Practical Guide for the Organization of a. Comprehensive Drug Dependence. Treatment System

Transcription

1 ORGANIZATION OF AMERICAN STATES (OAS) INTER-AMERICAN DRUG ABUSE CONTROL COMMISSION (CICAD) Practical Guide for the Organization of a Comprehensive Drug Dependence Treatment System DRAFT PREPARED BY A WORKING GROUP ON TREATMENT WASHINGTON D.C. October 2003

2 CONTENTS CONTRIBUTORS TO THIS DOCUMENT Working Group on Treatment, Standards Committee Reviewers ACKNOWLEDGMENTS PRESENTATION INTRODUCTION CHAPTER I: Clinical Characteristics of Drug Use Disorders Diagnostic Criteria CHAPTER II: General Principles of Treatment for Drug Use Disorders Treatment Goals General Characteristics of the Services (Minimum Standards) CHAPTER III: The Evaluation of Drug Users and Dependents Basic Evaluation Components Treatment Planning Role of the Treatment Team Selection of the Treatment Modality CHAPTER IV: Organization of a Drug Dependence Treatment System General design of a treatment system Therapeutic Process Treatment System Components of the Treatment System (Areas of Intervention) Treatment Modalities Levels of Care 2

3 CHAPTER V: General Criteria for Patient Placement in Drug Dependence Treatment Services Evaluation Dimensions The Problem of Placing Patients with "Dual Diagnoses Maintenance in and Discharge from a Level of Care CHAPTER VI: Patient Placement Criteria by Level of Care Immediate Attention/Acute Intoxication and Abstinence Syndrome Level I: Outpatient Level II: Intensive Outpatient/Partial Hospitalization Level III: Residential/Treatment Community Level IV: Hospital CONCLUSIONS AND RECOMMENDATIONS GLOSSARY REFERENCES ANNEXES 1. Tables Showing Patient Placement by Level of Care 2. ICD-10 (F10-F19) Mental and behavioral disorders due to the use of Psychotropic Substances 3. DSM IV-TR Substance Related Disorders 3

4 CONTRIBUTORS TO THIS DOCUMENT WORKING GROUP ON TREATMENT STANDARDS COMMITTEE Wallace Mandell Marc Fishman Enrique Madrigal Luis Alfonzo B. Wilbur R. Grimson Anna McG. Chisman María Eugenia Pérez REVIEWERS 4

5 Acknowledgments 5

6 Presentation 6

7 Introduction Drug use and trafficking is a problem whose increasing impact and magnitude have been a source of growing concern to countries throughout the world. Given its complex, multidimensional, and dynamic and changing character, the difficulties entailed in approaching this problem require a major effort to achieve the international cooperation necessary for the design and execution of activities to control and eventually eliminate the problem. This concern is recognized by the member countries of the Organization of American States in their formulation of a Hemispheric Policy on Drugs. Emphasis has been placed not only on cooperation, but also on the constant review and improvement of national policies in each country, according to the specific national circumstances in question. The costs associated with licit and illicit drug use in our hemisphere are adversely affecting the population's quality of life and integrity, particularly in terms of health, but also many other aspects of social, economic, and political life. Responsibility for this enormous social burden lies with the states, to the detriment of normal human development activities, making it imperative to take steps to promptly correct the situation. A particularly a high priority in this regard is providing comprehensive care for the problems associated with drug use, in terms of dependence as well as many other consequences. Such care represents an essential strategic component of demand reduction policies, entailing the design and application of timely, efficient, and broad interventions based on available scientific evidence to correctly understand the main trends and manifestations of these problems, but above all to pave the way for their rational management, including evaluation of the impact of particular measures on the population. Society has the inescapable ethical duty to develop mechanisms enabling the population affected by drug use to obtain treatment and rehabilitation and fully reengage in their family, community, and social environments. Accordingly, countries must develop means of exchanging and sharing 7

8 their experiences in the treatment and rehabilitation of drug users and dependents, with a view to providing the best care possible, accessible for all who require it. This objective represents an enormous challenge given the conditions faced by countries in our hemisphere, whose resources for addressing such problems are limited. Accordingly, particular emphasis has recently been given to the search for mechanisms to make more efficient use of the funds allocated to the treatment needs of drug users. This is tremendously important given the particular circumstances under which treatment services are provided in our region, usually without sufficient and up-to-date prior knowledge of the nature of actual demand for drugs, for lack of information mechanisms to provide a timely and reliable picture of the drug-use situation. As a result, the supply of treatment services, in terms of coverage, accessibility, effectiveness, and diversity of programs, is not what it should be. This is particularly true in the case of drugdependent patients with special needs, such as prison inmates, teenagers, or persons suffering from other physical or mental disorders, who either receive treatment not appropriate to their needs or are excluded entirely from treatment. Another factor complicating the supply of drug dependence treatment is the dynamic, rapidly changing character of supply and demand for commonly used substances, affected by a variety of circumstances. The range of substances abused at any given time or in a given situation is quite broad; new substances are constantly entering the market; the population of drug users is heterogeneous; and new population groups with particular needs are increasingly affected. In addition, in most of our countries, drug dependence treatment services have historically started as and evolved from organizations operating outside the framework of state policies and regulations, in terms of planning, the programming of services, quality standards, and the public's right to receive good care. This lack of a political and legal framework for treatment and rehabilitation services for the drugdependent population is the justification for measures being taken to develop reference parameters for rational interventions, such as a common definition of treatment, the elements constituting a 8

9 network of facilities, and programs to provide care in response to the population's specific needs in this area. To accomplish this objective, the characteristics of demand for treatment, necessary and available resources, and the coordination and organization of services to maximize access for persons in need of them at any given time or place must be described clearly. Relevant aspects include the availability of services, their financing, their duration and continuity, the diversity of supply, the analysis of results obtained from treatment, user satisfaction, etc. In recent decades significant progress has been made in the Americas in improving the quality of treatment services for drug users and dependents. Examples include the formulation of hemispheric guidelines for demand reduction policy, the recommendations of expert groups, institutional strengthening, publications on the quality of drug dependence treatment, and development of the necessary normative and legal framework. Of interest in this connection are recommendations for the integration of drug dependence treatment services within the general health care system; guidance for professional and auxiliary teams with respect to the structural organization of essential treatment components; general and specific rules governing treatment and rehabilitation interventions; the definition of a network of services; and the scope of treatment, rehabilitation, and social reintegration. As an initial consequence of these activities in the region, member countries of the Organization of American States have been devoting increased attention to the development of a normative and regulatory framework enabling them to successfully develop effective treatment systems, subject to scientific parameters. The approaches taken by different countries can be shared and adapted to specific local conditions. That said, the current situation in the region is far from ideal, as evidenced in the progress reports issued by the Multilateral Evaluation Mechanism (MEM). In most member countries: 9

10 o It has not been possible to plan for the provision of treatment services, since in many cases there are no studies permitting the number of drug-dependent persons requiring and potentially benefiting from such services to be estimated. o Drug treatment and rehabilitation programs currently existing in the hemisphere, both public and private, are not evaluated to determine their effectiveness. o Minimum standards of care for drug dependent persons are in place in most countries, although in several cases they are not mandatory for treatment centers. Nineteen countries (55.9%) have standards; of these, the standards are mandatory in 12 (63.2%) and voluntary in seven countries (36.8%) (MEM). In view of this situation, it is recommended to evaluate treatment programs to determine their effectiveness and impact on the beneficiary population. Against this backdrop, the purpose of this document is to provide a tool to help countries in the Americas construct a conceptual basis for developing drug dependence treatment service systems. Taking as a point of departure the progress made in this area by various organizations and experts engaged in treatment, at the national as well as international levels, such as in the case of the World Health Organization (WHO), the Inter-American Drug Abuse Control Commission (CICAD/OAS), the American Society of Addiction Medicine (ASAM), the National Drug Commissions, and the Ministries of Health in the various member countries. The aim is to develop a proposal for the organization of drug dependence treatment services so as to improve their quality, subject to systematic evaluation, on the basis of objective parameters, the definition of minimum standards of quality, good clinical practice, and user satisfaction. First, it is recommended that drug dependence treatment be considered as a continuum of services, ranging from interventions of minimal complexity, for cases where the complications associated with drug use are of minimal intensity, to cases requiring the use of advanced 10

11 technology and highly qualified teams to treat drug use and dependence of such severity that positive results can only be expected if sophisticated resources are applied to treatment and recovery. The continuum concept refers not only to all phases of the addictive disorder, but also to a wide spectrum of available treatment options to be applied according to the individual's or population's specific needs to obtain the best possible results. Second, treatment is defined within a frame of reference consisting of criteria applicable in planning for such key areas as preliminary patient evaluation, the selection of treatment options, admission, derivation, referral, and discharge mechanisms, duration of treatment; and evaluation of the treatment process and results. A series of guidelines is proposed, but their effective application requires adaptation to specific regional and local characteristics. Third, the stage is set for development in the near future of a set of practical recommendations for intervention in the various areas of treatment, in the nature of a common guide for necessary measures in response to the particular needs of the different individuals or groups affected by drug use and dependence. This contribution is designed to provide support for treatment policy makers working directly in the delivery of services, the development of human resources for treatment, or the financing and evaluation of related activities, providing them with a reference source for use in making decisions to improve the quality of treatment services provided to drug users and dependents in the Americas. 11

12 Chapter I: Clinical Characteristics of Drug Use Disorders Mental and behavioral disorders stemming from drug use are the behavioral manifestation of physiopathological alterations produced in various organs and systems, and especially the central nervous system, as a consequence of the toxic effect of socalled psychoactive drugs. These alterations can manifest themselves immediately or over the medium or long term. The severity of the disorder is a function of the interaction between physiopathological change and the particular psychological, social, and cultural circumstances in which the drug use takes place. According to some authors, the clinical evolution of drug use into dependence occurs in gradual phases, corresponding to patterns of increased use and addiction. The main factors contributing to this evolution are the principal motivation for use, tolerance to the substance concerned, and capacity for controlling use. Within this classic framework, there are five phases or types of use: 1. Experimental: Use motivated by curiosity, group pressure, and risk-seeking. 2. Social: Use associated with specific recreational or social activities. 3. Instrumental: Use associated with a desire to experience pleasant emotions or to relieve anxiety through the use of chemical substances. 4. Habitual: The incorporation of drug use into daily life style. 5. Compulsive: Loss of control; lifestyle shaped by drug use, with a consequent deterioration in all areas. (Cohen and Estroff 2001) based on proposals by Johnson (1980), McDonald (1984), and Nowinsky (1990). 12

13 It should be stressed that the problems associated with drug use may occur at any of these stages, not only after a compulsive pattern has developed. In the case of many drug users, a more or less typical pattern of evolution toward addictive disorders can be described. They begin with episodes of use generally motivated by curiosity or social pressure exerted by a group of peers or friends. Depending on the extent of interaction with factors of various kinds, use can become prolonged, with deterioration in selfcontrol and willpower as the functioning of the central nervous system is altered. This is evidenced by behavior generally oriented toward procurement and use of the substance concerned or to re-experience its effects, gradually affecting the user's health and performance in various areas. The clinical manifestations of drug use disorders range from acute intoxication without complications, to abuse, dependency, and even psychotic complications or dementia. These disorders, especially dependence, constitute complex clinical conditions that tend to become increasingly chronic and lead to recurrent behavior, with frequent relapses and repeated attempts at treatment. The most striking clinical characteristics of these disorders include the imperative need to use the substance, to the point of compulsion that is sometimes uncontrollable, and behavioral patterns centered on procurement of the substance, to the detriment of the user's customary behavior and family, work, academic, and social obligations, as the user persists in drug use even in the knowledge of its harmful effects. The following characteristics of drug use are of capital importance diagnostically and for the purposes of treatment planning: Type of drug and current pattern of use: means of administration, frequency of use, and quantity used. Prior history of use: Age of first use, evolution of the disorder, prior treatment. The user's physical, psychological, and social characteristics: Factors predisposing individuals to use drugs, prior illnesses, history of family drug use or dependence, 13

14 mental illnesses Biomedical, psychological, and social impact and complications: Academic, family, and work environment Criteria for the diagnosis and classification of drug use disorders Historically, the operative definition of a drug use disorder has been a subject of some controversy, creating numerous problems for the development and application of treatment programs and the evaluation of their impact. The diagnostic classification instruments that are now most frequently used in the Americas are the World Health Organization s Tenth Revision of the International Classification of Diseases (ICD-10) and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR). Both Instruments give special attention to drug use disorders and proposed clinical diagnostic criteria for identifying demand for treatment services on the basis of uniform criteria. Based on the criteria established for both classifications, various grades and types of alterations resulting from the use of different types of drugs can be identified. Parameters are established for the diagnosis of Dependence and the condition prior to it, such as Abuse or Harmful Use. The instruments also describe the acute and chronic behavioral complications that result from drug use, and in particular Acute Intoxication and Acute Abstinence Syndrome, as well as psychotic, emotional, and cognitive disorders. Each of these disorders is described for the most frequently used types of drugs 1 : alcohol, opioids, cannabinoids, sedatives or hypnotics, cocaine, stimulants (amphetamines, caffeine), hallucinogens, tobacco (nicotine), volatile solvents (inhalants), and multiple substances. 1 DSM IV-TR includes separate categories for disorders resulting from the use of PCP, amphetamines, and caffeine. 14

15 Dependence The diagnosis of dependence refers to a condition in which the subject's behavior during the past year has been characterized by an intense need to use a substance; loss of ability to control use; the appearance of physical symptoms associated with discontinued use or use of reduced quantities (abstinence syndrome); the development of tolerance, requiring greater quantities of the substance to obtain the desired effects; as well as evident deterioration in performance (social, family, academic, work, etc.) and failure at repeated attempts to stop or control use, even in the knowledge of its harmful consequences. In the case of abuse or harmful use, the emphasis is on deterioration or anxiety, harm to physical or mental health as a consequence of substance use, but not to a point where all of the criteria necessary for the diagnosis of dependence have been met. Abuse can be considered a "minor" threat associated with drug use, prior to the development of an addictive illness, or in the worst case, posing a high risk of the development of a dependence disorder. Drug-use related disorders: This refers to a set of clinical entities directly related with acute or chronic drug use. The acute conditions include intoxication, abstinence syndrome, and acute organic psychosis (delirium), as well as situations requiring immediate or emergency attention and a series of chronic complications that include chronic psychosis, emotional disorders, dementia, and other alterations in the user's mental functioning. Dual diagnosis The coexistence of drug use disorders with other health disorders requires special attention, especially in the case of other psychiatric disorders that account for much of the demand for treatment that must be provided by treatment establishments. 15

16 This condition is known as "dual diagnosis", and the relationship between disorders is not necessarily a one-way causal link; influence can be considered to run in both directions. The conditions most frequently encountered in connection with drug use are mood disorders (depression, bipolar disorder) personality disorders (antisocial, etc.), behavioral disorders (aggressive type), schizophrenia, anxiety disorders, eating disorders, pathological games, and suicidal behavior. Nonpsychiatric problems frequently associated with drug use include cardiac toxicity, respiratory problems, hepatic psoriasis, infections (endocarditis, HIV infection, hepatitis), malnutrition, trauma, etc. The coexistence of general and psychiatric medical problems with drug use disorders, either in the form of "dual diagnoses" or acute and chronic complications, calls for a more complex treatment panorama, which in turn makes it necessary to design and implement therapeutic strategies that are usually based on the capacity of traditional services to respond to the needs of dependent patients. These services must be upgraded to provide better response capacity, develop new options, and coordinate with services of different kinds. 16

17 Chapter III: The Evaluation of Drug Users and Dependents Evaluation is the cornerstone for the treatment of drug-use disorders, with respect to the diagnosis as well as the degree of the user's functional impairment, in biological, psychological, and social terms. Evaluation provides the basis for proposing a set of integrated therapeutic interventions or "treatment plan", according to the patient's detected needs. BASIC EVALUATION COMPONENTS At a minimum 2, the evaluation of a patient with drug-use problems should include a review of: Data on drug use. Description of the patient's pattern of drug use, age of first use, type of substance used, quantities, frequency of use, and past and current history of use. It is important to describe the cognitive, psychological, and behavioral effects attributed to the drug or group of drugs; to identify the drug preferred by the patient; and to determine the patient's attitude toward treatment. General medical and psychiatric history. Details should be gathered about prior treatment and hospitalizations and the results obtained. This review should include an appropriate physical examination and laboratory tests and such additional explorations as may be necessary to rule out any other co-occurring pathology or complications. Social and family history. Relevant background information on the patient and his current situation should be described and analyzed. Toxicological evaluation. Detection of substances of abuse in blood, urine, or on the breath. 2 In defining minimum standards requiring the availability of greater technological or financial resources, consideration should be given to local realities (the availability of these resources in each country). Toxicological evaluations or laboratory analyses are good examples in this regard. 17

18 Evaluation findings can be reported in two areas that are essential to the development of a treatment plan: Diagnostic evaluation, on the basis of which the clinical condition is defined according to the criteria set out in current diagnostic classifications (ICD-10; DSM IV-TR). Evaluation of the severity of the disorder, using such instruments as the Addiction Severity Index (ASI), or the equivalent thereof, so as to obtain a detailed picture of the patient's functional impairment in various areas, the implications for the treatment to be pursued, and the prognosis for future evolution of the clinical condition. Treatment needs are determined on the basis of the evaluation, with three possibilities: 1. Immediate intensive treatment when there is imminent danger to the patient or other persons. 2. Outpatient treatment when there is potential but not imminent danger. 3. Guidance and therapeutic induction pending admission to a formal dependence treatment program. Treatment planning The treatment plan summarizes the goals or objectives to be pursued in treatment. It provides a guide or "roadmap" prepared by a treatment establishment's professional team, in consultation with the patient and adjusted to the extent possible to the needs expressed and detected during evaluation, and the treatment resources available in an effort to establish a balance between expressed demand and the feasible supply of services. To design the plan, the problems identified are enumerated and prioritized, and an inventory of the patient's potential and sources of external support, and the extent to which they lend themselves to recovery, is prepared. The treatment plan specifies the expected results of treatment and the possible means of achieving them, within a given spatial and temporal context, so as to detect progress and make the necessary adjustments to ensure the best possible result. 18

19 Indicators are developed to monitor the program's progress within a tentatively indicated period of time, subject to adjustment. This also applies when addressing other pathologies, where treatment can be shortened or extended relative to initial expectations according to progress in accomplishing the goals and finding coherent solutions. In an effort to optimize the patient's general level of functioning, adjustments are made in the treatment plan components in terms of the selection of methods, intensity, frequency, type of service provided, and duration according to their effectiveness in resolving current critical situations as well as their long-term effect on the evolution of the illness. Role of the treatment team The medical and psychiatric team plays an increasingly vital role in the treatment of drug dependence and is assigned central importance in this process by a number of authors. The complexity of the problem and the variety of treatment tasks to be performed also calls for the establishment of multidisciplinary professional and technical teams acting in a variety of settings, such as basic community organizations, clinics, hospitals, detoxification programs, residential care, etc. FUNCTIONS OF THE TREATMENT TEAM Obtaining and strengthening the patient's commitment to treatment. Assessing the patient's clinical condition throughout the recovery process. Providing support in achieving and maintaining abstinence. Reducing the impact of drug use in cases where abstinence is not possible. Managing any acute complications that may arise. Treating concomitant medical or psychiatric disorders. Encouraging the patient to stay in treatment. Preventing, detecting, and dealing with relapses on a timely basis. 19

20 Providing tools through psychological awareness activities to help patients and their families understand drug use disorders. Minimizing disorder-related incapacitation, morbidity, and mortality and improving the subject's overall level of functioning. Selection of the treatment modality The intervention modality or specific treatment setting selected during planning depends on such factors as: 1. Whether the specific treatment modalities required are available when and where they are needed. 2. The degree of control desired over the subject's access to drugs. 3. The resources needed for comprehensive, general medical and psychiatric care. 4. The general treatment environment. 5. The treatment philosophy. 6. The risk of "imminent harm" associated with problems that may have serious consequences for the patient or others, justifying immediate treatment, such as the following: High probability of relapse or continued drug use. Significant risk of severe adverse consequences for the individual or others. The likelihood of this occurring in the immediate future. 7. Estimated duration of treatment. 8. The availability of toxicological monitoring for drug use. 9. The continuity of service over time and the degree of coordination among services at different levels of care. 10. Coordination with other community services, without confining care to modalities that can be incorporated into a specific treatment program. 11. Flexibility and objectivity in the application of placement criteria to optimize the patient's safety and comfort. 20

21 12. The results expected from treatment for each problem identified, according to severity. The results obtained from treatment must be documented based on the available medical and scientific literature. 13. The availability of alternatives in the event of therapeutic failure. Circumstances in which patient placement criteria are not applied There may be circumstances where specific criteria justify patient placement in a given treatment facility, but such placement is not possible currently or indefinitely. Consideration should be given to such situations since rigid application of the criteria could make it harder to meet the user's needs. Examples of circumstances in which patient placement criteria cannot be applied are provided below: When the criteria indicate a type of service or level of care that is not available. When the current program has failed, and the patient needs to be transferred to another treatment program or level. When exercise of the healthcare profession or the operation of an establishment is subject to legal restrictions. TOXICOLOGICAL MONITORING FOR SUBSTANCE USE This is a key factor to be included among the treatment interventions when available, particularly: When there is a high risk of relapse. During the initial stages of treatment When the patient is moved to less intensive levels of care. During the first year of follow-up, after the completion of active treatment. 21

22 The reasons for indicating a particular form of treatment, and for the patient accepting such treatment, are extremely varied. Here are a few examples: The patient's ability to participate and cooperate. Resources (physical, psychological, and social) enabling the patient to benefit from treatment. The degree of structure and external support needed. The patient's capacity to stop using drugs and willingness to adopt behavior to help maintain abstinence. The patient's capacity to avoid high-risk behavior. The need for a particular type of intervention available only in certain treatment settings. The "ideal" treatment It is often asked what constitutes the best drug-dependence treatment program, and there are extremely varied opinions on this point. We would submit that several fundamental components should be present in order for the quality of treatment to be classified as good. The patient should be treated in the least restrictive, freest, safest and most effective setting, with sufficient flexibility to permit movement between different levels of care according to a patient's particular needs and in order to respect his human rights. 22

23 Chapter IV: Organization of a Drug Dependence Treatment System General design of a treatment system The characterization of drug dependence treatment as a "continuum of care refers to complementary approaches to, or dimensions of, service delivery: the longitudinal approach and the crosscutting approach. Under the longitudinal approach to the sequence of treatment interventions the historic approach to some extent the recovery process for a drug user or dependent is divided into distinct phases. The therapeutic measures taken during each of these phases could be provided in different settings but require a logical sequence enabling the patient to progress steadily toward recovery and rehabilitation based on different perspectives with respect to the timing of interventions, ranging from prevention, to the management of relapses, to social reintegration. The crosscutting approach to treatment refers to coordination between different available programs and interventions, in the nature of a services network. These options may take the form of a set of complementary, simultaneous, or short-term interventions, reflecting the diversity required to adequately address the various facets and needs associated with drug-use disorders. Systematic treatment lies at the intersection between these two approaches, as in the case of an integrated organization offering different types of activities or programs and providing care to drug-dependent persons. These patients can be placed in the same institution, in a centralized fashion, but also, and perhaps more commonly, treatment can be coordinated between different institutions through patient referrals so as to ensure proper coverage and continuity. An integrated approach to treatment programs, as opposed to the traditional coordination of services between isolated, parallel establishments specialized in the treatment of drug dependence, is gaining increasing acceptance. As part of this integrated approach, drug dependence treatment programs are linked not only with each other but also with the 23

24 general network of services, particularly primary and specialized healthcare services. Community services play a key role in this context, especially self-help and mutual-help groups, which can provide support at all levels of care. Within the system or network of care, it is important to define the structural elements or basic components, the functional relationship between them, and the different processes used in treatment. For example, in a hospital or clinic, several programs may operate simultaneously or in parallel even though they correspond to different basic components of treatment, as in the case of an outpatient relapse prevention program, or group treatment in the context of short-term inpatient programs, both of which are conducted in hospitals by the same treatment team. Taken together, these components are considered minimum requisites for a system to be regarded as providing high-quality care for drug-use problems. The various treatment components, operating in coordination with the general services network, constitutes the treatment system, which is organized to provide quality care to persons affected by drug use. The various therapeutic interventions are coordinated simultaneously or in sequence and constitute the therapeutic process, which entails varying degrees of intensity and complexity in the use of technology, referred to as levels of care and treatment modalities. Therapeutic process Therapeutic process.-set of activities conducted in a defined setting, program, or establishment, for a particular level of care, as part of the treatment and to satisfy the detected needs of the patient The process or functional components consist of all activities designed for the treatment of drug-use problems according to identified needs, whose execution is defined within a specific setting, program, or establishment (structural component), along the continuum 24

25 of care. These components generally consist of combinations of two types of interventions: a- Pharmacological.-These interventions occur under the control and responsibility of the medical team and are designed to reestablish the user's equilibrium through the use of pharmaceutical products. The objectives include: The treatment of acute intoxication or abstinence syndrome Attenuation of the fortifying or pleasant effects of the drugs being abused The inducement of disagreeable effects when using drugs (aversion effect) Replacement of the drug of abuse with another, having an antagonistic effect The treatment of complications and other concomitant problems b -Psychosocial.- This term covers a series of interventions of various kinds, coordinated by a multidisciplinary team, and designed to address functional impairments resulting from an addictive disorder. The interventions of this kind that have been reported as effective include cognitive-behavioral therapies, behavioral therapies, family and group interpersonal psychodynamics, self-help and mutual held groups, etc. Therapeutic process Therapeutic process: Set of activities performed in a defined setting, program, or establishment, at a specific level of care, as part of the treatment and to satisfy the detected needs of the patient. Pharmacological interventions: Under the control and responsibility of the medical team and designed to reestablish the user's equilibrium through the use of various pharmaceutical products Psychosocial interventions: Responsibility of a multidisciplinary team, designed to address different areas of impairment related to the addictive disorder. Management of: Acute intoxication Acute abstinence syndrome Dependence Biomedical complications Psychological complications Social complications Dual disorder Social reintegration Treatment system 25

26 Treatment system.- A combination of therapeutic interventions, in the nature of a continuum, covering the full spectrum of services (establishments, programs) that are available to substance users at a given time, according to their needs, as well as all services offered subsequently over the course of the disorder as part of the drug-use disorder recovery process. Each of these components is considered extremely important for the establishment and operation of a comprehensive drug dependence treatment system, but they do not have the same relative weight and are rarely encountered in their entirety in most countries of the hemisphere at the current time. The treatment system includes several components or areas of intervention that relate to the distinct stages of addiction, as in the case of emergency or immediate attention, treatment for dependence per se, or social reintegration. In each of these cases, the therapeutic intervention can take place physically in an independent unit, integrated with the operation of the general or specialized healthcare establishment, as well as with social service units or community organizations. Briefly, the following areas of intervention can be identified in a treatment system: Components of the treatment system (areas of intervention) a- Early intervention This refers to a set of services designed to provide timely treatment for high-risk persons who have a strong propensity to develop a drug use problem. This group includes treatment for users whose condition is classified as abuse or harmful use, i.e. for whom the available information does not support a diagnosis of dependence. The activities conducted consist of evaluation and guidance in connection with drug use cases, determination of the need for treatment and the intensity of the treatment to be provided. 26

27 The duration of early intervention various according to the patient's ability to understand information provided and apply it to a change in lifestyle, as well as the development of new problems calling for other interventions. b- Management of intoxication Set of therapeutic measures designed to restore the subject to normal functioning following alteration as a result of recent drug use. These interventions include compensation for such alterations through the use of antagonistic drugs, and the inducement of metabolic and excretory processes. c- Management of abstinence syndrome Set of therapeutic measures designed to correct or compensate for functional alterations and to alleviate the subject's discomfort following a recent and significant reduction or discontinuation of intense and copious drug use. d- Treatment of dependence and abuse Includes all treatment measures designed to restore the functions of psychoactive drug abusers or dependents, which may be carried out in more or less restrictive settings depending on the patient's needs. This includes outpatient treatment of varying degrees of intensity, ranging from early intervention and guidance, external consultations, outpatient or day-hospital care, residential settings, hospitals, and social and community reintegration programs. e- Management of comorbidity (Dual diagnosis and Complications) This refers to treatment for patients with diagnoses indicating a drug use disorder as well as another health disorder, and especially a mental health disorder, that can be carried out in establishments specialized in treating this type of patient or certified for this purpose: i.e. those with professional teams specifically trained in the diagnosis and management of such cases, qualified to conduct psychoeducational activities and establish formal coordination with other external services as needed. 3 3 On the one hand there are patients whose primary disorders are drug-related but who also have a concomitant, but relatively stable, mental disorder. The appropriate treatment for patients in this category can be provided by 27

28 f- Social reintegration This refers to a set of interventions designed to fully restore persons affected by drug dependence or abuse in terms of their level of functioning in family, school, and social environments. Social reintegration involves the following components: Family Vocational/employment support. Job-training Educational counseling Accommodation or housing Treatment modalities Treatment modality.- This refers to the technology used in treating a drug-related problem or group of problems, whose characteristics lend themselves to management using resources with similar degrees of complexity, i.e. treatment activities or processes carried out at a particular level of care. A treatment modality can refer to one or several areas of intervention. For example, an immediate attention service, such as a general hospital emergency room, can intervene to a service designed for drug problems; the patient's characteristics indicate that he is capable of adequately managing his mental disorders. This type of service requires the patient to continue operating autonomously and independently with the capacity to participate in the drug dependence program, which is the main focus of his treatment. The other type of demand comes from patients with unstable, symptomatic, and incapacitating mental disorders, requiring the specific intervention of a psychiatrist and a mental health team in conjunction with the drug treatment, as well as hospitalization in order to participate in a drug treatment program. If the patient's mental state is highly precarious, either because his conditions have become more acute or deteriorated markedly, signaling an imminent danger to the patient or others. Such cases may require permanent psychiatric care, and this condition must be stabilized before entering treatment for both concomitant pathologies. 28

29 manage acute intoxication or abstinence syndrome as well as to evaluate drug-use cases and provide guidance. Immediate attention.- This entails intervention alternatives for the management of patients with clinical conditions requiring a prompt response, since delays in treatment could prove harmful to the patient. This could include acute complications from use (intoxication or abstinence syndrome), but also persons requiring guidance and referral to other modalities. Examples of immediate attention modalities include: o Detoxification unit o General or specialized hospital emergency rooms o Guidance and referral services Outpatient treatment.- Interventions under this treatment modality take place in a nonresidential setting, with time in treatment limited to a few hours with low-frequency (weekly or every other day): Early intervention.- This is a low intensity therapeutic approach to provide timely assistance to drug users at risk of developing a dependence or abuse disorder. The purpose is to minimize the impact of drug use on the subject's life by addressing risk and protective factors. Duration is usually limited to a few weeks and includes psychosocial interventions. A good example of this modality is a community service providing immediate attention to young offenders or drivers under the influence of alcohol. External consultation.- Systematic treatment designed by qualified professionals for drug users or dependents who can benefit from a low intensity setting, following an outpatient treatment plan with defined objectives. Such interventions include professional medical, psychiatric, psychosocial, care; control of medication; evaluation; treatment; rehabilitation; and family-based approaches, with low 29

30 intensity programming on a weekly or twice-weekly basis. The outpatient services of a mental health facility are a good example. Medium intensity care.- Treatment is provided in a nonresidential setting with visits lasting several hours morning, afternoon, or both roughly on a daily basis. Interventions include: Intensive outpatient.- Systematic treatment designed by qualified professionals for drug users or dependents who can benefit from a medium intensity setting, following an outpatient treatment plan with defined objectives. It includes professional medical, psychiatric, psychosocial, care; control of medication; evaluation; treatment; rehabilitation; family-based approaches among other interventions, with medium-intensity programming on a daily basis or three or more times a week. Partial hospitalization (Day clinic / Day hospital).- Systematic treatment designed by qualified professionals for drug users or dependents who can benefit from a medium-intensity setting, following an outpatient treatment plan with defined objectives. Such interventions include professional medical, psychiatric, psychosocial, care; control of medication; evaluation; treatment; rehabilitation; and family-based approaches, with medium-intensity programming on a daily basis or three or more times a week, all day, mornings, afternoons, or weekends. Inpatient treatment.- Systematic treatment designed by qualified professionals for drug users or dependents who can benefit from a high-intensity setting, following a 24-hour inpatient treatment plan with defined objectives. Such interventions include professional medical, psychiatric, psychosocial, care; control of medication; evaluation; treatment; rehabilitation; and family-based approaches. 30

31 Residential:- Emphasis is on the need for a residential, structured setting for users. Such interventions include residential-type services; medical, psychiatric, and psychosocial care; control of medications; evaluation; treatment; rehabilitation; and family-based approaches. Depending on the duration of stay, these programs can be classified as: Short-term.- With a stay of 4-6 weeks. medium- or long-term.-with a stay longer than six weeks, and even years in some cases Treatment Communities (TC), either exclusively residential or with various degrees of participation by healthcare professionals, are a typical example of this treatment modality. Medically-managed hospitalization.- 24-hour inpatient treatment modality emphasizing the need for general and specialized medical attention for needs resulting from drug use disorders and mental health and medical complications, following a treatment plan with defined objectives. Such interventions include residential-type services; medical, psychiatric, and psychosocial care; control of medications; evaluation; treatment; rehabilitation; family-based approaches etc., under the control of a team of qualified healthcare professionals. Community Services These include psychosocial support structures to reinforce interventions at the various stages of treatment, including inducement as well as treatment for dependence and related complications. They cannot be considered treatment programs in the strict sense of the term, but they play an important role in helping individuals recover from addictive disorders. The classic example of this modality is the mutual-help or self-help group, 31

32 such as AA and NA. Other examples include organizations providing academic or employment counseling, transportation support services, childcare centers, etc. Levels of care Level of care.- The institutional or programmatic framework within which the treatment activities take place. The operation and complexity of activities in some establishments may correspond to a single level of care; others may include integrated components corresponding to several levels. A level of care represents a combination of structural elements or types of establishments providing care or conducting activities in response to expressed needs, which will determine the complexity of the service required to adequately treat a drug-use disorder. Emergency/crisis intervention: Management of acute intoxication and abstinence syndrome As we have seen in previous sections, in reviewing the treatment system and treatment modalities, the management of intoxication and abstinence syndrome entails services of medium intensity that do not necessarily represent specific treatment alternatives for addictive disorders but which are undoubtedly extremely useful and help to improve the patient's prognosis. In reality, this therapeutic approach addresses two clinical conditions directly caused by drug use (either current use or discontinuation). The first concern, however, is imminent risk to the subject's life; the technology involved is therefore essentially of the general or specialized medical type (intensive care, toxicology), and nursing, but social and psychological support services are required for patients and their families to manage circumstances related to the medical event per se. Components can be defined to manage these clinical conditions at all levels of care, with greater or lesser intensity of care as appropriate. At each of these levels, the team should be composed 32

33 according to the complexity of care provided. In turn, detoxification services are combined with treatment services according to the patient's needs if the patient has to be placed at a single level. The detoxification service can be offered independently or as part of the drug dependence treatment program. In any case, a comprehensive (biological, psychological, and social) evaluation is required. When detoxification is carried out independently it must be in coordination with the treatment program, in order to maintain continuity and avoid repeated cycles of recovery and relapse, with repeated admission to treatment for acute symptoms, as often occurs when treatment is interrupted in its early stages. Level I: Outpatient. (Early intervention/ External consultation) This level includes a series of organized treatment services or programs to treat a wide variety of conditions. The intervention of a multidisciplinary team specifically trained in the treatment of substance use or mental health disorders is required. Evaluation, treatment, and rehabilitation activities are carried out under the direction of qualified professionals, with regularly conducted sessions following a set of standards and guidelines for intervention according to scientific protocols and within a regulatory policy framework. The treatment provided by outpatient services is designed to bring about permanent change in drug-use behavior and to achieve acceptable levels of mental functioning to the extent allowed by the individual's level of clinical severity. The treatment includes guidance with respect to lifestyles and patterns of behavior that reinforce progress toward therapeutic objectives, and especially a drug-free life. Given the availability of establishments at this level of care, it is important to develop strategies that allow for access to treatment for patients with medical or psychiatric comorbidity, and for those lacking sufficient motivation to undertake a recovery process. Level II: Intensive outpatient / Partial hospitalization. 33