1. PUBLIC-PRIVATE GOVERNANCE IN DRUG-USERS REHABILITATION AND RECOVERY Member of Italian Council of the Department of Antidrug Policies at Italian Presidency of the Council of Ministers Member of the Expert Group on Treatment and Rehabilitation United Nations Office on Drugs and Crime (ONU) President of the Italian Society on Drug Addiction Pathologies (S.I.Pa.D.) Department Director for Coordination of Inpatient and Outpatient Facilities and of Drug Addiction Centers - Local Public Health Organization (ASL Rome 2) Claudio Leonardi, MD PhD

2. We are going to talk about The Italian Network 1 Managing Opioid Addiction Italian Experience 2 Public & Private Governance of Addicts 3 Conclusions 4

3. 550 Drug Addiction Centers in Italy Department of addiction Single Drug Addiction Centers Alcohol Unit Opiates Unit Psycho-rehabilitative Unit Prevention Unit Street Unit Gambling Unit Local Health Authority (ASL) Public Health System RegionalHealthAssessorship RegionalWelfareAssessorship 1,200 Therapeutic Communities (mostly private) funding Welfare Minister Health Minister Eeating Disorder Unit The Italian Network DPA National Dept. for Antidrug Policies G.P.s

4. Psychologists Social workers Nurses Prison Health System Ser.T. Directors Ser.T. Physicians PsychiatristsInternal MedicineToxicologistsPharmacologistsOther spec.s Pharmacological Detox Treatments Pharmacological Mid Term Treatments Pharmacological Long Term Treatments Psychological Support Psychotherapy Socio-rehabilitative Support Treatments Drug Addiction Center

5. AGONIST  METHADONE PARTIAL AGONIST  BUPRENORPHINE PARTIAL AGON/ANTAGONIST  BUPREN/NALOXONE ANTAGONIST  NALTREXONE ITALY: Heroin Addiction Therapy

6. DUAL DRUG DEPENDENCY MOST HEROIN ADDICTS ALSO ABUSE OTHER DRUGS LIKE COCAINE, ALCOHOL, BENZODIAZEPINES, STIMULANTS AND OPIOIDS PRESCRIBED

7. DUAL DIAGNOSYS  DRUGS DIRECTLY CAUSES MENTAL ILLNESS  MENTAL ILLNESS DIRECTLY CAUSES DRUGS USE AND ABUSE (SELF MEDICATION)  DRUG USING LIFESTYLE INDIRECTLY CAUSES MENTASL ILLNESS  MENTASL ILLNESS HANDICAPS INCREASES VULNERABILITY TO DRUG USE AND ABUSE  COMMON FACTORS PREDISPOSES TO BOTH PROBLEMS

9. DIFFERENT OPIATES AFFECTS  HEROIN AND OTHER DRUGS ABUSE CAUSE PROGRESSIVE BRAIN AND MIND IMPAIRMENT AND INTERMITTENT WITHDRAWAL  METHADONE MAINTENANCE REMOVES INTERMITTENT WITHDRAWAL AND MAY IMPROVE DEPRESSIVE MOOD  BUPRENORPHINE MAINTENANCE REMOVES INTERMITTENT WITHDRAWAL AND IMPROVE DEPRESSIVE MOOD

10. ITALY: Number of Treatments YEAR 2015± 90.000

11. ITALY Methadone & Buprenorhine Treatments Ratio

12. BENEFITS OF PHARMACOTHERAPY (1) THE BENEFITS OF MAINTENANCE THERAPY ARE IMPRESSIVE  ALL THE BRAIN MOOD AND COGNITIVE FUNCTIONS  PSYSICAL HEATH IMPROVES  SEXUAL FUNCTION IMPROVES  MORTALITY IS REDUCED  OFFENDING BEHAVIOUR IS REDUCED  SOCIAL STABILITY IMPROVES  COMORBIDITY ARE STABILIZED  FAMILY RELATIONSHIPS IMPROVE  ACCOMODATION AND WELFARE IMPROVE  CRIME BEHAVIOUR REDUCED

13. BENEFITS OF PHARMACOTHERAPY (2) THE BENEFITS OF DETOXIFICATION THERAPY  REVERSING NEUROADAPTATION  PROMOTING UPTAKE OF POST DETOX TREATMENT  PSYSICAL HEATH IMPROVES  SEXUAL FUNCTION IMPROVES  MORTALITY IS REDUCED  OFFENDING BEHAVIOUR IS REDUCED  SOCIAL STABILITY IMPROVES  COMORBIDITY ARE STABILIZED  FAMILY RELATIONSHIPS IMPROVE  ACCOMODATION AND WELFARE IMPROVE  CRIME BEHAVIOUR REDUCED

14. HOWEVER, COMPLETION WITHDRAWAL IS DIFFICULT FOR MOST!!!

15. RELAPSES OLD “DRUGS” FRIENDSOLD “DRUGS” FRIENDS PLACESPLACES RITUALS BEHAVIOURRITUALS BEHAVIOUR FAMILYFAMILY NO WORKNO WORK PROTECTION ENVIRONMENT CAN BE BETTER?

16. Brief History of Care Interventions in Residential Therapeutic Community

17. Yesterday Today Yesterday Today The same approach for each type of psychotropic substance Rigidly drug free program No substance in any phase of the rehabilitation program Diversified approach according to the different substances of abuse Use of pharmacotherapies as an integral part of the rehabilitation program Closed structure with strong away from public service Physical and temporal area wider and open to the territory, integrated with social and public health services

18. Everyone must be treated equally Community operator was proposed as authorities Eeach one is different and is treated in a personalized way Authority exercise is not placed from above, but based on interactive relationship. Prevails a non-judgmental attitude, or punitive damages, based on listening and dialogue Yesterday Today Yesterday Today

19. The target was referring to specific parameters: Withdrawal Time Autonomy Integrating social and work Now the goal is integration in the social and health network The perspective changing from linear to circular and needs a more comprehensive assessment Yesterday Today Yesterday Today

20. JOINT VENTURE PUBLIC & PRIVATE Mission impossible to achieve about 15 years ago to the absolute incompatibility ideal and ideological between therapeutic program in community and drug treatment, with methadone in particular DEVIL AND HOLY WATER DEVIL AND HOLY WATER

21. JOINT VENTURE PUBLIC & PRIVATE Designing to three hands: Health, Social, Community without a priority and in synergy Fairness in the various phases of the contact: –Process –Reception –Diagnosis –Pharmacotherapy –Stabilization –Evaluation Tools –Follow-up

22. STRENGTHS Mutual cooperation Continuity of care Strong integration Management in a unique and exclusive environment Diagnostic residential Flexibility in the interventions Multiprofessional teamwork Pharmacotherapy as an integral part of community treatment Informal individual counseling

23. OUR EXPERIENCE From 2001 to 2014 Reception Phase (Public towards Private or Private towards Public) Treatment plan shared (Public & Private) Individual pharmacological plan (progressive decrease) Psychological and community containment phase during pharmacologic decrease Drug Free Phase Orientation phase towards the community programmes in Ce.I.S. or others

24. OUR DATA 320 subjects welcomed 272 programmes completed on average in 3 months 192 subjects in various Ce.I.S. programmes Follow-up for two years with drug free status

25. Final Conclusions 1. WHO/UN-ODC. Principles of drug dependence treatment. Discussion paper. March 2008. Multi-factorial health disorder Relapsing and remitting chronic condition Treatable Best treated by pharmacological and psychosocial interventions together Drug Dependence

26. 26 GOALS Permanent staff monitoring Remodeling cognitive maps Motivational stop Place of awareness and care (orientation) Knowledge expansion (use of logic) Pharmacotherapy decrease in a protected environment Addiction management and acting out (comorbidity). Reshaping family relationships Stabilization and rewrite identity Rapid resocialization