ORGANIZATION OF AMERICAN STATES INTER-AMERICAN DRUG ABUSE CONTROL COMMISSION FIRST INTER-REGIONAL FORUM OF EU-LAC CITIES:PUBLIC POLICIES IN DRUG TREATMENT April 2 5, 2008 Santo Domingo, Dominican Republic OEA/Ser.L/XIV.4 CICAD/EULAC/doc.9pp/08 2 April 2008 Original: Spanish DRUG ADDICTION TREATMENT POLICY IN BARCELONA Dr. Isabel Ribas i Seix Public Health Delegate Barcelona City Council Chair of the ASPB GENERAL SECRETARIAT OF THE ORGANIZATION OF AMERICAN STATES, WASHINGTON, D.C. 20006
DRUG ADDICTION TREATMENT POLICY IN BARCELONA Dr. Isabel Ribas i Seix Public Health Delegate Barcelona City Council Chair of the ASPB (iribas@bcn.cat)
Population: 1,605,602 47.5% men and 52.5% women Percentage over the age of 74: 7.8% of men and 13.4% of women Aliens: 16.5%. Unemployment: 5.3% among men and 7.6% among Women Disposable per capita family income:16,555 (2005) Barcelona is divided into 10 different districts.
BACKGROUND I The heroin use epidemic began in Barcelona in the late 1970s, and peaked in the early 1990s. In the late 80s, signs began to surface of a possible increase in problems stemming from cocaine abuse. In the mid 1990s, an uptick in the number of cocaine-related disorders began to be detected. Given the magnitude of the phenomenon, in 1988 a city plan was devised that was the product of a consensus built among all political forces. At the same time, the Barcelona City Council established its Drug Addictions Policy Group. In 1990 the Generalitat s DSS and the Barcelona City Council entered into an agreement under which the functions of the PDGC in Barcelona were incorporated into the Drug Addiction Action Plan (PADB).
BACKGROUND II to the extent possible, prevent drug use, thereby avoiding the individual and collective social alienation that drug abuse causes; to assist those who want to quit the habit or addiction to become functioning members of society or, at the least, to ensure that drug use takes as little toll as possible on the user s health, life and social milieu. PADB 1988 The main thrusts of Barcelona s Drug Addiction Action Plan (the PADB) were: Prevention Assistance for social re-integration Safety-deterrence-repression Support: science, information, research Territorial A firm commitment to the strategy of mitigating the hazards and harm Treatment system
WHAT WE RE STARTING FROM...
LEGAL DRUGS: TOBACCO AND ALCOHOL As in the rest of Spain, the tobacco epidemic is on the decline in Barcelona. 29% of the adult population smoke on a daily basis. Tobacco is the psychoactive drug that exacts the heaviest toll on health and society, 336 per capita/year. Accounts for 12% of all illness. The pattern of alcohol consumption has changed in recent years; persons dieting consume less; consumption increases on weekends. Ranks second in terms of problem consumption In BCN, 3% population 15-64, a. Risk consumption.* Alcohol s high social and health cost, 265 per capita/year. Alcohol accounts for 8% of all illness.
Estimación usuarios problemáticos heroína y cocaína. BCN 2004 APROXIMATE NUMBER OF PROBLEM USERS IN BARCELONA Nº users 14000 12000 10000 8000 6000 4000 2000 0 7571 13613 4168 1881 1093 1429 257 866 Heroin Cocaine Starting treatment for the first time Starting treatment Patients in treatment Estimated number of problem users The total cost of illegal drug consumption is 58 per capita
HOW WE HANDLE THE PROBLEM IN BARCELONA
DRUG ADDICTION TREATMENT RESOURCES IN CATALUNYA PRINCIPAL TREATMENT AND SOCIAL REINTEGRATION PROGRAMS AND RESOURCES DRUG FREE PALLIATIVES/MEASURES TO MINIMIZE HARM Treatment phases Ambulatory Residential Maintenance with agonists Detoxification CAS* Hospital detoxification PMM: CAS, prisons, hospitals, pharmacies units Needle Exchange Programs Breaking the habit CAS* Therapeutic communities Coffee and Conversation Programs Joining/rejoining society Day Centers Apartments where Social re-integration recovering addicts can program with reintegrate into Supervised use programs community resources society. *CAS = Outpatient drug treatment center
ORGANIZATION Catalonia Health Department Barcelona City Council Barcelona Board of Health Public health Agency
Drug Addiction Treatment Resources in Barcelona H v v h III & B VII ø Q IV & Q Q 3 ( Q Q H H 5 II & 8 F & Q ( 6 Q 7 H CAS = Outpatient treatment center 4 v ø q I H VII H Q Q & VI 2 & v F H F V Q 1 A. RECURSOS ESPECÍFICS CENTRES D ATENCIÓI SEGUIMENT I I II II III III IV IV V VI VI VII 1 2 3 4 5 6 7 CAS BARCELONETA CAS SANTS CAS SARRIÀ HORTA-GUINARDÓ CAS NOU BARRIS CAS GARBIVENT CAS VALL HEBRON CASA BLOC UNITAT D ALCOHOLOGIA DE L HOSPITAL CLÍNIC UNITAT D ALCOHOLISME DE LA GENERALITAT SERVEIDE PREVENCIÓI ORIENTACIÓ(SPOTT) UNITATDE TOXICOMANIES ST. PAU-CITRAN SERVEIDE TOXICOMANIESDE CREUROJA CENTRE CATALÀ DE SOLIDARITAT CECAS(CARITAS) CENTRES DE REINSERCIÓ & TALLERSSOCIO-EDUCATIUS PISOS TERAPÈUTICS TALLER D ALCOHOL B COMUNITAT TERAPÈUTICA ( ASSOCIACIÓ RAUXA ÀMBIT ESPORT SERVEI D ASSESSORAMENT TÈCNIC (SAT) H CENTRE DE DIA ALTRESRECURSOS I PROGRAMES ø Q h q ø v F H AGENTS DE SALUT AL CARRER SERVEI D ATENCIÓ I PREVENCIÓ SOCIO-SANITÀTIA(SAPS) PROGRAMA CALOR I CAFÉ (SPOTT) SALA DE CONSUM BALUARD AGENTS DE SALUT FARMÀCIA PROGRAMA RECOJE PARCSI JARDINS SALA DE CONSUM MÒBIL ZONA FRANCA CENTRE CALOR I CAFÈROBADORS SALA DE CONSUM CAS VALL HEBRON FARMÀCIES DISPEN. METADONA BUS METADONA C.D. METADONA GENERALITAT CENTRE PENITENCIARI(MODEL, WAT-RAS, TRINITAT) UNITAT DESINTOXICACIÓHOSP. (VALL D HEBRON, MAR, CLÍNIC, SANT PAU) B. RECURSOS INESPECÍFICS SERVEIS SOCIALS, SERVEIS SANITARIS,ASSOCIACIONSDE POBRESA
OUTPATIENT AND HOSPITAL TREATMENT CENTERS 14 outpatient drug treatment centers, 6 run by the ASBS which outsources management to various providers. Four detoxification units. PREVENTIVE RESOURCES Drug counseling service, SOD De Marxa Sense Entrebancs Program A program promoting responsible dispensing of alcoholic beverages RESOURCES TO MITIGATE RISKS Five areas devoted to supervised consumption. Needle exchange programs Three coffee-and-conversation locations
The Baluart Room is within these medieval walls.
OTHER THERAPEUTIC RESOURCES A center for dispensing methadone treatments (Health Department, Generalitat de Catalunya) A mobile unit for dispensing methadone treatments Socio-educational workshops (Nou Barris, Sants, Sarrià, Ciutat Vella). A re-integration program A therapeutic community A unit dispensing methadone treatments in the Model Prison and methadone treatment centers in the city s three prisons A system of drug addiction recovery apartments run by various agencies The main public health complications (tuberculosis, AIDS, other infectious diseases, death by overdose, etc.) have eased considerably in recent years, probably because of the control measures and the policies implemented since the early 1990s aimed at mitigating risks. Coverage of 93% of the population of chronic users of opium derivatives
The Drug Addiction Action Plan (PADB) has to be prepared with the participation and involvement of various agents (health, social, education, law enforcement, etc.). Using the Health Impact Assessment method, the various sectors involved discuss the evidence of the intervention techniques employed in order to reach a consensus. 1988-91 1992-95 1996-99 2000-03 2003-05 2006-08
Methodology Health Impact Assessment (HIA) Broad-based participation process Inclusion of proposals Discussion and debate in the ASPB Preparation of draft documents Final proposal Return workshop with participants Discussion in the Drug Policy Group Presentation to the Municipal Plenary Arguments Final approval by the Municipal Plenary
THE STRATEGY The Plan s purpose: To prevent and reduce the use of psychoactive drugs and the negative effects on the individual, family, schools, the workplace and society. 6 main objectives: To protect the rights of non-users To prevent drug use To encourage abstinence among those who want to quit To reduce risks and adverse effects on users To minimize the dangers associated with addiction To encourage those who seek help in quitting.
THE CITY FOCUS The focus here is on: Involving the citizenry as a social health agent, encouraging activities geared toward prevention and toward health and healthy lifestyles. Avoiding clustering of marginalized populations Reordering consumption locations Enforcement Ensuring inter-sectoral coordination of the various governments, NGOs and neighborhood associations.
CHILDREN ADOLESCENTS - YOUTH The focus here is on: Universal prevention for non-consumers Selective, targeted prevention for the at-risk population and for those who have started using. WOMEN The focus here is on: Promoting the inclusion of the gender angle in all interventions (prevention programs, treatment programs, etc.) Reducing the factors that leave women users more vulnerable (motherhood, women working in the sex trade, etc) Pressing for research into gender differences in the use of psychoactive substances and addictive behaviors.
THE ADDICT POPULATION The focus here is on: The focus here is on: Providing the support that those who want to quit need. Strengthening measures that help individuals change behaviors that put them at risk. Promoting treatment resources and programs of proven efficacy. Promoting and facilitating the prevention programs (mitigation of dangers) needed to avoid illness and death caused by overdose, infectious disease, attendant psychiatric disorders, etc. Promoting programs that enable persons with drug addiction problems to become functioning members of society. Stimulating coordination of and collaboration among various public institutions and NGOs Promoting training, applied research and development of data systems on drug addictions.
WHAT CHALLENGES LIE AHEAD?
The drug addiction picture has changed in Barcelona. Recent years have seen a steady increase in problems associated with cocaine use (cardiovascular and psychiatric disorders). Life expectancy among heroin users has increased but is still 21 years less than it is for the general Death caused by overdose, cirrhosis of the liver, accident and other external causes remains high. Drug use is spreading and increase, as is recreation drug use. Society is reacting less and less to the drug problem. No marginalization. Significant but very different dangers like heroin appear to be more tolerated in society.