Regional framework for action to strengthen the public health response to substance use
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Regional framework for action to strengthen the public health response to substance use
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Regional framework for action to strengthen the public health response to substance use
- 1. Tehran, Islamic Republic of Iran 14–17 October 2019 Agenda item 3(f) Dr Khalid Saeed, Regional Adviser, Mental Health and Neurological Disorders Regional framework for action to strengthen the public health response to substance use
- 2. Background 2
- 3. Target 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol The Sustainable Development Agenda, anchored around 17 Sustainable Development Goals (SDGs) and 169 targets, is a universal, people-centred and planet- sensitive agenda, with a set of goals and targets, which outlines a roadmap to transform our world 3 2015 2016
- 5. Mortality and disability-adjusted life years (DALYs) attributable to drugs (by drug type) 2017 Type of substance Age-standardized deaths (per 100 000s) Annual rate of change in deaths attributable to drug use (%) Age- standardized DALYs (per 100 000s) Annual rate of change in DALYs attributable to drug use (%) Global Region Global Region Global Region Global Region Opioids 4.78 5.09 433.0 723.0 Cannabis 0.17 0.14 18.6 13.6 Amphetamine s 0.51 0.36 40.0 19.2 Cocaine 0.38 0.12 26.7 9.3 Other 0.60 0.27 42.4 17.1 All drugs 6.44 5.98 1.88 2.83 560.8 782.0 0.69 1.60 5
- 6. Mortality and disability-adjusted life years (DALYs) attributable to drugs (by cause) 2017 Cause Age-standardized deaths rates (per 100 000) Age-standardized DALY rates (per 100 000) Global Region Global Region HIV 1.10 1.00 58.6 49.9 Hepatitis B 0.14 0.04 4.8 1.4 Hepatitis C 1.99 2.30 60.4 69.1 Drug use 2.27 1.42 371.5 589.4 Road injury 0.54 0.75 36.2 45.8 Suicide 0.53 0.46 29.3 26.7 All causes 6.44 5.98 560.8 782.2 6
- 8. Screening and brief intervention in only 3 countries Receive evidence-based treatment 1 medication for detox 1 medication for maintenance No specialized facilities Outreach services for people who inject drugs Harm reduction programmes 8
- 9. Proposed regional framework for action to strengthen the public health response to substance use Consensus following consultation with stakeholders to bridge implementation gap and operationalize recommendations made in UNGASS 2016 outcome document in line with WHO mandate Overarching principles • Evidence-based • Multisectoral • Life-course approach • Promoting equity and observance of rights • Gender- and culture-sensitive • Active engagement of civil society • Integrated care delivery across the continuum of care 9
- 11. Intervention Comments Authoritative advice to physicians Some evidence it changes prescribing behaviour Restrict over the counter sales and monitor prescription May have some impact Drug courts Reduces illicit drug use and related crime and health problems Primary level care Screening and brief intervention Short-term reduction in drug use Secondary/tertiary level care Pharmacotherapy: Opioid replacement therapy Psychotherapy: CBT for cannabis, opioids and psychostimulant dependence Short-term impact Reduces risk of overdose and opioid use Harm reduction Needle and syringe exchange, voluntary counselling/testing for HIV/hepatitis C, oral naltrexone and emergency naloxone provision (opioid overdose), supervised injecting facilities Needle and syringe exchange may reduce HIV infection but no effect on hepatitis C infection Healthsector response Evidence for policy options Governan ce 11
- 12. Evidence for policy options Promotionand prevention Intervention Comments Universal prevention Skills and psychosocial interventions with primary school children Parenting skills training Multicomponent community programme/prevention in workplace Good behaviour game: long-term effects (up to 15 years) Evidence from programmes for employees with identified substance use problems Selective prevention Skills training with adolescents Early intervention with at-risk youth Short-term effect Short-term effects Indicated prevention Self-help and mutual aid groups Peer self-help organizations Very cost-effective in managing chronic users There is limited/no evidence for the effectiveness of mass media campaigns, drug testing in schools, drug education, and only providing information 1 2
- 14. Governance Develop/update national substance use policies and legislation(s) Develop programmes offering alternatives to incarceration International cooperation Promote active sharing of information and evidence Monitoring & surveillance Develop a core set of indicators Health sector response Integrating screening and brief intervention in primary health care Harm reduction measures Pharmacological and psychosocial interventions Regulatory system for prescription medicines Prevention & promotion Parenting skills, family strengthening, and life skills education in community, educational and workplace settings Proposed regional framework 1 4
- 15. The 66th session of the Regional Committee is invited to endorse the proposed regional framework, which incorporates the best available evidence-informed policy options and cost-effective interventions to address the problem of substance use Conclusion 1 5
Editor's Notes
- PICTURES
- The substance use problem constitutes a serious threat to public health and to the safety, security and well‐being of humanity
- It is inextricably linked with all aspects of the 2030 Agenda for Sustainable Development and humanitarian agendas, as indicated by the inclusion of a specific target (3.5) under SDG 3 to “strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol” The outcome document of the 2016 United Nations General Assembly Special Session (UNGASS) on the world drug problem, acknowledges the need for a multidimensional, comprehensive, integrated and balanced approach to addressing and countering the drug problem, within the framework of the three international drug control conventions.
- According to the WDR 2019, worldwide, around 271 million people are estimated to have used an illicit drug at least once during the preceding year, and some 35.3 million people who suffer from substance use disorders. These drugs are predominantly cannabinoids, opioids, cocaine, and/or amphetamine-type stimulants. Prevalence of substance use varies greatly in the countries of the Region (12.6%-0.5%). Cannabis is the drug most commonly used by the adult population with a median annual prevalence of 3.6%. The prevalence of opioid dependence in the Region is estimated to be 0.29%, which is higher than the global prevalence, while the estimated prevalence of cocaine and amphetamine dependence is similar to their estimated global prevalence. There are emerging trends in drug use in the Region, including use of tramadol and amphetamine-type substances such as Captagon (fenethylline). The emergence of newer psychotropic substances, particularly synthetic cannabinoids, has been reported in some countries; however, their use is relatively low in the Region
- Substance use disorders account for about 0.5 million deaths globally and for 0.55% of the total global burden of disease (0.70% for men and 0.37% for women). Although cannabis is still the most widely used drug globally, opioids account for 76% of deaths, and 75% of DALYs attributable to substance use disorders, globally as well as regionally. The rate of change is significantly higher in the Eastern Mediterranean Region.
- About 11.3 million people worldwide inject drugs. This subgroup endures the greatest health risks, with about 5.6 million individuals living with hepatitis C, 1.4 million people living with HIV, and 1.2 million people living with both these preventable conditions. Highlight hepatitis C as cause of death and drug use disorders as cause of DALYs.
- About 50% of countries either do not have any specialized treatment facilities or these are only available in the capital city. Fewer than one in 7 people with a substance use disorder worldwide receive evidence-based treatment, while in countries of the Eastern Mediterranean Region only one in 13 receives treatment. Screening and brief interventions are only available in < 10% of primary health care services in three countries. Only 1/3 of countries have needle/syringe exchange programmes and condom distribution programmes. Outreach services for injecting drug users are available in only 25% of countries. 63% of countries have at least one medication available for detoxification treatment. 50% of countries report the availability of at least one medication for maintenance treatment (either methadone, buprenorphine or buprenorphine/naloxone).
- Strong leadership and governance at the national level are needed to provide an enabling environment to address the structural barriers to the implementation of policies and access to health services through supportive legislation, policy and financial commitment, and for considering alternatives to punishment for behaviours such as drug use (in full compliance with international drug control conventions), addressing stigma and discrimination (in the health sector and beyond), enhancing community empowerment, and addressing violence against key populations. It is therefore important to consider policy and legislative alternatives that incorporate a public health perspective, and to shift the focus from supply-reduction measures to demand- and harm-reduction measures. Drug treatment is increasingly being provided as an adjunct to the criminal justice system, or as an alternative to incarceration. The treatment of substance use disorders has been consistently shown to reduce illicit drug use and related crime and health problems such as HIV, and to facilitate reintegration into society. Cost-benefit analyses of substance use treatment have estimated that the returns on investment range from 7:1 to 18:1
- Effective prevention starts early, and effective interventions and policies have been identified across many settings (family, school, community, workplace, health sector, and so on) and levels of risk (universal, selective and indicated).