impacts are reviewed ad reported elsewhere (EMCDDA, 2014). Like other parts of the health ad social sector, drug treatmet systems are uder icreasig pressure to demostrate value for moey. I this cotext, this publicatio builds o the collaboratio with the Reitox atioal focal poits to iform discussios about the cotributio that residetial treatmet makes to the drug treatmet systems across Europe, as well as actig as a baselie for assessig future chages i the patter of residetial services desig, fuctio ad provisio. I Scope ad coverage Residetial treatmet may be defied i a umber of differet ways. For example, it might be defied as oe or more of a broad rage of therapeutic itervetios provided withi the cotext of residetial accommodatio, or a defiitio might require a miimum duratio of treatmet. For the purposes of this publicatio, residetial treatmet programmes are defied as ivolvig therapeutic itervetios aimed at log-term chage i drug use, usually alogside the other rehabilitative activities, withi a residetial settig. It is importat to ote that residece ca occur withi a rage of settigs: commuity-residetial, hospital ad priso eviromets. This publicatio focuses o treatmet facilities i commuity-residetial ad hospital settigs; drug treatmet provisio i priso is cosidered i the Europea Moitorig Cetre for Drugs ad Drug Addictio (EMCDDA) Selected issue Prisos ad drugs i Europe: the problem ad resposes (EMCDDA, 2012a). This publicatio does ot iclude data ad iformatio about supportive residetial programmes dedicated to the provisio solely of social support (e.g. shelters, supported housig services), although these may have a role i the treatmet, care ad support of drug users i differet stages of their recovery. I some istaces, the boudaries may be blurred betwee some types of supported housig services ad residetial treatmet, as supported accommodatio services may have similar treatmet aims ad may provide a structured daily programme of activities for their residets. The goals of residetial treatmet programmes geerally are to prevet a retur to active drug use, provide idividuals with healthy alteratives to drug use ad help drug users to uderstad ad address the uderlyig factors supportig drug use ad make healthier decisios (NTA, 2006). Residetial programmes thus potetially offer a umber of beefits i a coheret package that removes people from their drug-usig eviromet ad provides a safe ad supportive place to lear the skills coducive to livig a sober ad rewardig life. However, chagig views o addictio as a chroic disorder ad emergig theoretical isights that questio treatmet episodes i closed eviromets are likely to have a impact ad prompt chages i the treatmet goals ad methods of residetial programmes (McLella et al., 2000). I this report we distiguish betwee ipatiet detoxificatio ad residetial treatmet. The mai differeces are i terms of aims ad itervetios. Ipatiet detoxificatio provides safe withdrawal from a drug of depedece ot so much a form of treatmet but a gateway to treatmets that are aimed at log-term chage. Residetial treatmets aim to help idividuals to attai cotrol over drug use, achieve recovery from drug problems, improve health ad well-beig ad chage lifestyle, icludig family ad social relatioships, educatio, volutary activities ad employmet. Key features of such programmes iclude the provisio of idividually tailored psychosocial support ad a structured programme of 3 / 31

4 Data sources ad defiitios used for this report Data o residetial treatmet i Europe for this report are primarily sourced from the Reitox atioal focal poits the EMCDDA s etwork of atioal parters i the 28 EU Member States, as well as Turkey ad Norway supplemeted by treatmet demad data routiely collected by the EMCDDA ad reports i the scietific literature. The sources used to provide the iformatio icluded were varied ad raged from atioal statistics through olie directories of facilities to expert impressio ad estimatio. The report eeds to be read with that caveat i mid. The Residetial treatmet cliets sectio draws o the EMCDDA s treatmet demad idicator (TDI) database, which covers aroud 60 % of existig residetial uits i the reportig coutries ad does ot iclude data ad iformatio o residetial uits i six coutries (Spai, Italy, Portugal, Sloveia, Latvia ad Lithuaia). Residetial treatmet is defied as a rage of treatmet delivery models or programmes of therapeutic ad other activities for drug users, icludig the 12-step/Miesota model, therapeutic commuity ad cogitive behavioural (or other) therapy-based itervetios, withi the cotext of residetial accommodatio i the commuity or hospital settig. This defiitio excludes (i) programmes providig ipatiet detoxificatio oly, (ii) drug treatmet provisio i priso (reviewed by the EMCDDA, 2012a) ad (iii) supportive programmes dedicated to the provisio solely of social support (e.g. shelters, supported housig services). daily activities that residets are required to atted over a plaed period of time. There may also be a iitial detoxificatio phase i the programme. I 2. Historical perspective of residetial treatmet for drug users This sectio provides a overview of how the activities ad orgaisatio of residetial drug treatmet i Europe have chaged durig the last half cetury. That forms a backdrop agaist which curret practice may be cosidered. Residetial addictio care i Europe at the ed of the I 1960s Util the late 1960s, o specific drug-related treatmet system existed. Addictio was maily take care of by the geeral health system ad i most coutries cosisted of medico-psychiatric care delivered i ipatiet wards of psychiatric hospitals; alcohol users costituted the mai cliet group. Early iitiatives i outpatiet treatmet for people with alcohol problems were reported from the Netherlads (1910), ad i the UK ( 1 ) from the 1920s medical doctors were able to prescribe maiteace with opioids to addicted patiets i a outpatiet regime. Dedicated addictio facilities such as the therapeutic farm, established i 1932 i Alsace as Frace s first residetial facility for the treatmet of alcohol depedece, were a rarity. A alterative, democratic ad user-led form of therapeutic eviromet, therapeutic commuities, were itroduced i psychiatric hospitals i the UK i the 1940s (Joes, 1953). They represeted a shift from idividually orieted psychiatric treatmets to a group therapy approach with a focus o social iteractio, based o a psychological ad social perspective of metal illess which had gaied groud i psychiatry. These developmets also affected the treatmet of addictio i psychiatric wards. At the same time, other ew approaches, specific to the treatmet of addictio, developed, such as the Apoliar residetial uit i Prague, which combied medical treatmet with collective educatio ad behavioural approaches i the treatmet of patiets depedet o alcohol, medical opioids, stimulats or ihalats. Aother iovative iitiative was the alterative therapeutic commuity set up by Jaez Rugelj i Sloveia ad based o a treatmet method he iveted, which etailed a ope (outpatiet) therapeutic group settig for up to 120 members with differet addictios, icludig gamblig ad eatig disorders, who could joi ad leave the programme freely. These pioeerig uits later became models for other specialised residetial addictio treatmet i their ow coutries ad abroad. I the Europea coutries formig part of the Soviet Uio, drug use was ot a topic of public discussio durig this period. I The creatio ad expasio of specialised residetial treatmet facilities for drug addicts (late 1960s util early 1980s) I the late 1960s ad durig the 1970s, the spreadig use of illicit drugs was reported from a umber of coutries, icludig Belgium, Demark, Germay, Frace, Italy, the Netherlads, Swede, Norway ad the UK. I 1972 i the Netherlads, fuelled by ecoomic recessio ad uemploymet, heroi use reached epidemic proportios for ( 1 ) I 1965, prescribig of arcotic drugs was temporarily possible i Swede. 4 / 31

5 the first time. By the early 1980s, however, heroi use had markedly icreased i several coutries, icludig Germay, Greece, Frace, Italy, Luxembourg, Spai, Swede, Norway, Portugal ad the UK, ad, i Polad ad Lithuaia, the ijectig of opioids extracted from poppy plats had become popular. Adolescet drug users represeted a ew type of cliet i the 1970s ad were a challege for existig addictio services, where psychiatric approaches domiated ad which had thus far maily focused o treatig alcohol depedece. I respose to this icreasig prevalece of drug use, ew specialised treatmet cetres bega to emerge ad ew policies ad laws were adopted i Europea coutries, which paved the way to chael public fudig ito specialised drug treatmet facilities. For example, i Germay, addictio was recogised as a disease i 1968 ad costs for treatmet were, heceforth, to be covered by public isurace fuds; i Austria i 1971, the eed for health ad social itervetios was, for the first time, clearly defied i a amedmet to the arcotics act; ad, i Frace, the law of 31 December 1970 opeed the door to state fudig for various ew ad sometimes experimetal treatmet iitiatives, icludig therapeutic apartmets, foster families ad facilities i rural eviromets, offerig a way back to healthy livig to drug users. Durig the 1970s ad 1980s, self-help groups such as Release (UK) ad ex-addicts took the lead i developig treatmet programmes ad cetres i several coutries. For example, i 1978, Marek Kotaski established the first Moar therapeutic commuity (TC) i Polad. It became the ucleus of the Moar youth associatio, which set up aother 10 Moar TCs uder a fudig agreemet with the Miistry of Health. Religious-led treatmet cetres also emerged maily i the Catholic coutries of the south as well as the model of hierarchically structured drug-free cliics, followig the Alcoholics Aoymous (AA)-ispired TC model of Syao ad other US models (e.g. the first Phoeix house i Europe was opeed i Lodo i 1970). I the course of the 1970s i the UK, the widespread geeral practitioer-led maiteace prescribig model was replaced by much more cotrolled prescribig by psychiatrists i specialised regioal drug-depedece cliics, based at hospitals. I the early 1980s, residetial care was available i 14 drug-free rehabilitatio houses, typically located far away from ier-city areas where drug use ofte cocetrated. I the coutries of the Soviet Uio, the public image of addicts as offeders domiated ad compulsory treatmet of drug users was itroduced i the 1970s. People diagosed as depedet had to udergo 60 to 90 days of hospital treatmet ad were set to work regime treatmet if they did ot comply (Latypov, 2011). Thus, this period saw the establishmet of specialised drug treatmet facilities ad the the rapid expasio of residetial drug treatmet i the Europea coutries hit by the heroi epidemic. Drug-free TCs iitiated by ex-users ad their families predated the establishmet of public services i may coutries ad became the referece for residetial treatmet util AIDS called ito questio professioal practices based solely o abstiece. I Adaptatio of the treatmet ladscape i Europe i respose to the HIV/AIDS epidemic ad the curret situatio (mid-1980s util today) AIDS was first diagosed i 1981 i the USA ad shortly afterwards i Europe. Whe HIV testig became available i 1985, large umbers of ijectig heroi users were foud to be ifected. As the HIV epidemic swept over much of the Europea regio, it highlighted the eed for greater treatmet capacity ad for a differet approach that was able to reach problem heroi users who were ot i cotact with treatmet services. The result was a drastic reshapig ad expasio of the drug treatmet offer, icludig outreach work, lowthreshold facilities ad opioid substitutio treatmet, delivered to heroi users i the framework of commuitybased outpatiet services. I the secod half of the 1980s, church-led residetial programmes were established i several coutries where drug treatmet did ot exist before, such as Hugary i 1986 ad Malta i 1989; ad, i the 1990s, TCs with a religious orietatio were fouded i Croatia. Several Europea coutries experieced a icrease i the use of illicit drugs oly i the course of the 1990s, followig the opeig of borders after political chage (Hugary, the Czech Republic, Slovakia, Bulgaria ad Romaia) or regaiig idepedece (Estoia, Latvia ad Lithuaia). I these cases, the establishmet of ew residetial treatmet i the 2000s may have beefited to some extet from iteratioal traiig iitiatives (e.g. US-led traiig of 50 Bulgaria professioals), from exchage with Europea professioals through etworks ad at cofereces ad from iformatio about best practice i drug treatmet itervetios made available olie sice the late 1990s (EMCDDA website: Exchage o Drug Demad Reductio Actio (EDDRA)). Today s drug treatmet systems i Europe are characterised by a broad ad diversified rage of providers ad itervetios. The provisio of outpatiet treatmet, i particular, has icreased cosiderably sice the begiig of the 2000s, ecompassig a rage of services. Residetial treatmet facilities i most coutries form a small but essetial part of the overall treatmet respose to drug use i atioal drug systems. The best idicatio curretly available of the share of treatmet provided through residetial 5 / 31

6 treatmet at the Europea level is the share of treatmet demads collected through the EMCDDA treatmet demad idicator (TDI) ad this will be explored i the cotext of a overview of residetial treatmet cliets (Sectio 4). I 3. Extet ad ature of residetial treatmet This sectio addresses issues related to the availability of treatmet i residetial settigs i Europe ad its place i drug treatmet systems today. This is followed by a descriptio of residetial treatmets alog two dimesios: (i) therapeutic approach ad (ii) treatmet compoets. Fially, this sectio outlies the provisio of residetial treatmet for specific cliet groups, highlightig examples of implemetatio ad good practice ad what is kow about what works. The aim is to give a idicatio of the availability ad degree of variability across Europe, i terms of the: umber of facilities (atioal availability); therapeutic models employed; typical plaed treatmet duratio. I Availability of treatmet facilities i Europe This review idetified residetial treatmet facilities providig services for drug users (Table 1). Italy, Germay, Swede, Spai, the UK ad Irelad reported over 100 facilities each ad betwee them accouted for over two-thirds of all reported facilities i Europe. These facilities are divided ito two broad groups based o the settig commuityresidetial or hospital for service delivery: 1. Commuity-residetial facilities residetial facilities withi the commuity for the treatmet of cliets with drug-use problems. 2. Hospital-based facilities providig beds for the treatmet of cliets with drug-use problems i a hospital eviromet. These ca be either stad-aloe facilities used for othig but treatmet of cliets with drug-use problems or wards withi psychiatric or geeral medical facilities that are theoretically available for drug users but i practice could be ad are occupied by geeral or medical psychiatric cliets. Commuity-residetial facilities form the larger group ( = 2 330), with 17 coutries reportig all of their residetial facilities to be of this variety, ad 170 hospital-based oes exist across Europe. Twelve coutries reported the existece of residetial facilities i both the commuity ad hospital eviromets. I four coutries, hospital-based residetial facilities make up the bigger share of available residetial treatmet facilities just over half i Belgium ad Irelad ad three-quarters i Bulgaria ad Latvia. TABLE 1 Number of residetial facilities i commuity ad hospital eviromet (2011, uless otherwise oted) Coutry Commuityresidetial facilities Hospital-based facilities Total Belgium Bulgaria Czech Republic Demark Germay Estoia Irelad Greece Spai Frace Croatia Italy Cyprus Latvia Lithuaia Luxembourg Hugary Malta Netherlads Austria Polad Portugal Romaia Sloveia Slovakia Filad 75 /a 75 Swede UK Turkey /a /a /a Norway Total Notes: Czech Republic: reported rages are, for commuity residetial facilities, = ad, for hospital-based facilities, = 13 17, of which the meas ( = 18 ad = 15 respectively) are used to calculate the total umber of residetial facilities. Netherlads: 80 residetial treatmet facilities are treatmet uits (i.e. parts of big addictio treatmet cetres). Each of these cetres has a umber of differet uits spread over the regio i which they are operatig. Irelad: 2010 data. The figures preset umbers of facilities reportig to the Natioal Drug Treatmet Reportig System; ot all uits i the coutry report to the system. I additio, these figures iclude ipatiet services, which provide detoxificatio oly ad/or treat oly problem alcohol use. Frace: 2013 data. Filad: 2010 data; estimate based o the Register of Istitutios i Social Welfare ad Health Care; hospital data could ot be accessed, as hospitals are aalysed as sigle etities ad are ot aalysed by specialisatio. Luxembourg: hospital-based facility operatioal oly sice /a: ot available. 6 / 31

7 However, care is eeded i iterpretig these data. For example, the facilities ca vary cosiderably i size, as do the populatios that they serve ad the prevalece of drug problems i the differet coutries. The completeess of the iformatio may also vary; for example, i Irelad, the iformatio covers oly those facilities that report to the Natioal Drug Treatmet Reportig System ad, i Filad, hospital iformatio was ot available. Therapeutic approaches used i residetial facilities I i Europe Residetial treatmet programmes aim to foster recovery beyod detoxificatio ad stabilisatio, focusig o health, persoal ad social fuctioig ad ehaced quality of life. These programmes, however, ca differ markedly, as they ca be based o a umber of differet therapeutic approaches (or philosophies) ad employ a rage of differet treatmet compoets (or itervetios). Therapeutic approaches relate to the programme s theoretical uderpiigs, ethos ad method of deliverig programme What are the mai therapeutic approaches that guide residetial services provisio? The mai therapeutic approaches foud i residetial treatmet programmes i Europe are based o: therapeutic commuity priciples i a programme usig therapeutic commuity priciples, the pillars of the therapeutic process are self-help ad mutual self-help; cliets ad staff live together i a orgaised ad structured way that promotes chage ad makes possible a drug-free life i society; 12-step/Miesota model i a programme with a 12-step orietatio, group sessios focus primarily o ecouragig cliets to accept that drug depedece is a disease; psychotherapy, usig: cogitive behavioural therapy (CBT) i a programme with a CBT orietatio, group sessios emphasise helpig residets to idetify situatios i which there is a risk of relapse ad to lear appropriate copig resposes; or other psychotherapeutic models, for example psychodyamic, gestalt, family-orieted. However, some residetial treatmet programmes use a mixture of approaches. itervetios. Based o key characteristics of idividual residetial programmes, the followig mai distict types of residetial treatmet ca be idetified: 12-step/Miesota model, therapeutic commuity approach ad psychotherapybased, usig either CBT or other models. However, treatmet programmes ofte ivolve combiatios of goals ad activity compoets that are determied by programme directors ad staff beliefs about effective drug treatmet, staff traiig ad experiece, ad the types of cliets i the programme. Staff may adhere to oe or two primary approaches, or they may be eclectic ad combie multiple orietatios ad approaches. Therapeutic approaches may be delivered oe to oe ad/or i group format. Typically, these itervetios are specific to the tasks ad challeges faced at each stage of the treatmet process ad eable staff members to use suitable stepwise approaches i developig ad usig treatmet protocols. Therapeutic commuity approach The therapeutic commuity (TC) approach has may features i commo with 12-step treatmets. Both approaches focus o abstiece as the overridig goal of treatmet ad see recovery from addictio as requirig a restructurig of thikig, persoality ad lifestyle i additio to givig up drug-takig behaviour. The key distictio of the TC approach is the use of the commuity itself as a fudametal chage aget ( commuity as a method ) (De Leo, 2000). Two of the defiig features of the commuity as method are a commuity eviromet with a rage of structured activities where both staff members ad residets are expected to atted commuity meetigs ad share activities; ad the otio of peers as role models who give the right example by livig accordig to the TC s philosophy ad value system. At first, residets are completely isolated from their former life ad are ot permitted to have visitors, letters or telephoe calls. Daily life withi the commuity is very structured ad with little opportuity for doig aythig aloe. This forces iteractio with other residets ad permits costat scrutiy of their behaviour by their peers. Residets who show persoal growth i terms of hoesty ad self-awareess move up i the hierarchy, assumig greater resposibilities ad icreased privileges, so that seior residets become models for ew residets. A recet systematic review (EMCDDA, 2014) of the evidece for the TC approach the most widely applied approach i residetial settigs i Europe foud that studies coducted i North America suggest that therapeutic commuities are at least as effective for the treatmet of addictio as other (residetial or commuity) itervetios i terms of lowerig 7 / 31

8 drug ad alcohol use ad recidivism rates. These fidigs, however, are predomiatly based o imprisoed drug users; similar evidece for the effectiveess of commuity residetial treatmet usig the TC approach has yet to be developed. The same review foud that Europea studies o therapeutic commuities show improvemets o a umber of outcomes (e.g. drug use, recidivism, quality of life, health) measured at differet time poits after treatmet. However, because of the observatioal ature of the studies coducted i Europe ad the related methodological limitatios, the possible coclusios that ca be draw remai tetative. 12-step/Miesota model Both 12-step ad Miesota model programmes owe their origis to the ifluece of Alcoholics Aoymous (AA), which views addictio as a disease. The two types of treatmet have a umber of features i commo, although Miesota-type treatmet is typically delivered by professioals ad is less reliat o self-help compoets tha 12-step treatmet. Both types of programmes geerally provide a highly structured ad relatively short (three to six weeks) package of residetial treatmet ivolvig a itesive programme of daily lectures ad group meetigs desiged to implemet a treatmet pla based upo the 12 steps. This usually ivolves a iitial therapeutic rehabilitatio phase, i which residets work with therapists idividually ad i groups to aalyse their persoality ad their patters of behaviour. Much of the focus of this iitial phase is aroud dealig with the issues that led the idividual ito active addictio. This is followed by therapeutic work cetred o startig o the path to a ew life, which, while maitaiig a clear therapeutic philosophy ad approach, is very much about developig the key skills eeded for a ew life. Two systematic reviews of the evidece o the effectiveess of residetial programmes idicated the effectiveess of treatmet programmes based o a 12-step/Miesota model (or a mixed 12-step/CBT model) i reducig drug use ad associated problems amog adolescets (Elliott et al., 2005) ad people with dual diagoses (Bruette et al., 2004). Cogitive behavioural therapy Cogitive behavioural therapy is a geeral therapeutic approach that seeks to modify egative or self-defeatig thoughts ad behaviours. CBT uses the residet s thikig errors (cogitive distortios) as the basis for idetifyig activities to promote behavioural chage. The priciple is to fid out which modifiable behaviours ad beliefs are maitaiig drug use ad to decide what chage is wated ad how this chage ca be achieved. Thus, before therapy ca be iitiated, a behavioural ad/or cogitive aalysis is carried out so that the curret behaviours ad ways of thikig are uderstood, goals are idetified ad the ways of achievig these goals are defied. Accordig to the idividual aalysis, the residet s programme may be arrow, focusig oly o the problem of drug use, or broad, ecompassig a rage of related problems ad dealig with various aspects of the idividual s behaviour ad belief system. There is a family or collectio of cogitive behavioural approaches rather tha a sigle cogitive behavioural method. This icludes motivatioal iterviewig (MI) (Miller ad Rollick, 1991, 2002), aimed at ehacig a idividual s motivatio to chage by explorig ad resolvig ambivalece ad helpig the residet to clarify goals ad commit to cotiuig chage; relapse prevetio (Marlatt ad Gordo, 1985), aimed at developig the residet s ability to recogise cues ad to itervee i the relapse process so that lapses occur less frequetly ad with less severity; ad behaviour modificatio (Skier, 1953; Badura, 1969), focused o arragig cotigecies of positive reiforcemet to develop ad maitai appropriate patters of behaviour. Oe systematic review of the evidece o the effectiveess of residetial programmes idicated that treatmet programmes based o a CBT model (or a mixed 12-step/CBT model) ca be effective i reducig drug use ad associated problems amog people with dual diagoses (Bruette et al., 2004). Combied approaches Combied approaches, sometimes called itegrative or eclectic approaches, combie two or more therapies to maximise a perso s progress. Sometimes, staff at residetial programmes would have a primary orietatio, such as CBT, but supplemet it with techiques from family therapy, givig a eclectic idetity to the residetial programme. Combied approaches have a broader theoretical base ad may be more sophisticated tha approaches usig a sigle theory. They offer greater flexibility i treatmet idividual eeds are potetially better matched to treatmet whe more optios are available. However, the lack of a defied therapeutic approach may result i the loss of theoretical backgroud ad idetity, thereby rederig the programme less ameable to evaluatio ad its ature less uderstadable to cliets, their families ad fudig bodies. Distributio of differet therapeutic approaches i Europe Although all the above types of therapeutic approach ca be foud withi Europea residetial treatmet facilities, idetifyig the specific categorisatio that applies to each facility is difficult. For istace, i the majority of coutries, 8 / 31

9 FIGURE 1 Therapeutic approaches applied i residetial facilities i Europe FIGURE 2 Predomiat therapeutic approaches i residetial facilities as a percetage of the total umber of residetial facilities Psychotherapy/other 5 % 12-step/Miesota 4 % Psychotherapy/ cogitive behavioural therapy 7 % Therapeutic commuity/ Therapeutic commuity priciples 46 % Combied 38 % may of the residetial facilities state that they use a umber of differet programmes ad either offer ay idicatio of their primary or predomiat approach or idicate if the programme that would be used depeds o the idividual presetig for treatmet. Furthermore, there is substatial variatio amog coutries i the capacity to classify residetial treatmet facilities ad, at the atioal level, a rage of approaches may be adopted to gather iformatio that helps to associate facilities with a predomiat therapeutic approach. I Demark, idicators such as the umber of employees traied i a certai treatmet approach or school of psychotherapy were used to guide the classificatio of residetial facilities; i Hugary, atioal associatios ad relevat therapy istitutes were approached to access relevat iformatio ad to determie the correct assigmet of residetial facilities to oe of the above categories. For each coutry, the total umbers of residetial facilities that do ad do ot provide iformatio o their predomiat treatmet approach were established. The latter were grouped ad marked as havig a combiatio of approaches. Overall, of the reported residetial facilities, 46 % (1 160) followed therapeutic commuity priciples. The philosophy of the remaiig facilities could be described as combied (38 %; = 942), CBT-based (7 %; = 163), based o some other psychotherapy approach (5 %; = 131) or 12-step/Miesota type (4 %; = 104) (Figure 1). There was some variatio betwee coutries i the therapeutic approaches used by residetial facilities (Appedix 1). The TC approach or its priciples represet the predomiat treatmet approach applied i all or most residetial facilities Therapeutic commuity /Therapeutic commuity priciples Psychotherapy/cogitive behavioural therapy Psychotherapy/other 12-step/Miesota Combied No data i 15 coutries. CBT is applied i most residetial facilities i Belgium, Bulgaria, Austria ad Norway. Most facilities i Frace ad Cyprus idetify themselves with other psychotherapy approaches such as psychoaalysis ad family therapy, whereas 12-step-orieted facilities prevail i Estoia. Although residetial facilities i most coutries ca be associated with a predomiat therapeutic approach, a combiatio of approaches is used i most residetial facilities i Germay, Irelad, the Netherlads, Slovakia, Filad, Swede ad the UK. Figure 2 shows the reported predomiat therapeutic approach i residetial facilities i Member States as a percetage of the total umber of all residetial facilities i the coutry. Plaed treatmet duratio i residetial I programmes Treatmet duratio has bee show to be related to improved outcomes i a umber of studies (see Box Duratio of treatmet ) ad a miimum threshold of three moths for treatmet impact has bee idetified. The residetial programmes idetified i this study ca be categorised accordig to their reported plaed treatmet duratios, as short-term (plaed stay of three moths or less) ad logerterm (plaed stay of more tha three moths). The plaed treatmet duratio for the majority of programmes is over the threshold of three moths, but some are shorter. The duratio varies accordig to the therapeutic approach adopted. 9 / 31

10 Three-quarters of residetial programmes followig the 12-step approach or applyig some form of psychotherapy have a plaed treatmet duratio of three moths or more. Additioally, the majority of TCs ad programmes applyig TC priciples (93 %) are loger-term. Where programmes provide facilities for o-site medically assisted detoxificatio (usig methadoe or bupreorphie), the legth of the detoxificatio phase typically does ot exceed 28 days. Residetial treatmet is typically medium to log i duratio, with the actual legth varyig accordig to idividual requiremets. However, it was reported that recet years have see a decrease i the plaed legth of time i residetial treatmet i some Europea coutries, through the evolutio of treatmet but also i respose to fiacial pressures. Whereas some coutries, such as Estoia, report o chage to plaed residetial treatmet duratio, others (e.g. Latvia, Demark, Germay, the UK) cotiue to see shorteig of plaed residetial treatmet programmes. I Demark, most otably, plaed courses of treatmet of oe to two years are rarely see, if at all, accordig to atioal treatmet experts. I Duratio of treatmet: miimum retetio thresholds The legth of time i treatmet has bee foud to be related to favourable post-treatmet outcomes i studies of residetial ad outpatiet settigs ad with cliets depedet o opiates or cocaie (e.g. Gossop et al., 2000; Moos et al., 2000). Treatmet outcomes ted to improve as retetio icreases from three moths up to 12 to 24 moths or more (Simpso, 1997; Simpso et al., 1999). Such fidigs have bee used to support the cocept of miimum retetio thresholds for effective opiate treatmet, ofte defied as 90 days for residetial treatmet (Simpso, 1981). Other studies have foud a more liear relatioship betwee the time spet i treatmet ad improved outcomes, with a stroger relatioship betwee treatmet duratio ad improvemet for log-term residetial treatmet (Moos ad Moos, 2003; Zhag et al., 2003). Cliets from the UK s Natioal Treatmet Outcome Research Study (NTORS) residetial programmes who remaied i treatmet for loger periods of time achieved better oe-year outcomes tha those who left earlier, i terms of abstiece from opiates ad stimulats, reduced ijectig ad reduced crimial behaviour (Gossop et al., 2000). The effect of time i treatmet is cofirmed after cotrollig for the ifluece of other potetial predictive factors. a era of spedig cuts, plaed residetial treatmets typically last less tha 24 weeks, ad are most ofte offered for 12 weeks. However, idividuals may drop out of treatmet before it is completed, ad this may be a more commo reaso for treatmet duratio beig below the miimum threshold. The legth of stay is shaped by both programme characteristics, such as therapist caseload size ad the balace betwee therapy, demad for domestic duties ad programme-free time (Meier ad Best, 2006), ad idividual cliet features, such as motivatio for chage ad treatmet readiess (Meier et al., 2005). Promisig practices i ehacig egagemet ad retetio iclude: the use of motivatioal iterviewig (e.g. Carroll et al., 2006); usig more seior staff to iduct ew residets ito treatmet (e.g. De Leo et al., 2000); icreasig the focus o the therapeutic relatioship i staff traiig ad supervisio (e.g. Meier et al., 2006). Although the applicatio of the above meas a more resourceitesive approach, it is liked with earlier cliet egagemet i the treatmet process, which, i tur, is liked to better retetio ad improved outcomes (Simpso, 2004). I 4. Treatmet elemets i residetial programmes Havig provided a overview of the therapeutic approaches used withi residetial programmes i Europe, this sectio will cosider the differet elemets or phases of the treatmet process. Treatmet elemets are the specific chage techiques or services that ca be offered at differet poits withi each treatmet approach to achieve certai goals ad meet idividual cliets eeds. The categorisatio of these compoets is ot stadardised ad the termiology differs across coutries ad facilities i Europe. Noetheless, the pricipal elemets iclude stages such as itake assessmet, treatmet plaig, treatmet implemetatio ad cotiuig care, sometimes called aftercare (Figure 3), as well as specific therapeutic (psychotherapy ad pharmacotherapy) ad social reitegratio (e.g. educatio, vocatioal skills traiig, voluteerig opportuities) itervetios, which may be used at differet times over the course of the residetial treatmet programme. While outliig all treatmet elemets, this paper focuses greater attetio o two of them: pharmacotherapy i 10 / 31

11 FIGURE 3 Treatmet elemets: activities I Implemetig treatmet Detoxificatio Itake assessmet Treatmet plaig Treatmet implemetatio Cotiuig care Detoxificatio is a medically supervised itervetio to resolve withdrawal symptoms associated with chroic drug use, ad is sometimes a prerequisite for iitiatig log-term abstiece-based residetial treatmet. I most Member States, residetial facilities provide o-site detoxificatio from opiates, bezodiazepies ad alcohol ad, i may cases, medicies are used durig detoxificatio. residetial treatmet programmes ad cotiuig care. These areas are udergoig cosiderable chage ad developmet, yet are largely uexplored withi the EMCDDA publicatios to date. I Itake assessmet The itake assessmet typically icludes a umber of areas (e.g. drug use, physical ad metal health, family ad social support) evaluated upo etry ito a residetial treatmet programme. It is a way of gatherig iformatio about the idividual i order to better treat them ad egagig i a process that eables uderstadig of their readiess for chage, problem ad resource areas. I additio, the basic iformatio ca be augmeted by some objective measuremet. It is essetial for treatmet plaig that the collected iformatio from assessmet be orgaised i a way that helps to establish a treatmet pla. I Treatmet plaig Treatmet plas spa from itake assessmet to cotiuig care plaig ad oward referral. They coordiate the rage of itervetios ad supports (e.g. legal, educatioal, employmet services) provided to a idividual cliet. I essece, these documets typically outlie what is expected of the cliet ad what the programme will provide i retur. They are formulated by the cliet ad the residetial treatmet programme staff ad are used to moitor ad documet treatmet goals ad accomplishmets. Typically the treatmet pla recogises that treatmet may occur i differet settigs (residetial as well as outpatiet) over time ad reiforces log-term participatio of the patiet across settigs. Evidece from the UK idicates sigificatly better outcomes whe ipatiet detoxificatio is followed up with residetial treatmet. Ghodse et al. (2002) reported sigificatly lower rates of relapse i cliets completig detoxificatio whe it was immediately followed by residetial rehabilitatio treatmet tha whe this was ot available. Therefore, there are grouds for assumig that the provisio of detoxificatio ad rehabilitatio withi the same treatmet cotext would reduce the likelihood of treatmet dropout betwee services. I the UK, Meier et al. (2007), based o a atioal sample of 87 residetial treatmet facilities, established that over oe-third (39 %) offer medically assisted detoxificatio withi their treatmet programmes. Although there were o differeces i treatmet philosophies, residetial treatmet i facilities that offered detoxificatio were typically of shorter duratio ad reported offerig more group work tha residetial treatmet services that did ot offer detoxificatio. Opioids for substitutio treatmet Substitutio treatmet refers to the treatmet of drug depedece by prescriptio of a substitute drug with the goal of reducig or elimiatig the use of a particular substace, or of reducig harm ad egative social cosequeces. For this aalysis, data were available for 25 coutries. Of these, just uder three-quarters ( = 18) report some availability of itegrated pharmacological (opioid substitutio) residetial programmes, i which residets receive opioid substitutio treatmet for their heroi addictio ad follow a structured therapeutic programme. Withi the 18 coutries reportig residetial facilities that provide itegrated opioid substitutio treatmet (OST), just over half ( = 10) idicated qualitatively the level of availability (acceptace) of this treatmet withi residetial programmes; a further eight coutries supplied quatitative data o the facilities offerig cotiuatio of OST to residets. 11 / 31

12 FIGURE 4 Availability of itegrated opioid substitutio withi residetial programmes i Europe, 2011 Sorese et al. (2009) assessed the outcomes of treatig cliets i OST i a residetial therapeutic commuity. Based o a sample of 231 therapeutic commuity cliets, the study compared the 24-moth outcomes of methadoe-maitaied cliets ( = 125) with opioid-depedet drug-free cliets ( = 106). Regardig a umber of outcomes, otably retetio i treatmet ad illicit opioid use, methadoe cliets were foud to fare as well as other opioid users i therapeutic commuity treatmet. Wider health itervetios High availability Low availability Not available No data The 18 coutries i this aalysis were subdivided ito those with high availability of OST withi residetial treatmet (e.g. Spai, Portugal, Luxembourg), where more tha half of the residetial treatmet facilities i the coutry offer a itegrated opioid substitutio programme i a residetial settig, ad those with low availability (rare acceptace) (e.g. Hugary, Austria, Sloveia, Polad, Irelad, Malta), where fewer tha half of the residetial facilities admit cliets who cotiue to receive prescribed opioids durig their residetial stay (Figure 4). I the eight coutries for which umerical data are available, the residetial treatmet facilities that are reported to offer itegrated OST vary cosiderably (ragig from oe i Polad to early all facilities i Spai). Thus, although opioid substitutio services are o offer to opioid-depedet cliets i residetial programmes i a umber of Europea coutries, the access to these services ad the cosequet uptake vary cosiderably. Because, traditioally, residetial programmes, otably therapeutic commuities ad 12-step-based programmes, have had ufavourable views about substitutio treatmet ad cocers that the use of substitutio medicies by residets would pose a threat to the programme, valid questios arise about the cosequeces of treatig cliets i OST i residetial settigs. Cosequetly, there is a emergig sciece of itegratio that is begiig to explore the effectiveess of admittig opioid-depedet cliets curretly i substitutio treatmet i residetial settigs. There is a variatio i the degree to which cliets i residetial treatmet receive services for health coditios other tha drug depedece, such as HIV or hepatitis C virus (HCV). I particular, whereas several coutries report that residetial treatmet facilities have referral systems i place for testig cliets for HCV or HIV, oly a few (e.g. Greece, Lithuaia, the UK) metio residetial facilities that offer o-site HIV/HCV testig ad vacciatio (hepatitis A ad B). No HIV or HCV treatmet delivery is reported i residetial treatmet facilities i Europe. The reasos cited by atioal experts for ot offerig routie testig ad vacciatio iclude the lack of facilities for testig ad/or medical persoel for treatmet. For example, i Demark, residetial treatmet is separated from the healthcare system, so residetial programmes do ot have the ecessary resources to offer medical itervetios. Orgaisatioal factors thus appear to ifluece the provisio of o-site medical services to cliets i residetial treatmet. Drug users are at high risk of hepatitis C ifectio ad also costitute a group that is medically uderserved. Advaces i the treatmet of hepatitis C ifectio with direct ativiral agets ad a growig evidece base for its effectiveess amog drug users idicate the potetial for extedig strategies to treat hepatitis C amog drug users. To be successful, these treatmets iclude a emphasis o medicatio adherece ad appropriate maagemet of side effects residetial settigs are uiquely situated to provide comprehesive treatmet ad moitorig. Rosedale ad Strauss (2010), based o a aalysis of qualitative descriptive data from 20 cliets i three residetial drug treatmet programmes, reported o what cliets i residetial treatmet thik about depressio ad the risks of europsychiatric side effects associated with iterfero treatmet for hepatitis C. The results emphasised that residetial treatmet programmes offer a uique opportuity to udergo ativiral treatmet because they capitalise o cliets heighteed readiess for chage. Alog with that, cliets perceived isufficiet kowledge about hepatitis C amog psychiatric staff ad cliets fear that hepatitis C side effects would sabotage addictio recovery 12 / 31

13 Itegrated opioid substitutio residetial programmes i Spai Opioid substitutio treatmet (OST) became widely available i Spai i the secod half of the 1990s followig a chage i the Spaish legislatio that lifted restrictios o prescribig methadoe ad gave rise to a dramatic icrease i the umber of heroi users eterig this treatmet. However, the use of substitutio medicies i residetial facilities (maily therapeutic commuities) did ot occur util the late 1990s ad the begiig of the 21st cetury, sigifyig a chage i the the exclusively drug-free orietatio ad philosophy of these programmes. Accordig to 2012 data, about opioid-depedet idividuals receive substitutio treatmet i Spai. Although the majority (75 80 %) of cliets receive this treatmet i outpatiet facilities, outreach programmes, pharmacies or prisos, about oe-quarter receive substitutio treatmet i residetial (traditioally drug-free) programmes. It is estimated that almost all residetial facilities (a miimum of 90 %) offer cotiuatio of OST to residets. Methadoe is the most widely used medicatio. Of the 131 residetial facilities followig the therapeutic commuity approach, about 90 % allow residets to beefit from OST. Of the 77 residetial facilities applyig cogitive behavioural therapy or other psychotherapy, oe specialises i the treatmet of cocaie users oly ad the remaiig 76 preset o obstacle to cliets who are i receipt of OST at the poit of referral to residetial treatmet or wish to iitiate OST while i residece. Typically, therapeutic commuity residets who beefit from substitute medicatio are already egagig with a outpatiet methadoe prescriber at the time they are admitted ito a therapeutic commuity. The safe dispesig of methadoe prescriptios is carried out by available staff members at the therapeutic commuity, while the cliet is followed up by the outpatiet facility s professioals who iitiated substitutio treatmet for the cliet. I some therapeutic commuities, methadoe is both prescribed ad dispesed, cotiget upo availability of appropriate professioals (medical doctors or urses) who are also resposible for the follow-up of cliets. I cotrast, methadoe is typically dispesed i a coveietly located outpatiet facility for cliets egagig i cogitive behavioural ad other therapy programmes. Some challeges for the future relate to (i) ageig users i OST programmes, who will require better coordiatio betwee health ad social systems ad services providers; (ii) remaiig stigma attached to cliets i OST, which will eed to be resolved for the full acceptace of these idividuals by all health ad social service professioals ad by society i geeral; (iii) broadeig the rage of substitute medicies, to iclude bupreorphie, bupreorphie aloxoe ad others, available to cliets i residetial treatmet, that is if their profile meets the required criteria, ad idepedetly of ecoomic cosideratios about the cost of these medicies. were reported. The study cocluded with a recommedatio about icreased hepatitis C-specific psychiatric educatio ad staff traiig to facilitate better use of residetial treatmet programmes for treatig hepatitis C. Cosequetly, a traiig programme for staff has bee developed, employig a motivatioal approach, ad is available to guide the treatmet of hepatitis C-ifected drug users i residetial programmes (Strauss et al., 2007). Social reitegratio itervetios Although social reitegratio is ot defied cosistetly across EU Member States, it is accepted as a foudatio for drug treatmet. As such, it icludes all those activities that aim to develop huma, social ad ecoomic capital. The three pillars of social reitegratio are (i) housig, (ii) educatio ad (iii) employmet (icludig vocatioal traiig). Other measures, such as cousellig ad leisure activities, may also be used. Although recovery from drug use ad rehabilitatio of problem drug users (particularly i the traditioal abstiece-orieted sese) are ofte focused o the relatioship betwee a idividual ad drug use, social reitegratio is also cocered with the positio of the idividual i wider society. Social reitegratio itervetios, icludig educatio, vocatioal skills traiig ad employmet-related itervetios, are ofte a importat elemet of residetial treatmet programmes. A recet EMCDDA Isights report provides fuller detail o the availability of these itervetios i Europe ad their effectiveess for drug users udergoig treatmet icludig i residetial settigs (EMCDDA, 2012b). 13 / 31

14 I Cotiuig care How should we defie cotiuig care? It is exteded cotact ad support beyod the formal ed of the residetial treatmet episode. The period immediately after leavig residetial treatmet is oe of high risk of relapse to drug use ad icreased overdose related mortality (Ravdal ad Amudse, 2009; Davoli et al., 2007). Promotig ad esurig care ad support is oe possible way to sustai treatmet gais. Studies of cotiuig care followig residetial treatmet (for a review, see McKay, 2009) suggest that the followig may improve outcomes: mothly cotact for the first year of recovery, with adjustmets as ecessary (up or dow accordig to the cliet s level of fuctioig); exteded cotact for years, rather tha moths; availability of medicatios where ecessary; availability of treatmet optios of varyig types ad itesities, should the eed arise. Cotiuig care may be provided i a variety of differet ways, ragig from cotacts ad check-ups to supported accommodatio. For example: Alog with treatmet ad support, the above itervetios may ecourage adherece to atiretroviral medicatio ad to promote geeral health, as well as providig a rapid ad clear route back ito structured treatmet. Treatmet systems esure that referral pathways are i place, ad residetial treatmet services have a rapid re-etry optio. Cotiuig care practices i Europe I most Member States, may residetial facilities offer a programme of aftercare or some form of therapeutic follow-up that is appropriate for idividuals who eed that level of support. Such programmes are reported to be of varyig degrees of comprehesiveess. The itesity ad duratio of care followig a residetial treatmet episode depeds upo the idividual s eeds; available supports rage from loger-term ad self-cotaied therapeutic programmes (e.g. Luxembourg, Frace, Spai) to less supervised half-way ad quarter-way houses (e.g. Hugary, Sloveia) from which idividuals are trasitioig back ito the commuity. Reported practices typically relate to access to housig, employmet ad educatioal support i the commuity ad likage with support groups ad mutual aid groups or peer support (e.g. Narcotics Aoymous (NA)). the Cotracts, Prompts ad Reiforcemet (CPR) itervetio a cogitive behavioural approach desiged to facilitate treatmet ad aftercare by maitaiig cliets cotiuig egagemet with services (Lash ad Blosser, 1999; Lash et al., 2013); telephoe-based follow-up a programme that, after a iitial face-to-face sessio, uses weekly 15- to 20-miute telephoe calls to provide cousellig i cojuctio with behaviour moitorig (McKay et al., 2004; McKay et al., 2005a,b); recovery maagemet check-ups regular phoe calls to (or other cotact with) people who have left residetial treatmet to facilitate early detectio of relapse, reduce the time to treatmet re-etry whe ecessary ad improve log-term outcomes (Scott ad Deis, 2003, 2009, 2011); Oxford Houses abstiece support ad accommodatio i the commuity to former drug users who are willig to live together (Molloy, 1990; Jaso et al., 2007). I Eglad, a joit review carried out by the NTA ad the Healthcare Commissio (ow the Care Quality Commissio) (NTA ad Healthcare Commissio, 2007) foud that 88 % of ipatiet ad residetial services had policies to eable service users to effectively itegrate ito the commuity ad to provide appropriate aftercare followig the service user s exit. The NTA s report o the role of residetial rehabilitatio i a itegrated drug treatmet system foud that residetial rehabilitatio is ot a automatic door from the treatmet system but a itegral part of a etwork of services, ad the majority of residetial rehabilitatio cliets retur to commuity-based treatmet services for further structured support afterwards. Out of the 164 drug or drug ad alcohol residetial rehabilitatio services listed by Drik ad Drug News (DDN, 2011), 85 uits offer aftercare ad 69 uits offer resettlemet. 14 / 31

15 Cotiuig care i residetial treatmet i the Norwegia cotext: a case study Whe treatmet, employmet ad other support providers work i a uified way, cliets are more likely to achieve their treatmet ad social goals. Each idividual has distict treatmet ad social eeds, ad providers eed to work together closely to esure that care plaig is delivered i a seamless way. I Norway, to esure cotiuity of care for residetial treatmet cliets, treatmet ad social services agree commo referral ad care pathways that make use of three-way review meetigs to esure that a itegrated respose to treatmet ad social eeds is offered. While the cliet is i residetial treatmet, a cotact coordiator works with them i a rage of domais, icludig participatio i the Norwegia Labour ad Welfare Orgaizatio qualificatio programme, assistace i fidig accommodatio, ad domestic assistace ad advice. The social services are otified i good time ad with the cliet s coset about the rage of muicipal social services that a idividual cliet would use. The discharge from residetial treatmet is thus prepared i cooperatio betwee the cliet, social services ad the residetial treatmet facility. Drug users i eed of log-term coordiated services are also etitled to a idividual pla. The pla is iteded to be a tool for cooperatio betwee the cliet ad a rage of social services providers i the commuity. Furthermore, it also cotributes to stregtheig coordiatio betwee the relevat service providers health, educatio, employmet sectors to esure that the cliets gets the help they eed. Fially, the idividual pla that is draw up for cliets is supposed to esure that the risk of relapse after a stay i a residetial treatmet programme is reduced. Although the provisio of the rage of social ad therapeutic follow-up services is predomiatly a resposibility of the muicipalities, such services are sometimes offered by the residetial facilities as a itegral part of log-term rehabilitatio. The local authorities ca collaborate with volutary orgaisatios i a partership, but the service is usually achored i the Social Services Act to esure that the rules cocerig correct processig of cases are adhered to ad legal rights are protected. Impact of egagemet with cotiuig care o treatmet outcome There is good evidece that participatio i cotiuig care, icludig egagemet with self-help groups, is importat for sustaied outcomes from treatmets provided i residetial settigs. I Eglad, the Natioal Treatmet Outcome Research Study (NTORS), usig a logitudial, prospective cohort desig, icluded 142 drug-depedet cliets recruited at itake to residetial treatmet. It foud that cliets who atteded mutual aid groups (e.g. NA) after treatmet were more likely to be abstiet from opiates at follow-up, ad more frequet NA attedees were more likely to be abstiet from opiates ad alcohol tha both o-attedees ad ifrequet (less tha weekly) attedees (Gossop et al., 2008). The same coclusio about the beeficial effect of self-help group participatio i terms of icreased abstiece rates at follow-up ad reduced costs of cotiuig care has bee foud i a umber of studies, with a mixture of residetial ad outpatiet attedees (e.g. Moos et al., 1999; Ritsher et al., 2002; Vederhus ad Kristese, 2006; Humphreys ad Moos, 2007). Coutries with orgaisatio at a regioal level reported challeges to the maiteace of sufficiet quality of atiowide referral processes to ad from residetial treatmet ad related collaborative arragemets. For istace, i Austria, such processes ad arragemets are typically able to esure cliets moves from residetial services to the commuity (ad back) withi oe ad the same regio. However, as residetial treatmet facilities have atioal referral/ catchmet areas, it is vital that optimal collaboratio liks be established ad maitaied betwee all relevat service providers across geographical regios. These fidigs suggest that residetial treatmet i Europe should be see as a itegrated part of the etwork of services that form atioal drug treatmet systems. The data show that residetial treatmet is ot ecessarily a exit door from the treatmet system ad that, whe cliets complete their treatmet at a residetial facility, they frequetly retur to commuity-based structured support services from other parts of the system before they are ready to complete their drug treatmet. 15 / 31

16 I 5. Residetial treatmet cliets This sectio looks at the profile of treatmet cliets i residetial programmes ad provides a overview of some specific groups of usig cliets targeted by residetial treatmet. I lie with the TDI protocol ad defiitios (see box), this part of the paper uses the term ipatiet treatmet istead of residetial treatmet. Number of ipatiet treatmet cliets i Europe i I 2011 I the 22 Europea coutries providig data, aroud drug cliets etered ipatiet treatmet i 2011; of these were eterig for the first time. The umber of cliets eterig ipatiet treatmet raged from fewer tha 300 cliets i Luxembourg, Cyprus ad Hugary, through more tha i the Czech Republic, Swede, the UK, Norway FIGURE 5 Drug users eterig ipatiet treatmet i 2011, or the most recet year available, i 20 EU coutries, Turkey ad Norway Germay Norway Uited Kigdom Swede ( 1 ) Czech Republic Turkey Netherlads Greece Austria Belgium Irelad Romaia Slovakia Frace Croatia Polad Filad Bulgaria Hugary Demark Cyprus Luxembourg All cliets ( 1 ) 2010 data. New cliets ( 2 ) Drug treatmet is defied as a activity (activities) that directly targets people who have problems with their drug use ad aims at achievig defied aims with regard to the alleviatio ad/or elimiatio of these problems, provided by experieced or accredited professioals, i the framework of recogised medical, psychological or social assistace practice (EMCDDA, 2012d). ( 3 ) 2011 data ( = 21: Belgium, Bulgaria, the Czech Republic, Demark, Germay, Greece, Frace, Cyprus, Luxembourg, Hugary, the Netherlads, Austria, Irelad, Polad, Romaia, Slovakia, Filad, the UK, Croatia, Turkey, Norway); 2010 data ( = 1: Swede). ( 4 ) 2013 Statistical Bulleti Tables TDI-7 ad TDI-2. Methodological ote: data source ad additioal caveats The best available iformatio source to describe the profile of drug cliets eterig residetial treatmet i Europe is the TDI; see Statistical bulleti (SB) ( 2 ). I lie with TDI protocol ad defiitios, this part of the paper uses the term ipatiet treatmet istead of residetial treatmet. Data are collected o six types of treatmet cetres/ programmes, icludig ipatiet settigs. The category ipatiet settig refers to places where the cliets may stay overight ad iclude therapeutic commuities, private cliics, uits i hospital ad cetres that offer residetial facilities. This defiitio is broader tha the defiitio of residetial settigs used for this paper, although the terms ipatiet ad residetial treatmet are used iterchageably. The structure of TDI data does ot allow for disaggregatio of ipatiet detoxificatio ad residetial treatmet data; this is oe geeral caveat which eeds to be uderstood whe iterpretig the aalysis preseted i this part of the paper. Aother issue that may affect this part of the aalysis is that coutry differeces i the profiles of ipatiet cliets may be related to differeces i orgaisatio at the atioal level of the drug treatmet system, the role of the ipatiet sector ad data coverage of ipatiet cliets, besides actual coutry differeces amog cliets. For the preset aalysis o cliets who eter ipatiet treatmet, data were available from 22 coutries ( 3 ). It should be oted that, i six EU coutries ot reportig ipatiet data ( 4 ), the ipatiet treatmet is likely to play a importat role i the atioal drug treatmet, through either the system of therapeutic commuities (Spai, Italy, Portugal ad Sloveia) or the drug uits i psychiatric hospitals (Latvia ad Lithuaia). Therefore, the Europea picture of ipatiet treatmet cliets that is begiig to emerge should be take with cautio. I two coutries (Estoia ad Malta), all data o cliets eterig drug treatmet are reported without a breakdow by the type of treatmet cetre ad so could ot be icluded i the aalysis. 16 / 31

17 ad Turkey, to about ipatiet cliets reported by Germay ( 5 ) (Figure 5). Ipatiet cliets as a proportio of all treatmet cliets Drug cliets eterig ipatiet cetres represet oly a small proportio of all reported drug cliets; i 2011 they were aroud 11 % of all reported drug cliets i Europe (7 % amog ew cliets) ( 6 ) ( 7 ). The proportio reported to eter ipatiet treatmet varies by coutry (from 2 % i Frace to 79 % i Luxembourg). Those differeces may be partly the result of variatios i data coverage, ragig from 14 % to 100 % of existig ipatiet uits i the coutry, ad resultig i a average of aroud 60 % of ipatiet uits i Europe beig covered i data collectio. Data from 20 coutries i 2011 show that, o average, oe perso commeces ipatiet treatmet for every 11 people startig specialist outpatiet treatmet. However, substatial iter-coutry differeces exist. Equal demad for both modalities is reported i five coutries the Czech Republic, Romaia, Slovakia, Swede ad Norway with betwee 40 % ad 60 % of all treatmet demads beig for either outpatiet or ipatiet treatmet. Eight coutries (Belgium, Greece, Bulgaria, Irelad, Cyprus, Austria, Polad ad Filad) reported that betwee 15 % ad 40 % of all treatmet demad was for ipatiet treatmet. I cotrast, Demark, Frace, Hugary, Croatia ad the UK reported that fewer tha 15 % of all demads were for ipatiet treatmet, idicatig that residetial treatmet may play a lesser role i these coutries. Possible reasos could be costs or geographic coditios (low populatio desity teds to correlate with low availability of specialised services), but traditios ad geeral characteristics of the healthcare system could also be factors (Table 2). TABLE 2 Number of cliets eterig specialist outpatiet ad ipatiet treatmet i 20 Member States i 2011 ad the percetage of all cliets eterig ipatiet treatmet Coutry Ipatiet Outpatiet Ipatiet % Luxembourg Romaia Czech Republic Slovakia Swede ( 1 ) Polad Norway Filad Austria Belgium Greece Bulgaria Irelad Cyprus Netherlads Germay Croatia Hugary Demark Uited Kigdom Frace Total ( 2 ) ( 3 ) 11 Notes: ( 1 ) 2010 data. ( 2 ) More tha 50 % of all ipatiet cliets are reported by the Czech Republic, Norway, Swede, Austria, Belgium, Greece, Irelad, Germay ad the UK. ( 3 ) More tha 50 % of all outpatiet cliets are reported by Greece, Irelad, Germay, Demark, Frace, the UK ad Norway. Characteristics of treatmet cliets i Europe i I 2011: ipatiet versus outpatiet This sectio describes cliets eterig ipatiet treatmet i 2011, with a focus o a umber of sociodemographic features ad patters of drug use, ad also icludes a compariso with the profile of outpatiet treatmet etrats ( 8 ). ( 5 ) 2013 Statistical Bulleti Table TDI-7. ( 6 ) This descriptio is based o data from 20 coutries for which data o both ipatiet ad outpatiet treatmet cliets were available (2011 data, = 19 coutries: Belgium, Bulgaria, the Czech Republic, Demark, Germay, Greece, Frace, Cyprus, Luxembourg, Hugary, Austria, Polad, Swede, Romaia, Slovakia, Filad, the UK, Croatia, Norway; 2010 data, = 1 coutry: Irelad). Two coutries reportig ipatiet data are excluded: Turkey, which reports data oly o ipatiet cliets, ad the Netherlads, which does ot disaggregate ipatiet ad outpatiet data. ( 7 ) 2013 Statistical Bulleti Table TDI-1. ( 8 ) The compariso icludes data from 20 coutries where data o both ipatiet ad outpatiet treatmet settigs were available (2011 data, = 19 coutries: Belgium, Bulgaria, the Czech Republic, Demark, Germay, Greece, Frace, Cyprus, Luxembourg, Hugary, Austria, Romaia, Slovakia, Filad, Irelad, Polad, the UK, Croatia, Norway; 2010 data, = 1 coutry: Swede). A umber of differeces were idetified ad these are show i Appedix 2. Two coutries reportig ipatiet data are excluded: Turkey, which reports data oly o ipatiet cliets, ad the Netherlads, which does ot disaggregate ipatiet ad outpatiet data. 17 / 31

18 Age ad geder Ipatiet cliets are reported to be slightly older (32 years) tha outpatiet cliets (31 years) at treatmet etry, although variatios are reported by drug ad by coutry. The biggest differece is see amog caabis treatmet cliets (ipatiet 27 years vs. outpatiet 25 years). For those with primary opioid-use problems, ipatiet cliets were slightly youger (34 years) tha outpatiet heroi cliets (35 years). The social circumstaces of cliets varied betwee treatmet settigs ad are geerally more disadvatageous for ipatiet tha outpatiet cliets. Higher proportios of ipatiet treatmet etrats reportedly have o schoolig or a basic level of educatio (ipatiet 31 % vs. outpatiet 22 %), are uemployed (ipatiet 61 % vs. outpatiet 48 %) ad live i ustable accommodatio (ipatiet 16 % vs. outpatiet 10 %). Patters of drug use A higher proportio of primary users of amphetamies is oted i ipatiet treatmet (16 %) tha outpatiet treatmet (6 %). Overall, cliets eterig ipatiet treatmet ted to have more precarious patters of drug use, as show by the higher proportios reportig ijectig as the mai route of admiistratio for the primary drug for which they eter treatmet (ipatiet 22 % vs. outpatiet 18 %) (Appedix 2). I Cliets targeted i specialised residetial treatmet Some coutries provide specialised residetial treatmet tailored to the eeds of specific subgroups of cliets, icludig adolescets, people with dual diagoses, ad wome ad/or families with childre, as well as other cliet groups. Modificatios to residetial programmes to meet the treatmet eeds of youg people are available i some Member States (e.g. Germay, Estoia, Irelad, Greece, Frace, Spai, the Netherlads, Portugal, Filad). These programmes vary i the treatmet they provide. Noetheless, commo features iclude varyig degrees of family ivolvemet i the treatmet ad i the process prior to discharge ad the availability of aftercare support for youg people ad their families. Typically, treatmet for this specific group is reported to focus a lot more o persoal plas ad persoal developmet tha o drug depedece. As with other cliet groups, because each youg perso has uique issues ad eeds, programmes determie what is i the best iterest of each idividual before makig treatmet decisios (for more iformatio, see Fourier ad Levy, 2006). Residetial programmes with a special treatmet focus o dual diagoses are rarely reported. However, i a umber of Member States (e.g. Belgium, the Czech Republic, Spai, Italy, Portugal, Sloveia, Filad, the UK), residetial programmes are viewed o a cotiuum depedig o how suited (e.g. i terms of medical staff available, appropriate certificatio of the programme) they are to serve drug-depedet cliets who also suffer from a metal illess. (For reviews of research o residetial programmes for people with severe metal illess ad co-occurrig substace use disorder, see Bruette et al., 2004; Drake et al., 2004.) Specialised residetial programmes specifically tailored to the eeds of wome ad/or wome ad families with childre exist i a umber of coutries (e.g. Belgium, Bulgaria, Germay, the Czech Republic, Irelad, Greece, Spai, Frace, Italy, the Netherlads, Portugal, Sloveia, Filad, the UK, Norway). I additio, some geeral programmes have bee augmeted with special groups that discuss wome s issues, as well as idividual ad group cousellig (for additioal iformatio, see Selected issue o Pregacy, childcare ad family: key issues for Europe s respose to drugs, EMCDDA 2012c). Older drug users represet a growig proportio of drug treatmet demad, icludig i residetial settigs (EMCDDA, 2010). Whereas some coutries (e.g. the Netherlads) report residetial treatmet programmes that cater for the eeds of this ever-growig populatio of drug users, treatmet experts i other coutries (e.g. Spai) report that suitable (log-term) residetial programmes that offer care ad support to chroic, ageig drug users are yet to be fully developed. Modificatios to residetial programmes to meet the treatmet eeds of migrat drug users exist i Germay, Spai ad Greece, ad some Member States report refocusig of existig facilities ad therapeutic tools or establishig ew residetial programmes to address the eeds of idividuals with behavioural addictios such as gamblig (e.g. Bulgaria, Italy, Irelad). I a umber of coutries (e.g. Hugary), although residetial treatmet facilities are reported to be ope to drug users with a rage of eeds, residetial services are ot specifically tailored for particular groups; rather, provisio for specific subgroups of cliets is provided withi a uiversal treatmet framework. I a time of costraied fiscal resources, this approach, with o separatio of residetial services accordig to specific cliet groups, is beig icreasigly see as a attractive mechaism for efficiet resource use. For istace, i Spai, although experts i the coutry agree o the eed for specialised services for certai cliet groups, such as the dually diagosed, there is a growig emphasis o a serve-all approach ad i some autoomous commuities there are a icreasig umber of examples of residetial treatmet caterig for all cliet groups. 18 / 31

19 I 6. Orgaisatioal structure of residetial treatmet This part of the paper examies the orgaisatioal structures of residetial treatmet, that is o-therapeutic attributes that may ifluece the treatmet approach ad the types of services provided to cliets (Durki, 2002). Structural aspects of treatmet facilities iclude fiacig arragemets ad maagemet, owership ad quality maagemet (Heirich ad Ly, 2002; Olmstead ad Sidelar, 2004). local bodies ad private sources (Spai, Swede); local bodies, health isurace ad private sources (the Netherlads); health isurace ad private sources (Belgium, Sloveia); private sources (Bulgaria, Greece, Cyprus, Malta). There are 11 coutries where there is o cetral govermet ivolvemet. Local bodies accout for all residetial treatmet fudig i Demark, Italy ad Filad, whereas local or regioal bodies fiace residetial treatmet i combiatio with fudig from health isurace i the Czech Republic. I Fiacig ad costs First, we review the mai payers or fuders of residetial treatmet services i Europe, before movig o to examie owership ad programme accreditatio. Depedig o the coutry, the fuders of drug treatmet services ca iclude public sources, private sources ad social health isurace. Whe usig the term public sources, we mea fuds raised by govermets through taxes, door grats ad loas (Schieber ad Akiko, 1997). These sources are operated ad maaged at differet admiistrative levels, from atioal to regioal or local. I a umber of Europea coutries, healthcare is fiaced through health isurace, whereby workers ad employers are obliged to cotribute to health isurace fuds which also fiace drug treatmet. Health isurace programmes may also receive govermet fuds for uemployed idividuals ad other groups that are eligible for subsidised cotributios. Other sources iclude doors, either iteratioal or domestic, fiacig drug treatmet through grats, loas ad i-kid cotributios, as well as idividuals who pay out-of-pocket fees directly to providers of residetial treatmet services. I some comparative studies, the mode of fiacig is take as the mai or eve sole idicator for describig healthcare systems. It is clearly importat for cliets access to services whether they are etitled to healthcare o the basis of earmarked social isurace cotributios or citizeship (which, i geeral, meas tax fiacig) or it is ecessary for them to make the paymet privately (Mossialos ad Thomso, 2003). I Europe, govermets are crucial payers for residetial treatmet i 21 of the 23 reportig coutries (Table 3). The roles played by the various levels of govermet, however, differ betwee coutries. I Polad ad Portugal, residetial treatmet fudig is provided solely by the cetral govermet. I 14 further cases, the cetral govermet provides a proportio of the fudig for residetial treatmet, i a joit fiacig arragemet with: local bodies (Estoia, Lithuaia, Hugary, the UK); local bodies ad health isurace (Austria); Fudig of residetial treatmet by health isurace is reported by seve coutries. I three of these (Germay, Frace ad Luxembourg), health isurace is the sole fuder, whereas it is a supplemetary source i four others (Belgium, the Czech Republic, the Netherlads ad Sloveia). The existece of private sources of fuds is reported by ie coutries (Table 3). I the fiacig dimesio, the proportio of residetial treatmet budget as a percetage of the overall drug treatmet budget is a importat idicator for describig drug treatmet systems. A earlier aalysis of 2009 data that icludes three coutries (the Czech Republic, Germay ad Luxembourg) idicates that, i each of the differet coutries, residetial treatmet cosumes a differet share of the total allocatio of drug treatmet resources, ragig betwee 8 % (Germay) ad 43 % (the Czech Republic) (EMCDDA, 2011). Beyod the examiatio of fudig allocatio for residetial treatmet, uit costs, typically preseted i treatmet studies as the daily cost of providig a cliet with a particular sort of treatmet, are a crucial idicator for characterisig residetial TABLE 3 Fuders of residetial drug treatmet i Europe Public health cetral govermet Belgium Bulgaria Estoia Greece Spai Cyprus Lithuaia Hugary Malta ( 2 ) Netherlads Austria ( 2 ) Polad Portugal Sloveia ( 2 ) Swede UK ( 2 ) Public health local govermet Czech Republic Demark Estoia Spai Italy Lithuaia Hugary Netherlads Austria Filad Swede UK Health isurace Belgium Czech Republic Germay ( 1 ), ( 2 ) Frace Luxembourg Netherlads Austria Sloveia Source: Reitox atioal focal poits. Notes: ( 1 ) Health isurace icludes both health ad pesio fuds. ( 2 ) Public fudig icludes welfare fuds or social budgets. Private sources Belgium Bulgaria Greece Spai Cyprus Malta Netherlads Sloveia Swede 19 / 31

20 treatmet. Treatmet itervetios ad the level of professioal staff ivolvemet are amog the factors that have a impact o uit costs. Although the examiatio of residetial treatmet costs, as a simple costig of treatmet exercise or i the cotext of a ecoomic aalysis of the cost beefit variety, is crucial to determie if ad how (log-term) residetial treatmets fit the preset global public spedig cut pla, the data available for uit costig are very limited. Based o data from three atioal focal poits, residetial treatmet per cliet per day was estimated to rage from EUR 31 ( 9 ) (Hugary) through EUR 107 ( 10 ) (the UK) to EUR 622 (Cyprus) (year of referece: 2011). Regardig access to residetial treatmet providers, the share of public fudig idicates the extet to which it is cosidered a public resposibility to guaratee etry for those who require drug treatmet i a residetial settig. For the idividual cliet, aother idicator of the fiacig dimesio is the level of private out-of-pocket paymets. I the geeral health field, a umber of studies have show how private cost sharig reduces health service utilisatio ad icreases iequality (e.g. Thomso ad Mossialos, 2004; Va Doorslaer et al., 2006). Of the ie coutries that idicate that residets (ad/or their families) cotribute fiacially to residetial treatmet, the Netherlads, Spai, Sloveia ad Portugal provide data. I the Netherlads, sice 2012, i some cases, cliets are required to pay cotributios of EUR 5 per day (EUR 145 per moth). However, there are o full mothly cost data to estimate cliets cotributios as a proportio of the total mothly residetial treatmet fee. There are groups of cliets i residece i the Netherlads that are exempt from fees. These groups iclude (i) youg persos (17 years of age or less), (ii) cliets who are compulsorily placed i residetial treatmet ad (iii) crisis admissios. I Spai, a cliet s fiacial cotributio to residetial treatmet typically costitutes a small proportio of the total cost of the treatmet episode. Typically, a cliet s cotributio rages betwee EUR 7 ad EUR 27 per day (EUR 200 ad EUR 800 per moth respectively), although there are cases where cliets bear the total cost of their residetial treatmet. I private residetial facilities i Spai, mothly fees of betwee EUR ad EUR are paid i full by residets. I Sloveia, cliets i residetial treatmet programmes pay up to 20 % of the total treatmet fee. I Type of owership The type of owership idicates the type of etity resposible for the operatio of the residetial facility. Data suggest that, i Europe, residetial facilities fall ito three categories: ( 9 ) Maximum base fudig that ca be requested for the treatmet of a cliet per day i residetial settigs. ( 10 ) Costs are cosiderably higher whe detoxificatio is icluded. govermet, which breaks dow ito state/federal, local/regioal; private, for profit; private, o-profit. I all of the coutries i Europe, the public sector (i.e. govermets, state, local or both), shares a varyig degree of owership of residetial treatmet provisio. Spai, Austria, Filad, Swede ad Portugal report owership of residetial treatmet by private, for-profit, etities. Although a umber of coutries (e.g. Bulgaria, Greece, Austria, Luxembourg, Filad, Spai, Swede, Romaia, the UK) report that the resposibility for the operatio of some residetial treatmet facilities lies with private o-profit orgaisatios (also kow as ogovermetal orgaisatios (NGOs), as the vast majority of NGOs are o-profit), relevat data are limited. Noetheless, i Austria, it ca be established that, of the 24 reported residetial facilities, the legal structure behid 21 % is a NGO. I Swede, the distributio of publicly operated ad private for-profit compaies is almost equal, 40 % ad 42 % respectively, whereas NGOs ow the remaiig 18 % of residetial treatmet facilities. The picture, however, is more complex, as there is subcotractig of the provisio of residetial treatmet services (alog with cliical staff traiig ad workig with the local commuity) by govermets to NGOs. I some cases (e.g. i Spai ad Italy), religious etities maage residetial treatmet facilities o behalf of the state. Although NGOs i Europe have a history of commitmet to addressig the treatmet ad rehabilitatio eeds of drug users, this has bee predomiatly doe through grated subsidies. Recet years, however, have see formal subcotractig of residetial treatmet services to NGOs becomig a promiet ad commo arragemet. For example, i Spai, i order to esure trasparecy ad equity i the dispersio through NGOs of public moey for residetial drug treatmet, the govermet agecy for cotrol ad itervetio systems has istalled a mechaism whereby, aki to the participatio regulatio of the private sector i providig public services, NGO-provided residetial drug treatmet services are purchased by govermet agecies i a cotext of competitio ad biddig. Similar arragemets ca also be observed i the UK. Commetators o iteratioal NGOs ote that preset-day NGOs are ofte legal corporatios with full-time staff ad goverig boards; their orgaisatioal structures are more formal ad complex ad their operatios are more strategic ad busiess-like (Breslow, 2002). Although cotiuig support from govermets ad collaborative relatioships betwee NGOs ad govermetal orgaisatios may be 20 / 31

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