Jennifer Hillebrand, „Rehabilitation of Drug Addicted Persons: Experience of Lithuania and European Countries”, 18 October 2007 Improving drug treatment standards across Europe Status quo and challenges

Outline of this presentation Standards/guidelines – Background, definitions. Situation in Europe: inpatient/outpatient psychosocial interventions. Summary, EMCDDA work in this area - outlook

The importance and political background of this topic : EU Action Plan on Drugs : “improve coverage of, access to, quality and evaluation of drug demand reduction programmes and to ensure effective dissemination of evaluated best practices”. Task of EMCDDA: “Provision of information on best practices in the Member States and the facilitation of exchange of such practices”. The status quo of “knowledge transfer and exchange system of ‘good practice’” has to be considered in the context of “Quality Assurance Systems” So for analysing the status quo we look at the main aspects of the “Quality Assurance Systems” in Member States as indicators Background

Quality assurance – a definition Quality assurance can be defined as a system of procedures, checks, audits and corrective actions to ensure that a service and reporting activities are of the highest achievable quality (Last, 1995). Quality assurance can be implemented as a more or less formal control measure and with a higher or lower level of reporting through treatment providers and public control institutions.

What are quality standards in drug treatment? Aim at improvement of quality and effectiveness of drug treatment. Structural (formal) aspects of quality assurance. Process aspects of quality assurance General recommendations for quality of services up to mandatory guidelines in the framework of authorisation of services

Status quo in Europe Source of the information: Structured Questionnaire on treatment, 2005 Structured Questionnaire to all REITOX units in Member States (based on the corresponding chapter of SQ27) July 2007 Replies from 19 countries (17 MS, Croatia, Norway) Quality guidelines Outpatient psychosocial interventions Inpatient psychosocial interventions Substitution/maintenance treatment Detoxification

Some definitions Outpatient services refer to facilities which deliver psychosocial interventions such as structured counselling, motivational enhancement, brief interventions, case management, care-coordination, psychotherapy, day care, relapse prevention, and after care. Inpatient services cover all psychosocial interventions where clients spend the night in a facility ´such as residential treatment units or rehabilitation centres.

Quality guidelines available for inpatient/outpatient psychosocial interventions Yes No No info 2007 data; DG Sanco Questionnaire on quality assurance

Quality guidelines available for substitution/maintenance interventions Yes No No info 2007 data; DG Sanco Questionnaire On quality assurance

Quality guidelines issued by (n=countries) Outpatient psychosocial interventions Inpatient psychosocial interventions Substitution/ maintenanceDetoxification Public authorities1110 Professional associations 1 Public authorities + Professional Associations3375 Public authorities + Professional. Associations +Research institutes1111

Basis for guidelines inpatient/outpatient psychosocial interventions Expert consensus Expert consensus + evidence base None of this No guidelines No information 2007 data; DG Sanco Questionnaire On quality assurance

MM 26% MD 4% TC 1% Psycho-social Treatments 8% Other Pharmacotherapy 61% RCT on treatment for opioid dependence. Specialized Registry. Cochrane Drugs and Alcohol Group. May 2006 (n=1137)

Mandatory for authorisation: inpatient/outpatient psychosocial interventions Yes No No guidelines No information 2007 data; DG Sanco Questionnaire On quality assurance

Guidelines precondition for funding: inpatient/outpatient psychosocial interventions Always Sporadically No precondition No guidelines No information 2007 data; DG Sanco Questionnaire On quality assurance

Guidelines contents Structure – Basic structural aspects; size, installations, accessibility Staff – Staff/client ratio, professional background Process 1 – Guidance for treatment, assessment, planning, referrals Process 2 – Accompanying process for treatment, documentation, evaluation

Monitoring, Evaluation and Research Register – Documentation of treatment entries and reporting Monitoring – Documentation of informations at entry, and discharge and reporting Evaluation – Evaluation (in or external) of treatment episodes with respect to outcome Funding – National funding for evaluation and improvement of treatment interventions

Quality classification of evaluated drug demand reduction projects in the EMCDDA EDDRA database 146 projects to be excluded (23%) 426 level 1 (68%) 48 level 2 (8%)=promising projects 2 level 3 (0,3%)= top level

Summary of the current situation (1) Quality assurance system has developed in the majority of the Member States Basics for knowledge transfer and best practice transfer are only partly implemented in Member States Evaluation, research – this is done sporadically Reviews, evidence reports – this is (with few exceptions) not standard in Member States; soonest in the medical areas a systematic procedure for producing and control new protocols (standard getting best practice) – this is not implemented consensus process – up to now there are at most expert panels

Summary... (2) In general; the area is at an initial stage compared to other areas of the health system compared to standards – that are required in the area of “evidence based” interventions and with regard to demands in drug treatment Gaps are especially the reality for an exchange system as to “Good Practice” and knowledge transfer No clear consensus of what standards/quality guidelines constitute Degree to which evidence is taken into account unclear With a few (national) exceptions this is the context of the coming “Best practice portal”

What can the EMCDDA do to foster development of standards? EMCDDA standards setting (EDDRA) Best practice portal Dissemination of information on national treatment guidelines and standards Policy briefing

EMCDDA best practice portal – Main objective and target groups To provide an overview on the latest evidence on what works in demand reduction field. It will also present tools and standards aimed at improving the quality of interventions, as well as highlighting best-practice examples from the field. It is primarily aimed at professionals, policy-makers and researchers in the drugs field.

Best-practice portal Evidence of what works (and gaps?) Overview on latest systematic reviews on efficacy of Interventions Summary of conclusions on what works/or does not work across latest systematic reviews and information on how the reviews arrived at the conclusions (methodology) Tools to evaluate practices Standards and guidelines for practices Evaluated DDR projects in MS Evaluation Guidelines Guidelines, quality standards for practices developed in different MS EDDRA + inclusion of quality levels in EDDRA Prevention Evaluation resource kit (PERK) Evaluation Instrument Bank + glossary Launch Jan 2008

Thank you to: Peter Degkwitz Consortium „Drugs Policy and Harm Reduction” – DG SANCO

Thank you for your attention.