Transcript the italian perspective

PUBLIC-PRIVATE GOVERNANCE
IN DRUG-USERS REHABILITATION
AND RECOVERY
Claudio Leonardi, MD PhD
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)
We are going to talk about
1
• The Italian Network
2
• Managing Opioid Addiction Italian Experience
3
4
• Public & Private Governance of Addicts
• Conclusions
The Italian Network
Health Minister
Regional
Health
Assessorship
Welfare Minister
Regional
Welfare
Assessorship
Local Health Authority
(ASL)
G.P.s
Public Health System
DPA
National Dept. for Antidrug Policies
funding
Alcohol Unit
550 Drug Addiction
Centers in Italy
Opiates Unit
Psycho-rehabilitative Unit
1,200 Therapeutic
Communities
(mostly private)
Department of addiction
Prevention Unit
Street Unit
Single
Drug Addiction Centers
Gambling Unit
Eeating Disorder Unit
Treatments
Drug Addiction Center
Pharmacological Detox Treatments
Psychologists
Pharmacological Mid Term Treatments
Social workers
Pharmacologists
Nurses
Pharmacological Long Term Treatments
Prison Health System
Psychological Support
Ser.T. Directors
Psychotherapy
Ser.T. Physicians
Socio-rehabilitative Support
Toxicologists
Internal Medicine
Psychiatrists
Other spec.s
ITALY: Heroin Addiction Therapy
AGONIST
 METHADONE
PARTIAL AGONIST
 BUPRENORPHINE
PARTIAL AGON/ANTAGONIST  BUPREN/NALOXONE
ANTAGONIST
 NALTREXONE
DUAL DRUG DEPENDENCY
MOST HEROIN ADDICTS ALSO ABUSE
OTHER DRUGS LIKE COCAINE,
ALCOHOL,
BENZODIAZEPINES,
STIMULANTS
AND
OPIOIDS
PRESCRIBED
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
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
ITALY: Number of Treatments
YEAR 2015
± 90.000
ITALY
Methadone & Buprenorhine
Treatments Ratio
1 BUPRENORPHINE TREATMENT
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
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
HOWEVER,
COMPLETION
WITHDRAWAL IS
DIFFICULT FOR
MOST!!!
RELAPSES
•OLD “DRUGS” FRIENDS
•PLACES
•RITUALS BEHAVIOUR
•FAMILY
•NO WORK
PROTECTION ENVIRONMENT CAN BE BETTER?
Brief History of Care Interventions in
Residential Therapeutic Community
Yesterday
Today
The same approach for each Diversified
approach
type
of
psychotropic according to the different
substance
substances of abuse
Rigidly drug free program
Use of pharmacotherapies as
an integral part of the
No substance in any phase of rehabilitation program
the rehabilitation program
Physical and temporal area
wider and open to the
Closed structure with strong territory, integrated with
away from public service
social and public health
services
Yesterday
Today
Eeach one is different and is
Everyone must be treated treated in a personalized way
equally
Authority exercise is not
placed from above, but based
Community operator was on interactive relationship.
proposed as authorities
Prevails a non-judgmental
attitude, or punitive damages,
based on listening and
dialogue
Yesterday
Today
Now the goal is integration in
The target was referring to the social and health network
specific parameters:
The perspective changing
Withdrawal Time
from linear to circular and
Autonomy
needs a more comprehensive
Integrating social and work assessment
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
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
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
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
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
Final Conclusions
Multi-factorial
health disorder
Relapsing and
remitting chronic
condition
Drug
Dependence
Treatable
Best treated by
pharmacological and
psychosocial
interventions together
1. WHO/UN-ODC. Principles of drug dependence treatment. Discussion paper. March 2008.
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
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