CHAPTER 5. POLICY AND LEGISLATION

CHAPTER 5. POLICY AND LEGISLATION 5.1 Alchl and drug treatment plicy in public health perspective Rbin Rm Fr centuries, physicians, clergy and charity wrkers have prvided treatment r care fr habitual use f alchl r drugs. But the treatment was prvided as part f their general practice f caring. Specialized institutins and prfessinals fr the treatment f alchl disrders first emerged in the 1800s and spread thrugh mre industrialized and urbanized cuntries (Baumhl & Rm, 1987). The initial institutins tended t take ne f tw frms: small hmes, ften run under religius auspices, and larger inebriates asylums, run under medical auspices. Treatment was predminantly inpatient, and ften lasted fr a year r lnger. Patients in inebriates asylums were ften there under a judicial civil cmmitment rder. By 1900, many such institutins were als taking cases with piate and ther drug disrders. In the early 1900s, utpatient treatment f alchl prblems als spread thrugh Eurpe in such frms as municipal advice clinics (Fürsrgestellen) and temperance bards. These early traditins f treatment were disrupted by many factrs: tw wrld wars and a depressin; the advent f alchl prhibitin in sme scieties, and then its failure; the advent f glbal drug prhibitin under the internatinal narctics treaties; and the cnceptual separatin f alchl frm drugs after 1920 (Curtwright, 2005). In many industrialized cuntries, the main institutins in which alchlics culd be fund in the 1940s were mental hspitals, public hspitals and lcal jails (e.g. Crwin & Cunningham, 1944; Rm, 1988). When specialized alchlism treatment began again in the 1950s, initially it was primarily inpatient treatment with relatively lng episdes f care. A separate system f drug addictin treatment agencies was ften set up in parallel as drug prblems emerged in ne cuntry after anther. Particularly fr drugs, treatment was ften cmpulsry, under judicial civil cmmitment rders. Gradually ver the last half-century there has been a trend twards the cmbinatin f treatment services and systems fr alchl and drugs (e.g. Weisner, 1992). Fr alchl in many places, there was a trend until recently twards less cmpulsin in treatment, whereas strng cercin t treatment has remained cmmn fr drugs, as discussed belw. Since the 1980s, there has been a grwth f harm reductin services, particularly fr injecting drug users. The winning plicy argument fr these services, ften against cnsiderable mral ppsitin, emphasized the well-being f the ppulatin at large. Methadne maintenance became plitically acceptable in the United States in the 1980s because it reduced crime rates. After the mid-1980s, harm reductin services fr injecting drug users were implemented in many cuntries as a way f reducing the spread f HIV and ther bldbrne infectins in the ppulatin, and smetimes als t reduce public nuisance n the streets. Harm reductin services thus tend t be justified as prviding benefits at the ppulatin level as well as assistance and care fr thse with drug use disrders. The histry and develpment f alchl and drug treatment services have been described fr a number f cuntries (Klingemann, Takala & Hunt, 1992; Klingemann & Hunt, 1998). 93

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 94 The general trend has been twards develpment f a range f specialized types f treatment and care. There are wide variatins in the mix f types available between cuntries and ften between areas within cuntries. On the ther hand, in a glbalizing wrld, there has als been cnsiderable internatinal diffusin f types f services and mdels f care, thrugh the media f intergvernmental rganizatins such as WHO, prfessinal scieties, internatinal nngvernmental rganizatins and the prfessinal and scientific literature. Almst universally, heavy alchl and drug users are stigmatized (Rm et al., 2001). Thse wh enter specialized alchl r drug treatment are als ften heavily scially marginalized and much less likely than the general ppulatin t be emplyed, stably hused, r in an intact family (e.g. Strbjörk & Rm, 2008). Since the internatinal drug cntrl treaties require that nnmedical use f drugs be criminalized, essentially all cuntries have specific criminal laws cncerning trafficking r ther invlvement in drug markets, and mst als have criminal laws cncerning the use f drugs. Many wh are in treatment fr drug use disrders are thus stigmatized as having criminal recrds, even if they are nt entering treatment specifically because f a criminal curt referral. These tendencies in alchl and drug treatment ppulatins give a special character t plicy and legislatin fr substance use disrders which differ frm the plicy and legislatin fr mst ther disrders. There is a great deal f special legislatin fr the treatment and rehabilitatin f thse with substance use disrders; ver ne-half f the cuntries in the ATLAS survey reprt it. Hwever, much f the legislatin is cncerned with prvisins fr cmpulsry treatment r fr treatment in lieu f jail r ther punishment (Prter et al., 1999). Nearly half f the cuntries included in the survey reprt legislatin cncerning cmpulsry treatment. Drug curts, a relatively new innvatin in which a prgramme f treatment is managed by a judge, with the patient cperating under threat f jail as an alternative, have spread frm the United States t many ther cuntries; 21% f the participating cuntries reprt the presence f drug curts. The unusual distributin f drug curts by incme grup f the cuntry may indicate that drug curts are mst likely t be instituted where the alternative punishment is severe. If ne cnsiders all types f prgrammes that divert clients away frm the criminal justice system and int treatment, sme such diversin is in place in a majrity f the cuntries reprting. The high degree f marginalizatin f many persns with alchl r drug disrders means that many have a cnsiderable need fr gvernment benefits such as disability payments r care. In abut 40% f the cuntries in the survey, such benefits are available (rughly equally t persns with drug use disrders and persns with alchl disrders). Reflecting general patterns f the availability f welfare supprt, the benefits are mre likely t be available in richer cuntries than in prer nes. Entering specialized alchl r drug treatment is itself ften stigmatizing (Rm, 2005); hw t prvide specialized treatment and yet avid cntributing t further stigma is a cntinuing challenge fr the field. The stigma assciated with heavy alchl r drug use, and the degree f cercin ften invlved in entry int treatment, mean that these treatment ppulatins have special needs fr the prtectin f their human rights (Barrett et al., 2008), including cnfidentiality cncerning their treatment. Alchl and drug prblems are relevant t mst f the majr scial handling institutins f mdern scieties: nt nly the health system, but als criminal justice, welfare and disability systems. Alchl and drug prblems thus shw up in the caselads f a brad range f health and human services (Weisner & Schmidt, 1995; Tam, Schmidt & Weisner,

Plicy and legislatin 1996). Specialized alchl and drug treatment services ften emerged in a situatin f neglect f the prblems in these majr systems, and were frequently set up by charismatic individuals r by self-help and ther nnprfessinal grups. Treatment services set up in such circumstances have made a very substantial cntributin t the prvisin f care in many cuntries. Hwever, there have als been instances in which such services have led t damaging results (e.g. Ofshe, 1980). Given the degree f cercin in much f the treatment, there is als a special need fr bth high and ethical standards f care in bth prfessinal and nnprfessinal services. Alchl and drug prblems are much mre widely spread in the ppulatin than the smaller streams f cases entering specialized alchl and drug treatment services wuld indicate. Hwever, the prblems tend t be mre diffuse and less severe in the wider ppulatin than in thse entering the specialized services (Strbjörk & Rm, 2008). Substantial effrts have been made in many cuntries t imprve screening, assessment and brief interventins fr alchl and drug prblems in primary health care and ther service systems, althugh prgress has been slw in institutinalizing these imprvements (Rche & Freeman, 2004). Destigmatizing specialist alchl and drug treatment, and prviding help and cunselling fr scially integrated heavy users wh are less severely affected, are urgent tasks in many places in a public health apprach t alchl and drug treatment plicy. 95

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 5.2 Plicy framewrks and special legislative prvisins (Figures 5.1 5.8) Backgrund Nminated fcal pints were asked abut the presence and nature f natinal substance abuse plicies in their cuntries. Fcal pints were asked abut the availability f special legislatin in their cuntries pertaining t treatment and rehabilitatin f substance use disrders. Mre specifically, fcal pints were required t indicate the presence and nature f special legislatin fr the cmpulsry treatment f substance use disrders in their cuntries. Fcal pints were asked in additin whether gvernment benefits such as disability pensins, subsidies fr fd r husing, r any ther benefits wuld be prvided t persns with alchl and drug use disrders in their cuntries. Salient findings Substance abuse plicies The majrity f cuntries in the survey (68.0%) reprted having a natinal substance abuse plicy, with 100% f high-incme cuntries reprting having such a plicy. The highest prprtin f cuntries reprting substance abuse plicies was in the Eurpean Regin (93.2%). The African Regin (32.6%) reprted the lwest prprtin f cuntries with substance abuse plicies. In Eurpe, 45.5% f cuntries reprted having separate plicies fr alchl and fr drugs. Separate plicies n alchl nly were reprted frm sme cuntries in Africa (2.3%) and Eurpe (18.2%). The largest prprtin f cuntries reprting separate plicies fr drugs were in the Eastern Mediterranean (21.0%), Suth-East Asia (20.0%) and Western Pacific (40.0%) regins. Cuntry incme level appears t have an effect n the availability f substance abuse plicies. A lwer prprtin f substance abuse plicies was reprted frm the lwincme cuntries (38.1%) cmpared with cuntries frm the lwer middle-incme (63.4%), higher middle-incme (79.3%) and high-incme grups (100%). Special legislatin fr treatment and rehabilitatin f substance use disrders The presence f special legislatin fr the treatment and rehabilitatin f substance use disrders was reprted by 55.2% f cuntries in the survey. The highest prprtins f cuntries in the survey reprting special legislatin fr the treatment and rehabilitatin f substance use disrders were in the Eurpean (75.0%) and Eastern Mediterranean (71.4%) regins. Acrss the regins, the lwest prprtin f cuntries reprting special legislatin fr the treatment and rehabilitatin f substance use disrders was in Africa (25.6%). 96

Plicy and legislatin The cuntry incme level affects the presence f special legislatin fr the treatment and rehabilitatin f substance use disrders. A greater prprtin f cuntries in the high-incme grup (82.9%) reprted having special legislatin fr the treatment and rehabilitatin f substance use disrders than cuntries in the higher middle-incme (60.7%), lwer middle-incme (58.5%) and lw-incme (24.4%) grups. Legislatin fr cmpulsry treatment f substance use disrders Special legislatin fr the cmpulsry treatment f substance use disrders was reprted frm 42.5% f cuntries in the survey, with 30% f cuntries reprting special legislatin fr the cmpulsry treatment f bth alchl and drug use disrders tgether. The Western Pacific Regin reprted having the highest prprtin f cuntries (80.0%) with special legislatin fr the cmpulsry treatment f substance use disrders. In this regin, 33.3% f cuntries reprted having special legislatin fr the cmpulsry treatment f drug use disrders nly. The lwest prprtins f cuntries with special legislatin fr the cmpulsry treatment f substance use disrders were reprted frm Africa (16.3%) and the Americas (25.0%). There is n strng effect f cuntry incme n the presence f special legislatin fr the cmpulsry treatment f substance use disrders. Special legislatin fr the cmpulsry treatment f substance use disrders was reprted frm 60.0% f high-incme cuntries, 44.8% f higher middle-incme cuntries, 47.5% f lwer middle-incme cuntries and 21.4% f lw-incme cuntries. Gvernment benefits fr substance use disrders Gvernment benefits fr peple with alchl and drug use disrders were reprted frm 40.6% f cuntries in the survey. The Western Pacific (78.6% fr alchl, 73.3% fr drugs) and Eurpean (69.0% fr alchl, 70.5% fr drugs) regins reprted the highest prprtins f cuntries prviding gvernment benefits fr persns with alchl and drug use disrders. N cuntry in Suth-East Asia reprted having gvernment benefits fr persns with alchl and drug use disrders. There is a strng effect f cuntry incme n the prvisin f gvernment benefits fr substance use disrders, with ver 80% f high-incme cuntries in the survey and apprximately 12% f lw-incme cuntries reprting the prvisin f gvernment benefits fr persns with alchl and drug use disrders. Ntes and cmments The questin n substance abuse plicies prvides an interesting insight int the distinctins between the areas f mental health, drugs and alchl in cuntries. One 97

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders predminant mdel is nt seen, thugh the mst cmmnly reprted mdel has alchl and drugs being cnsidered tgether, but separately frm mental health. It is nt clear why many cuntries d nt have any plicies, nr is it clear what the impact is f having r nt having such plicies. Special legislatin fr the treatment f substance use disrders is in place in many cuntries. A review f such legislatin was cnducted by WHO in 1999 (Prter, 1999). Such legislatin typically may be required fr a number f purpses, namely: t regulate cntrlled substances that are used in the treatment f substance use disrders such as methadne, t facilitate the referral f peple frm the criminal justice system t the treatment system, t enable the cmpulsry treatment f substance use disrders, r t prvide fr the structure f the treatment system. It is ntewrthy that the mst cmmn mdel is t include bth alchl and drugs tgether in such legislatin. The cmpulsry treatment f substance use disrders is cntrversial but is nnetheless envisined in the legislatin f many cuntries. A recent WHO reprt describes the nature f cmpulsry treatment in a number f cuntries in the Western Pacific Regin (WHO, 2009b). The data cllected in this survey d nt distinguish between the presence f legislatin nly fr cmpulsry treatment and the widespread implementatin f such legislatin. 98

Plicy and legislatin Separate plicy fr alchl and separate plicy fr drugs Separate plicy fr drugs nly Separate plicy fr alchl nly Plicy fr alchl and drugs tgether Plicy fr mental health, alchl and drugs tgether 93.2% 71.4% 78.6% 80.0% 73.3% 68.0% 100% 32.6% 79.3% Percentage f cuntries FIGURE 5.1 PRESENCE AND NATURE OF SUBSTANCE ABUSE POLICIES, BY REGION, 2008 63.4% n=147 Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa 38.1% Percentage f cuntries n=147 FIGURE 5.2 PRESENCE AND NATURE OF SUBSTANCE ABUSE POLICIES, BY INCOME GROUP, 2008 High Higher-middle Lwer-middle Lw 55.0% 75.0% 71.4% 64.3% 60.0% 55.2% Percentage f cuntries n=145 25.6% Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa FIGURE 5.3 PRESENCE OF SPECIAL LEGISLATION IN COUNTRIES FOR THE TREATMENT AND REHABILITATION OF SUBSTANCE USE DISORDERS, BY REGION, 2008 60.7% 58.5% 82.9% Percentage f cuntries n=145 24.4% FIGURE 5.4 PRESENCE OF SPECIAL LEGISLATION IN COUNTRIES FOR THE TREATMENT AND REHABILITATION OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 High Higher-middle Lwer-middle Lw 99

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Separate plicy fr alchl Plicy fr alchl and drugs tgether Plicy fr mental health, alchl and drugs tgether 80.0% 60.0% 56.9% 50.0% 42.5% Percentage f cuntries 16.3% 25.0% FIGURE 5.5 PRESENCE AND NATURE OF SPECIAL LEGISLATION FOR THE COMPULSORY TREATMENT OF SUBSTANCE USE DISORDERS, BY REGION, 2008 47.5% 44.8% 60.0% Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa Percentage f cuntries n=146 21.4% FIGURE 5.6 PRESENCE AND NATURE OF SPECIAL LEGISLATION FOR THE COMPULSORY TREATMENT OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 n=146 High Higher-middle Lwer-middle Lw Alchl use disrders [n=138] Drug use disrders [n=143] 70.5% 69.0% 78.6% 73.3% 41.7% 38.5% 40.6% 40.6% Percentage f cuntries 22.2% 22.0% 16.3% 16.3% 0% 0% Suth-East Asia Western Pacifi c Wrld FIGURE 5.7 PROVISION OF GOVERNMENT BENEFITS FOR SUBSTANCE USE DISORDERS, BY REGION, 2008 57.1% 53.6% 86.7% 81.8% Eurpe Americas Eastern Mediterranean Africa Percentage f cuntries 12.2% 11.9% 25.6% 25.0% FIGURE 5.8 PROVISION OF GOVERNMENT BENEFITS FOR SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 100 Lw Lwer-middle High Higher-middle

Plicy and legislatin 5.3 The criminal justice system and substance use disrders (Figures 5.9 5.12) Backgrund Nminated fcal pints were asked t prvide infrmatin abut the presence f drug curts in their cuntries. Fcal pints in cuntries were requested t indicate whether there wuld be prgrammes in their cuntries referring r diverting clients frm the criminal justice system twards treatment. Salient findings Drug curts The presence f drug curts was reprted in 20.5% f cuntries. The highest prprtin f cuntries with drug curts was in the Eastern Mediterranean Regin (38.5%). The African (14.0%) and Americas (14.3%) regins had the lwest prprtins f cuntries with drug curts. There was n effect f cuntry incme level n whether r nt cuntries had drug curts. Prgrammes diverting frm the criminal justice system twards treatment Half f the cuntries in the survey (52.2%) reprted having prgrammes referring r diverting clients frm the criminal justice system twards treatment. The highest prprtins f cuntries in the survey with prgrammes referring r diverting clients frm the criminal justice system twards treatment were reprted by Eurpe (66.6%), the Western Pacific (66.6%), the Eastern Mediterranean (61.6%) and Suth-East Asia (60.0%). Africa reprted the lwest prprtin f cuntries with these prgrammes (27.9%). Fr the majrity f surveyed cuntries in the African, Americas and Eurpean regins, prgrammes referring r diverting clients frm the criminal justice system twards treatment apply t bth alchl and drug use disrders. In the Eastern Mediterranean and Suth-East Asian regins, higher prprtins f cuntries (38.5% and 40.0% respectively) reprted having these prgrammes fr drug use disrders nly. There is an incme effect n the presence f these prgrammes acrss different incme grups f cuntries, with 84.9% f high-incme cuntries in the survey and 38.1% f lw-incme cuntries reprting the presence f these prgrammes. The lwer middle-incme cuntries reprted the highest prprtin f prgrammes fr drug use disrders nly (24.4%). 101

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Ntes and cmments Systems f referral frm the criminal justice system t the treatment system are present in the majrity f cuntries in the survey, and may warrant greater evaluatin and discussin. The predminant mdel f inclusin f bth alchl and drugs in schemes that refer frm the criminal justice system t the health care system suggests that in many cases the scheme is cncerned nt just with the crime f illicit drug use r pssessin but with crimes assciated with bth legal and illegal substance use. The reprted data n presence f drug curts in cuntries shuld be interpreted with cautin as the understanding f the term by nminated fcal pints culd vary, and reprted data culd als reflect the presence f special prcedures fr ffenders with drug use disrders. 102

Plicy and legislatin 38.5% 30.0% 26.7% 20.5% 20.5% 14.0% 14.3% FIGURE 5.9 PROPORTION OF COUNTRIES WITH DRUG COURTS, BY REGION, 2008 26.2% 22.5% 25.7% Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa n=146 3.4% High Higher-middle Lwer-middle Lw FIGURE 5.10 PROPORTION OF COUNTRIES WITH DRUG COURTS, BY INCOME GROUP, 2008 n=146 Fr bth alchl and drug use disrders Fr drug use disrders nly 66.6% 66.6% 61.6% 60.0% 52.5% 55.0% 27.9% FIGURE 5.11 PROPORTION OF COUNTRIES WITH PROGRAMMES REFERRING OR DIVERTING CLIENTS FROM THE CRIMINAL JUSTICE SYSTEM TOWARDS TREATMENT, BY REGION, 2008 55.5% 84.9% Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa n=143 38.1% 39.0% High Higher-middle Lwer-middle Lw FIGURE 5.12 PROPORTION OF COUNTRIES WITH PROGRAMMES REFERRING OR DIVERTING CLIENTS FROM THE CRIMINAL JUSTICE SYSTEM TOWARDS TREATMENT, BY INCOME GROUP, 2008 n=143 103