Public drug policies Catalonia Public Health Agency of Catalonia Xavier Majó Roca
Catalonia Barcelona Territory: 32.000 km2 Population: 7.523.000 M Own language and culture
1. What s happened in Catalonia in the 80s 90s? 3
Mortality evolution by cause in Catalonia, 1983-2003 Men and women aged 20 to 39 4
AIDS cases by transmission groups Catalonia 1981-2013 5
Costs of HCV, HBV, HIV for 10 EU countries prior to HCV combination therapy
2. Why? 7
Costs of HCV, HBV, HIV for 10 EU countries prior to HCV combination therapy
People on Methadone Annual breakdown 9500 8500 7500 6500 5500 4500 3500 2500 1500 500 8931 8945 8858 8480 8334 8441 7915 7320 6274 5116 3709 2698 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Needle Exchange Programme Coverage 1993-1994
Intervention Programme on Substance Abuse 11
What s the intervention modelin Catalonia? Public health perspective Public Health and Human Rights Perspective: Health maintenance and improvement of life quality Motivation to change (Proschaska and Di Clemente model) Diversity of services. Empowering drug users Magic and religious rituals Moral paradigm Healthcare model Health public model
The programme on Substance Abuse The Programme on Substance Abuse of the Government of Catalonia is in charge of drug policy planning, implementation and evaluation in the Region of Catalonia in Spain. Main objectives of the Programme: Surveillance of drug use and abuse and the morbimortality related to the use of drugs Definition of policies to deal with the problems related to drug consumptions and to treat people with substance disorders Financing drug resources to prevent, treat and reduce the harm related to drug use Evaluate the measures implemented in Catalonia.
Introducció Planning Tools MENTAL HEALTH DIRECTOR PLAN Assessment, planification and coordination tool about: Mental health promotion Prevention and treatment of mental and substance disorders and Prevenció i el tractament de les malalties associades amb la salut mental i les addiccions, Millora de la qualitat de vida dels afectats. PREVENTION PLAN IN CATALONIA DRUGS USE AND ASSOCIATED PROBLEMS Recull l estratègia nacional de prevenció del consum de drogues i problemes associats a Catalunya
Intervention areas Harm Reduction Harm reduction Based on a Public Health Model Programs: To prevent the risk of infectious diseases and overdoses between people who inject drugs. Working areas:; HR programs (NSP, OST, Overdose Prevention, DCRs, outreach work, HIV/HCV testing and access to treatment, Treatment Coordination of the Drug addiction care and treatment network (XAD). Prevention PROGRAM ON SUBSTANCE ABUSE Epidemiology Prevention programs: To reduce the prevalence of drug consumption. To delay the onset age of drug consumption. To avoid risky behaviors of experimental, occasional and regular drug users. Minimize the harms associated on drugs addiction. Working areas: community, family, working, education, leisure, health. Drug Dependence Information System in Catalonia (SIDC): Monitoring drug care centers (including HR services) School and household surveys Drug related Mortality Drug related Emergencies Infectious disease prevalence among PWID
Drug addiction care and treatment network Drop in centres: 16 (12 Drug Consumption room) Mobile Units: 6 (3 with DCR) Street work: 11 Detox units: 11 Beds: 65 Drug treatment centres 59 Therapeutic C. Units: 20 Places: 596 Dual Diagnosis Units: 5 Crisis Units: 1 Social rehabilitation centres: 12 day centres and 21 social rehabilitation schemes 140 Places on rehabilitation apartments 16
7 Key interventions ECDC & EMCDDA GUIDANCE. Prevention and control of infectious diseases among people who inject drugs. October 2011 1. Access to syringes and injecting material 2. Treatment for drug addiction: Opiates substitution treatment 3. Vaccinations 4. Screening of infections 5. Treatment of Infectious diseases 6. Health Education: safer injection, safer sex, BBV prevention,. 7. Combined interventions adapted to drug users and to the local conditions: outreach work, drop in centres, drug consumption rooms,... 17
Harm Reduction interventions in Catalonia 1 2 3 4 5 6 7 8 9 10 11 12 Opioid substitution programme: 8.000 people Syringe exchange programme (also in prisons): 700.000 syringes/year Outreach work: Street work, Mobile units, Peer involvement, Low thereshold centres (drop in) with social and health care. Blood Borned Viruses tests & counselling (rapid tests) + HBV/HVA vaccinations. Access to HIV and Hepatitis treatment Supervised drug consumption rooms: 100.000 syringes/year Training in a more hygienic consumption, safer sex... Action plan in drug trafficking and consumption areas Access to Health care system for all drug users Heroin trial Overdose Prevention Programme 1.273 professionals trained 6.031 users trained and 5.864 naloxone vials distributed. Promotion and support of drug users and patient organisations 18
1 Opioid Sustitution Therapy Programme (OST) People in OST Programme 7.915 8.480 8.931 8.945 8.858 8.334 8.441 7.768 8.050 7.639 7.923 7.214 8.055 7.103 8.029 8.062 7.452 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Where? Source: Subdirecció General de Drogodependències. Departament de Salut CAS Drug treatment centres Primary care centers Mental Health care centers Harm Reduction Hospitals Community pharmacies Therapeutic communities Prisons 2 nd centers Meeting, Barcelona, June 1 st and 2 nd June, 2017 19
2 Syringe Exchange Programme Evolution of the amount of distributed syringes 1.418.183 1.423.023 1.298.691 1.396.000 471.901 963.674 719.901 790.478 609.263 832.419 867.527 795.584 746.778 734.270 779.205 844.775 851.734 809.193 701.220 745.465 267.297 402.341 85.193 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Where? CAS Drug treatment centres Primary care centers Harm Reduction centers Hospitals Community pharmacies Prisons 20
2 Injecting risk Behaviors (last 6 months) % 90 80 70 60 50 40 30 20 10 0 1993 1998 2002 2008 2012 Injected with an used syringe Passed on a used syringe Shared paraphernalia Injecting drug users attending Harm Reduction facilities 21
3 Outreach work: Street work Professionals, mainly social workers, that work outdoors, in areas of consumption and socially deprivate. 11 Street work teams working in situ with active drug users who don t go to harm reduction resources. Actions: Dynamise the project "Snowball". Pickup of injection material in public spaces. Coordination and referral to social and health resources. Health education. 22
3 Outreach work: Mobile units Main objective: bring the social health services closer to the consumption areas and with high risk exclusion. 6 Mobile Units (3 with Drug Consumption Room) Actions: multiple actions and plans Opioid substitution therapy (OST) Consumption rooms Exchange syringes programme (PIJ) Place for health care Socio-educational care Monitoring the HIV, hepatitis C and tuberculosis treatment Preventing overdose by opioids and/or psychostimulants 23
4 Low thereshold centres (drop in) with social and health care Social and health services for active drug users Main objective: minimize the damages and risks related to drug use 16 centres 10 Actions: Social care Consumption room Syringe exchange programmes Opioid substitution therapy HIV, TBC and HC screening Health education Prevention of opiate and psychostimulants overdoses 24
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5 Access to HIV and hepatitis treatment Main objective: Prevent, diagnose and facilitate the access to the treatment to those drug users infected by HIV and HCV. Actions: Training to professionals and users Edition of professional guides and awareness materials aimed at drug users. Awareness campaigns aimed to the general public. Monitoring of prevalence Early diagnosis (quick tests) Better Treatment for Ageing Drug Guidelines User to increase access to 2 nd Meeting, Barcelona, June 1 st and 2 nd June, Hepatitis 2017 C treatment for drug users 26
5 Prevalence among IDU recruited from Harm Reduction Facilities (antibody test HIV & HCV) The estimation of HIV incidence among new drug injectors (injecting during 5 years or less) is 8,71/100 cases/year and 25,6/100 in HCV cases (Folch C, 2012). 27
5 HIV diagnoses by transmission groups. Catalonia 2001-2013 28
6 Supervised drug Consumption Rooms Installations where people can consume with some privacy and under supervision of one or more professionals, who can help if necessary. Objectives: Preventing contagious diseases among its users. Preventing overdose. Facilitate the contact and the work with active drug dependence Facilitate the access to the treatment. Total: 12 9 in fix installations (2 with smoking room) + 3 in mobile units. 8 29
6 Supervised drug Consumption Rooms Material procured for the supervised consumption: Sterile syringe Distilled water Cup Filter Smart Alcohol pads 30
6 Supervised drug Consumption Rooms Number of CONSUMERS 2007-2014 6.000 5.000 4.523 4.682 5.061 4.581 4.701 5.100 4.000 3.870 4.099 3.000 2.000 1.000 37-44% are foreigners 773 750 625 662 702 0 2007 2008 2009 2010 2011 2012 2013 2014 Better Injectors Treatment for Smokers Ageing Drug User 31
6 Supervised drug Consumption Rooms Number of CONSUMPTIONS 2007-2014 120.000 100.000 84.894 105.751 97.370 106.572 86.841 89.137 93.513 100.101 80.000 70.737 60.000 40.000 20.000 9.196 10.405 9.467 9.789 10.112 10.277 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 Injections Better Treatment Smoked for Ageing consumptions Drug User 32
7 Training: Health care workshops for active drug users 6 teams provide health prevention trainings: Overdose prevention Safer sex, Safe injecting, 55 sessions/year More than 200 different users/year 34
8 Action plan in drug trafficking and consumption areas Demarcated areas or urban areas (neighborhood or set of streets) where there is all kind of consumptions in public places, mainly heroin and cocaine. Girona: 16 PIX points 1 HRS Often these areas are near traffic areas. Lleida: 1 HRS + 4 PIX points Reus: 2 HRS + 22 PIX points Constantí: 1 HRS + 1 PIX points Barcelona: 14 HRS + 70 PIX points El Prat de Llobregat: 2 HRS L Hospitalet de Llobregat: 1 HRS + 11 PIX points HRS: Harm Reduction Services: Harm Reduction Centers, Street work and/or Movbile units PIX points: Syringe Exchange programme (PIX) integrated in pharmacies, primary care centers, treatment centers, hospitals and Creu Roja Badalona: 1 HRS + 20 PIX points Sant Adrià de Besos: 1 HRS Gavà: 1 HRS + 4 PIX points 35
9 Access to Health System for all drug users. Immigrants without documentation. Guarantees access to public health and resources to treat drug addiction. 663 514 559 430 354 339 362 265 314 245 212 282 137 238 193 201 123 14 19 27 40 44 57 68 431 83 104 2008 2009 2010 2011 2012 2013 2014 2015 2016 Active drug users by sex (2008-16) Women Men 36
0 Heroin Trial 37 37
11 Overdose prevention programme Programme to train drug users on overdose prevention and response. Drug users are trained by professionals in Drug Care Centres. Once trained, they are provided with a kit with naloxone. 1.273 professionals trained 6.031 users trained. 5.864 naloxone vials distributed. 38
11 Mortality by acute adverse reaction to drugs. Barcelona 200 180 160 140 120 100 80 60 40 20 0 39
Drug user population Do get they older? 40
Admissions to treatment by main drug Treatment admissions by main drug. 2016 5% 12% 46% 14% 19% 4% Alcohol: 46% Cocaine: 19% Cannabis: 14% Heroine: 12% HEROÏNA COCAÏNA TABAC CÀNNABIS ALCOHOL ALTRES 11.751 starts of treatment (2016) 41
Admissions to treatment by age Admissions to treatment by age. 2016 de 71 a 99 anys 159 de 61 a 70 anys 706 de 51 a 60 anys 1893 de 41 a 50 anys de 31 a 40 anys 3424 3468 de 26 a 30 anys de 18 a 25 anys 970 895 de 11 a 17anys 236 0 500 1000 1500 2000 2500 3000 3500 4000 76 % males --- 24 % females 52% over 40 y/o 42
Harmreduction services HRC users by age 2016 1% 13% Over 40 y/o: 2.680 49 % 35% 51% Under 39 years old 40-49 y/o 50-59 y/o Over 60 y/o 5.455 HRC users 49% HRC users are over 40 y/o 43
Harmreduction services HRC users by residence statuts 2016 2% 2% 3% 0% 3% 9% Houses, floors, apartments Homeless Occupied houses 41 % without or unstable residence 27% 54% Unstable accomodation Pensions,hotel,hostels Prison Another institutions Others, unknown xxxx % of them are more than 40 y/o 44
Visits in HRS by age 242.404 visits (2016) 86 % males and 14 % females) Number of visits to HRS by age. 2016 under 29 y/o 9% 22.611 30-34 y/o 19% 45.438 35-39 y/0 20% 47.321 40-44 y/o 45-99 y/o 55-99 y/o 20% 14% 18% 34.977 44.204 47.853 0 10.000 20.000 30.000 40.000 50.000 52% visits: =+40 y/o 45
Drug users and homeless in Catalonia 37.000 persons with unstable accomodation 31% (11.500) of them are homeless 40% of them with a mental disorder or addiction
Challenges Knowing more about the health and socials problems associated with the age becomes a priority: drugs users and/or people in treatment get older It s necessary to develop an specific attention plan for old drug users on an integral perspective. Nowadays the subject of this current European project is a challenge in Catalonia and surely in Spain: We have more and more ageing drug users (pick of the epidemic 80-90s) Many have chronic diseases (HIV / HCV epidemics), lack of education, not having worked much in their lifetime, Social benefits are very low in Catalonia: Only a rent of 400-500 a month for people who have not worked. No housing, no food subsidies Support from parents. who are dying Economic crises means cuts on social benefits Positive thing: universal access to the health system, regardless of legal situation and tax contribution.
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