Alcohol and drug treatment systems in public health perspective: mediators and moderators of population effects

Closing the treatment gap for alcohol use disorders in low- and middle-income countries

The alcohol-attributable disease burden is greater in low- and middle-income countries (LMICs) as compared to high-income countries. Despite the effectiveness of interventions such as health promotion and education, brief interventions, psychological treatments, family-focused interventions, and biomedical treatments, access to evidence-based care for alcohol use disorders (AUDs) in LMICs is limited. This can be explained by poor access to general health and mental health care, limited availability of relevant clinical skills among health care providers, lack of political will and/or financial resources, historical stigma and discrimination against people with AUDs, and poor planning and implementation of policies. Access to care for AUDs in LMICs could be improved through evidence-based strategies such as designing innovative, local and culturally acceptable solutions, health system strengthening by adopting a collaborative stepped care approach, horizontal integration of care into existing models of care (e.g., HIV care), task sharing to optimise limited human resources, working with families of individuals with AUD, and leveraging technology-enabled interventions. Moving ahead, research, policy and practice in LMICs need to focus on evidence-based decision-making, responsiveness to context and culture, working collaboratively with a range of stakeholders to design and implement interventions, identifying upstream social determinants of AUDs, developing and evaluating policy interventions such as increased taxation on alcohol, and developing services for special populations (e.g., adolescents) with AUDs.

Comparing Cannabis Use Disorder in the General Population with Cannabis Treatment Seekers Using Multi-Source National Datasets: Who Receives Treatment?

INTRODUCTION

Given the increased prevalence of cannabis use in Ireland and increase in cannabis potency, this study aimed to estimate the size of the potential population in Ireland that may be in need of cannabis treatment and the percentage of people with cannabis use disorder (CUD) who actually access treatment. We also compared the profile of those with CUD in the general population to those who receive treatment for their cannabis use to explore whether certain subgroups are more or less likely to enter treatment.

METHOD

This was a retrospective, multi-source database study. Data were obtained from (1) Ireland's 2014/2015 national general population survey (GPS) on drug use and (2) treatment data from the Irish National Drug Treatment Reporting System (NDTRS) for 2015. The profiles of GPS cases with CUD and NDTRS cases were compared using 2-sided t tests designed for independent samples.

RESULTS

The prevalence of last year cannabis use among adults aged 15 and older was 6.5% and the prevalence of CUD was 2.6%, representing 94,515 of the Irish population. A total of 4,761 cases entered treatment for problem cannabis use. NDTRS treatment cases were significantly more likely than GPS cases to be unemployed (63.7% vs. 26.6%) and have no or primary level only educational attainment (56.3% vs. 21.2%). Over half (53.3%) of NDTRS cases first used cannabis before the age of 15 years, compared to 14.7% of CUD cases in the population.

DISCUSSION/CONCLUSION

Our findings suggest that earlier users and those with more complex or disadvantaged lives are more likely to seek treatment. A broad population health approach that engages multiple sectors such as health, social welfare, and education is recommended to ensure that there is increased opportunity for people with CUD to be identified and signposted towards treatment.

Posttraumatic Stress Disorder Symptomatology and Substance Use in an Outpatient Concurrent Disorders Sample

OBJECTIVE

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) present a complex and often severe clinical presentation within a concurrent disorders context. The objective of this study was to examine associations between PTSD symptoms and SUD outcomes to better understand the clinical phenomenon of comorbid PTSD and SUD. Multivariate statistical methods were used to test the hypothesis that elevated PTSD symptoms, both at the level of global severity and specific PTSD symptom clusters, are associated with greater substance use and related problems.

METHODS

Data were collected from an intake assessment battery within a specialized concurrent disorders outpatient service in Hamilton, ON. The sample comprised 326 participants (mean age = 37.19, 45.4% female). Structural equation models examined associations between PTSD and alcohol, cannabis, and substance use frequency and problems, controlling for age and sex. Alcohol was ultimately dropped from the model due to non-significant bivariate associations.

RESULTS

Higher global PTSD symptomatology was significantly associated with higher cannabis and other substance use frequency and related problems. Analyses using PTSD cluster scores showed higher scores for alterations in arousal were positively associated with cannabis-related problems, drug-related problems, and cannabis and other substance use frequency. Avoidance was significantly associated with cannabis frequency and cannabis-related problems. In general, effect sizes were small in magnitude, accounting for between 9% and 25% of variance.

CONCLUSION

Significant cluster-level associations indicate the importance of specific PTSD symptoms (hyperarousal, avoidance) in relation to substance use when identifying therapeutic targets among individuals presenting with comorbid PTSD-SUD. This multivariate approach provides a higher resolution and potentially more clinically informative representation of the complex clinical presentation of PTSD and SUD in a concurrent disorder population and could guide the development of more effective treatment paths.

Is disinvestment from alcohol and drug treatment services associated with treatment access, completions and related harm? An analysis of English expenditure and outcomes data

INTRODUCTION

The positive impact of substance use treatment is well-evidenced but there has been substantial disinvestment from publicly funded treatment services in England since 2013/2014. This paper examines whether this disinvestment from adult alcohol and drug treatment provision was associated with changes in treatment and health outcomes, including: treatment access, successful completions from treatment, alcohol-specific hospital admissions, alcohol-specific mortality and drug-related deaths.

METHODS

Annual administrative data from 2013/2014 to 2018/2019 was matched at local government level and multi-level time series analysis using linear mixed-effect modelling conducted for 151 upper-tier local authorities in England.

RESULTS

Between 2013/2014 and 2018/2019, £212.2 million was disinvested from alcohol and drug treatment services, representing a 27% decrease. Concurrently, 11% fewer people accessed, and 21% fewer successfully completed, treatment. On average, controlling for other potential explanatory factors, a £10 000 disinvestment from alcohol and drug treatment services was associated with reductions in all treatment outcomes, including 0.3 fewer adults in treatment (95% confidence interval 0.16-0.45) and 0.21 fewer adults successfully completing treatment (95% % confidence interval 0.12-0.29). A £10 000 disinvestment from alcohol treatment was not significantly associated with changes in alcohol-specific hospital admissions or mortality, nor was disinvestment from drug treatment associated with the rate of drug-related deaths.

DISCUSSION AND CONCLUSIONS

Local authority spending cuts to alcohol and drug treatment services in England were associated with fewer people accessing and successfully completing alcohol and drug treatment but were not associated with changes in related hospital admissions and deaths.

Specialist alcohol inpatient treatment admissions and non-specialist hospital admissions for alcohol withdrawal in England: an inverse relationship

AIMS

We assessed the relationship between specialist and non-specialist admissions for alcohol withdrawal since the introduction of the UK government Health and Social Care Act in 2012.

METHODS

Using publicly available national data sets from 2009 to 2019, we compared the number of alcohol withdrawal admissions and estimated costs in specialist and non-specialist treatment settings.

RESULTS

A significant negative correlation providing strong evidence of an association was observed between the fall in specialist and rise in non-specialist admissions. Significant cost reductions within specialist services were displaced to non-specialist settings.

CONCLUSIONS

The shift in demand from specialist to non-specialist alcohol admissions due to policy changes in England should be reversed by specialist workforce investment to improve outcomes. In the meantime, non-specialist services and staff must be resourced and equipped to meet the complex needs of these service users.

Balancing welfare and market logics: Procurement regulations for social and health services in four Nordic welfare states

Aim:

In increasingly market-oriented welfare regimes, public procurement is one of the most important instruments for influencing who produces which services. This article analyses recent procurement regulations in four Nordic countries from the point of view of addiction treatment. The implementation of public procurement in this field can be viewed as a domain struggle between the market logic and the welfare logic. By comparing the revision of the regulations after the 2014 EU directives in Denmark, Finland, Norway, and Sweden, we identify factors affecting the protection of a welfare logic in procurement. We discuss the possible effects of different procurement regulations for population welfare and health.

Data and theoretical perspective:

The study is based on the recently revised procurement laws in the four countries, and adherent guidelines. The analysis is inspired by institutional logics, looking at patterns of practices, interests, actors, and procurement as rules for practices.

Results:

Procurement regulations are today markedly different in the four countries. The protection of welfare and public health aspects in procurement – strongest in Norway – is not solely dependent on party political support. Existing service providers and established steering practices play a crucial role.

Conclusion:

In a situation where market steering has become an established practice and private providers are strongly present, it can be difficult to introduce strong requirements for protection of welfare and population health in procurement of social services.

Successes and failures in treatment of substance abuse: Treatment system perspectives and lessons from the European continent

Objective:

The article offers an inventory of controversial basic issues related to treatment responses and their sociocultural political context, highlighting policy failures and successes, with a focus on Europe. As a reference point for this assessment, serves a conceptual framework of an “ideal type of treatment system”, which is built upon the following normative assumptions: the objective of harm minimisation or preventing substance-use-related consequences, evidence-based decision making, securing equity and accessibility also from a user perspective as well as efficiency in terms of the diversity and choice of treatment options.

Method:

Five major issues of addiction treatment systems, as identified and exemplified by an expert survey among 14 countries conducted in 2014, served as a reference for discussing fundamental gaps between an assumed ideal type of treatment system and the treatment response in practice: (1) Resistance to change, consensus building and innovation, (2) Political influence and target group bias beyond evidence, (3) Assumptions about rationality and universal evidence, (4) Myths of addiction and ethical deficits and (5) The treatment gap and user perspectives.

Results/conclusions:

Recommendations relevant for politicians, system planners, and clinicians are formulated for each of the five issues, specifically focusing on embeddedness of treatment systems in macro-societal conditions, the abstinence paradigm and outcome diversity, ethnocentric biases of the “evidence credo”, learning from self-change as the major road to recovery, and questioning implicit conceptions of the “addict as a human being”. Furthermore, it is concluded that theories regarding the diffusion of innovation and knowledge exchange can inform future research.

How Substance Use Treatment Professionals Manage Organisational Tensions

Abstract. Aims: The study examined how substance use treatment professionals managed problems and tensions in their work, and explored if the strategies varied by organisational features related to New Public Management (NPM). Methods: A total of 69 semi-structured interviews (2017–2018) with treatment staff in nine sampled local/regional areas formed the basis for constructing a web survey administered to staff across Sweden in 2019 (n=606). The means showed how often the different strategies were used. Regression analyses examined organisational differences, and central strategies were illustrated by the interview study. Results: Treatment professionals in general reported satisfactory freedom in their work. Staff in more NPM-like organisations were less likely to report autonomy and more inclined to report conflicting demands. When conflicts emerged, the staff used both passive strategies indicating adaptation or resignation, and active strategies including boundary spanning, protest, and liberty-taking. Some challenging strategies such as looking for other jobs or reporting one thing but doing another were more common in more NPM-like organisations. The opposite was found for customer orientation. Conclusions: While NPM features on customer orientation and steering methods appeared to create fewer problems, more NPM-like organisations appeared to be less favourable overall and should be applied with caution.

Estimating the Needs of Substance Problem Use Services: An Exercise in Seven Finnish Municipalities Using Nationally Collected, Municipal-Level Survey and Register Data†

OBJECTIVE

The needs of substance problem use services (SPUSs) should ideally be assessed locally to support the provision of appropriate, cost-effective services for the population. In this article we present a model for estimating the adult population's potential needs for and actual use of SPUSs. We used Finnish survey and register data as material for a qualitative assessment. The purpose of our article is to contribute to a discussion on the dimensions of assessment of the need for SPUSs at a local level.

METHOD

Seven Finnish municipalities were chosen as examples. The need for SPUSs was assessed by freely available register and survey data of the use of services, substance use and problem use, side effects of use, and lack of social support. Babor et al.'s (2008) description of links between the use of services and need for treatment, in terms of substance use and general social conditions, and Ritter's (2014a) set of methods for assessing the need for treatment are used as theoretical background.

RESULTS

The number of people using SPUSs varied from one municipality to the next. The local service system policy and the general well-being of the population have a remarkable role in the use of SPUSs.

CONCLUSIONS

Estimations of need and demand with indicators can be useful for local treatment system policy but must be interpreted with thorough knowledge of the local treatment and social handling resources and general social situation. Comparisons between different local areas should be made with caution.

Seven Core Principles of Substance Use Treatment System Design to Aid in Identifying Strengths, Gaps, and Required Enhancements

OBJECTIVE

System planners and funders encounter many challenges in taking action toward evidence-informed enhancement of substance use treatment systems. Researchers are increasingly asked to contribute expertise to these processes through comprehensive system reviews. In this role, all parties can benefit from guiding frameworks to help organize key questions and data collection activities, and thereby set the stage for both high-level and on-the-ground strategic directions and recommendations. This article summarizes seven core principles of substance use treatment system design that are supported by a large international evidence base and that together have proven applicable as a framework for several systems review projects conducted predominantly in Canada.

METHOD

The methodology was based on a narrative review approach.

RESULTS

The principles address a wide range of issues. Specifically, a broad systems approach is needed to address the full spectrum of issues; accessibility and effectiveness are improved through collaboration across stakeholders; a range of system supports are needed; need for services should be grounded in self-determination, holistic cultural practices, choice, and partnership; attention to diversity and social-structural disadvantages are crucial to equitable system design; systematic screening and assessment is needed to match people to appropriate treatment services in a stepped service framework; and, last, individualized treatment planning must include the right mix of evidence-informed interventions.

CONCLUSIONS

By bringing researchers and stakeholders back to the high-level goals of substance use treatment systems, these principles provide a comprehensive, evidence-based, organizing framework that has the potential to improve the quality of system design and review internationally.

Estimating Service Needs for Alcohol and Other Drug Users According to a Tiered Framework: The Case of the São Paulo, Brazil, Metropolitan Area

OBJECTIVE

The purpose of this study was to estimate the need for population-level services for alcohol and other drug abuse in support of local planning.

METHOD

Data were drawn from a subsample of 2,942 interviewees from the São Paulo Megacity Study, which evaluated mental health in the general population (18 years and older) of residents in the São Paulo metropolitan area. This population was classified into five hierarchical categories of severity, making it possible to obtain estimates of need for services, combining evaluation criteria regarding drug and alcohol use and general and mental health comorbidities over the last 12 months. For the at-risk groups in this population, estimates from the Potential Demand for the Use of Services survey interviews over the last year were generated.

RESULTS

Concerning the need for services, 86.5% of the population (Tier 1) had no problems related to drug and alcohol use, 8.9% (Tier 2) used heavily, 3.5% (Tiers 3, 4, and 5) met criteria for substance abuse disorders, among whom 1.3% (Tiers 4 and 5) require more specialized and intensive treatment and support. The following estimates for the Potential Demand for the Use of Services were found: 25.5% (Tier 3) and 51.1% (Tier 4), indicating that a significant number of individuals met criteria for substance abuse disorders but did not perceive any need for professional help or neglected the help available.

CONCLUSIONS

In São Paulo there exists a large sector of the population that requires prevention strategies regarding the risks and harm resulting from alcohol and drug use, followed by a group requiring more specialized care. But a large number of substance users requiring specialized support did not use services and did not believe that they needed professional help.

Needs-Based Planning for Substance Use Treatment Systems: Progress, Prospects, and the Search for a New Perspective

ABSTRACT

The articles presented in this issue of the Journal of Studies on Alcohol and Drugs (Supplement No. 18) describe the rapid improvements over the past decade in methods, theories, and data systems used for needs-based planning of addiction treatment services. In this concluding essay, the editors describe the progress, prospects, and implications of this new wave of research. It is concluded that these developments can be used to maximize the impact of treatment services at the population level.

Development of a Needs-Based Planning Model to Estimate Required Capacity of a Substance Use Treatment System

OBJECTIVE

Substance use services and supports have traditionally been funded without the benefit of a comprehensive, quantitative planning model closely aligned with population needs. This article describes the methodology used to develop and refine key features of such a model, gives an overview of the resulting Canadian prototype, and offers examples and lessons learned in pilot work.

METHOD

The need for treatment was defined according to five categories of problem severity derived from national survey data and anticipated levels of help-seeking estimated from a narrative synthesis of international literature. A pan-Canadian Delphi procedure was used to allocate this help-seeking population across an agreed-upon set of treatment service categories, which included three levels each of withdrawal management, community, and residential treatment services. Projections of need and required service capacity for Canadian health planning regions were derived using synthetic estimation by age and gender. The model and gap analyses were piloted in nine regions.

RESULTS

National distribution of need was estimated as Tier 1: 80.7%; Tier 2: 10.4%; Tier 3: 6.1%; Tier 4: 2.6%; and Tier 5: 0.2%. Pilot work of the full estimation protocol, including gap analysis, showed the results triangulated with other indicators of need and were useful for local planning.

CONCLUSIONS

Lessons learned from pilot testing were identified, including challenges with the model itself and those associated with its implementation. The process of estimation developed in this Canadian prototype, and the specifics of the model itself, can be adapted to other jurisdictions and contexts.

A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes

Objective: The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders? Methods: We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes. Results: This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care. Conclusions: Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.

Performance Measurement in Mental Health and Addictions Systems: A Scoping Review

OBJECTIVE

The purpose of this study was to evaluate how performance is defined, conceptualized, and measured in mental health and addiction service systems around the world.

METHOD

We conducted a systematic scoping review of English-language scientific and gray literature published from 2005 to 2015. Eligible documents (n = 222) described performance measurement systems and outlined the theory or empirical evidence for indicators. We used a structured approach for data extraction and descriptive and thematic analysis, supplemented with stakeholder consultation.

RESULTS

We identified seven themes in the literature: similarity in performance domains across frameworks; the ability of frameworks to inform care quality at client, program/facility, and system levels; the predominance of indicators of process and outcome, over structure; the lack of evidence on the links between domains and/or indicators; common, but limited, evaluation of family/caregiver involvement; equity as a cross-cutting domain of performance; and limited attention to performance measurement in peer support services.

CONCLUSIONS

The literature on performance measurement in mental health and addictions services is vast, and a wide variety of indicators is available to those designing a measurement system. Evaluations of commonly used performance indicators have yielded mixed evidence on their ability to discriminate high- and low-performing service providers, and their sensitivity to changes in policies and practices. As performance measurement efforts grow in scope and complexity, work will be needed to ensure that indicators are fair, appropriate, and suited to support quality improvement in services of different types.

Effectiveness of Optional Videoconferencing-Based Treatment of Alcohol Use Disorders: Randomized Controlled Trial

BACKGROUND

Treatment of alcohol use disorders (AUDs) is characterized by an adherence rate below 50%. Clinical research has found that patient adherence enhances treatment effect; hence, health authorities, clinicians, and researchers strive to explore initiatives contributing to patients receiving treatment. Concurrently, videoconferencing-based treatment is gaining ground within other addiction and psychiatric areas.

OBJECTIVE

The aim of this study was to test whether optional videoconferencing increases adherence to and effectiveness of AUD treatment in a randomized controlled trial (RCT). We hypothesized that the intervention would decrease premature dropout (the primary outcome), as well as increase successful treatment termination, treatment duration, and treatment outcome (secondary outcomes).

METHODS

We conducted this study in the public outpatient alcohol clinic in Odense, Denmark, between September 2012 and April 2013. It was an RCT with 2 groups: treatment as usual (TAU) and treatment as usual with add-on intervention (TAU+I). The TAU+I group had the option, from session to session, to choose to receive treatment as usual via videoconferencing. Data consisted of self-reported responses to the European version of the Addiction Severity Index (EuropASI). We collected data at baseline, at follow-up at 3, 6, and 12 months, and at discharge.

RESULTS

Among consecutive patients attending the clinic, 128 met the inclusion criteria, and 71 of them were included at baseline. For the primary outcome, after 180 days, 2 of 32 patients (6%) in the TAU+I group and 12 of 39 patients (31%) in the TAU group had dropped out prematurely. The difference is significant (P=.008). After 365 days, 8 patients (25%) in the TAU+I group and 17 patients (44%) in the TAU group had dropped out prematurely. The difference is significant (P=.02). For the secondary outcomes, significantly more patients in the TAU+I group were still attending treatment after 1 year (P=.03). We found no significant differences between the 2 groups with regard to successful treatment termination and treatment outcome.

CONCLUSIONS

The results indicate that offering patients optional videoconferencing may prevent premature dropouts from treatment and prolong treatment courses. However, the small sample size precludes conclusions regarding the effect of the intervention, which was not detectable in the patients' use of alcohol and severity of problems.

TRIAL REGISTRATION

The Regional Health Research Ethics Committee System in Denmark: S-20110052; https://komite.regionsyddanmark.dk/wm258128 (Archived by WebCite at http://www.webcitation.org/6tTL3CO6u).

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations

Background

Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature.

Objectives

To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems.

Design

A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work.

Results

A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations.

Limitations

Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention.

Conclusions

Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent.

Future work

The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public.

Study registration

The systematic review element of this study is registered as PROSPERO CRD42016026415.

Funding

The National Institute for Health Research Public Health Research programme.

Co-Occurrence of Substance use Disorders with other Psychiatric Disorders: Implications for Treatment Services

Introduction

This paper critically evaluates the literature on the co-occurrence of substance-use disorders (SUDs) with other psychiatric conditions. Our review considers the variety of different associations between the two, and suggests the implications of the literature for the design of treatment services that address both types of disorders. Methods: A narrative review of research and theory was conducted, covering epidemiology of co-occurring psychiatric disorders worldwide, mechanisms underlying co-occurrence, and treatment models. Results: Epidemiological research has documented a high prevalence of co-occurring disorders in both clinical samples and the general population, although the literature is based primarily on studies in high-income countries and some of the overlap might be due to the co-occurrence of milder forms of both types of disorders. Consistent with what has been reported in other reviews, we conclude that clients with co-occurring disorders tend to have a more severe course of illness, more severe health and social consequences, more difficulties in treatment, and worse treatment outcomes than clients with a single disorder; we address the implications of these findings for the design of treatment services. Conclusions: Much of the evidence shows that separately, treatments for both SUD and other psychiatric disorders are effective in reducing substance use and in improving behavioral, familial, and psychosocial outcomes. The evidence further suggests that these outcomes might be improved when treatment modalities are offered in combination within an integrated treatment plan that simultaneously addresses substance abuse and psychiatric problems. It is concluded that there is potentially more to be gained from taking a public health perspective and working on efforts to implement existing evidence-based practices at the systems level, than from the current tendency to look for ever more powerful individual-level interventions at the clinical level.

Stakeholders' Arguments for and against Moving Swedish Substance abuse Treatment to the Health Care System: How a Fat Reform Proposal became a Thin Government Bill

Background

Far-reaching changes in the Swedish substance abuse treatment system (SAT) were proposed by a state-commissioned inquiry in 2011. The proposal implied a break with the social tradition of SAT. It was suggested that the treatment responsibility should be transferred from the municipal social services to the regional-level health care system; and that compulsory treatment in its present form (assessed by/paid for by social services, run by the state) should be abolished and become incorporated into coercive psychiatric care provided by health care. A lively debate arose, and the vast majority of stakeholders sought to articulate their arguments.

Aim

The study analysed the development of Swedish SAT by examining the policy process from reform proposal to government bill in 2013.

Method

Content analysis was used to analyse written comments on the proposal submitted to the Ministry of Health and Social Affairs by close to 200 stakeholders. The goal was to empirically chart and examine the arguments for and against as well as advocates and opponents of the reform. With the government bill at hand, we retrospectively sorted out the winning arguments in the now highly contested SAT field and which actors were able to influence the process.

Conclusions

The article discloses that the mixed response and rather critical voices in most groups, including social/medical professions and government bureaucracy, helped block the responsibility shifts, and that reformations of subsystems like SAT are difficult to carry out as freestanding projects within larger systems of social and health care.

Evaluating the Complex: Alternative Models and Measures for Evaluating Collaboration among Substance use Services with Mental Health, Primary Care and other Services and Sectors

Many planners and administrators now look to “collaboration” or “integration” as a solution, or at least a partial solution, to challenges related to access and delivery of substance use and mental health services and health services in general. Among the major constraints in identifying best practices in this area and recommending optimal evaluation strategies are the plethora of terms and concepts used in the literature to describe collaboration or integration as well as the many alternative approaches and outcome expectations. It is helpful, therefore, to follow concrete steps to plan the evaluation, including the engagement of multiple stakeholders in the planning process and subsequent execution of the evaluation. The concrete evaluation strategies employed can follow a traditional, often linear model, of impact and are often categorized under the common typologies of process, outcome or economic evaluations. Each approach examines different domains of interest and can be at the individual/service level or at the level of the overall treatment system. Other less traditional evaluation models and methods based on systems theory, complex adaptive systems and developmental evaluation have much to offer the evaluation of interventions aimed at improving the collaboration and integration of substance use services with other health and social services and sectors. Realist evaluation is a particularly helpful approach that integrates many of the traditional approaches with these other models and methods.

Capabilities for Handling Complex Substance abuse Problems and its Relationship to the Treatment System: Using the DDCAT Instrument to Explore Local Treatment Systems in Finland

Background

Mental health problems in Finland have been the responsibility of the health care, and substance abuse problems have been handled within social care. In 2009, a national reform aiming at integrating mental health and substance abuse treatment systems (SATS) was launched. The critics of integration were concerned that it implies a medicalization and a narrowing of the social care goals.

Aim

This article analyses to what extent integration of mental health and SATS affect the capability to treat co-occurring substance abuse and mental health problems. A secondary aim is to assess the utility of the DDCAT (Dual Diagnosis Capability in Addiction Treatment) instrument in a Finnish context.

Data

The study is based on group interviews, using DDCAT, in six Finnish municipalities, three with integrated and three with separate mental health care and SATS. The assessment pertains to the main outpatient unit in the city.

Results

The dual diagnosis treatment capability did not depend on the system-level integration. Two municipalities where SATS was administratively separate from mental health care were able to achieve high dual diagnosis capability ratings while in one municipality with system level integration this capability was not very high. The DDCAT instrument puts an emphasis on medical staff and competence.

Conclusions

Strong, separate local SATS may adapt to the integration demands or needs by strengthening their psychiatric competence. This solution can result in treatment that is equally competent in treating mental health and substance abuse problems as integrated systems. The DDCAT instrument can be useful in a Finnish context to measure medical competence to handle dual diagnoses, irrespective of system solutions. For a balanced measurement, the instrument should be complemented with a section mapping competence to handle co-occurring social problems.

The SBIRT program matrix: a conceptual framework for program implementation and evaluation

BACKGROUND AND AIMS

Screening, Brief Intervention and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of services to those at risk for the adverse consequences of alcohol and other drug use, and for those with probable substance use disorders. Research on successful SBIRT implementation has lagged behind studies of efficacy and effectiveness. This paper (1) outlines a conceptual framework, the SBIRT Program Matrix, to guide implementation research and program evaluation and (2) specifies potential implementation outcomes.

METHODS

Overview and narrative description of the SBIRT Program Matrix.

RESULTS

The SBIRT Program Matrix has five components, each of which includes multiple elements: SBIRT services; performance sites; provider attributes; patient/client populations; and management structure and activities. Implementation outcomes include program adoption, acceptability, appropriateness, feasibility, fidelity, costs, penetration, sustainability, service provision and grant compliance.

CONCLUSIONS

The Screening, Brief Intervention and Referral to Treatment Program Matrix provides a template for identifying, classifying and organizing the naturally occurring commonalities and variations within and across SBIRT programs, and for investigating which variables are associated with implementation success and, ultimately, with treatment outcomes and other impacts.

Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice

AIMS

This paper describes the major findings and public health implications of a cross-site evaluation of a national Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program funded by the US Substance Abuse and Mental Health Services Administration (SAMHSA).

METHODS

Eleven multi-site programs in two cohorts of SAMHSA grant recipients were each funded for 5 years to promote the adoption and sustained implementation of SBIRT. The SBIRT cross-site evaluation used a multi-method evaluation design to provide comprehensive information on the processes, outcomes and costs of SBIRT as implemented in a variety of medical and community settings.

FINDINGS

SBIRT programs in the two evaluated SAMHSA cohorts screened more than 1 million patients/clients. SBIRT implementation was facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Although the quasi-experimental nature of the outcome evaluation does not permit causal inferences, pre-post differences were clinically meaningful and statistically significant for almost every measure of substance use. Greater intervention intensity was associated with larger decreases in substance use. Both brief intervention and brief treatment were associated with positive outcomes, but brief intervention was more cost-effective for most substances. Sixty-nine (67%) of the original performance sites adapted and redesigned SBIRT service delivery after initial grant funding ended. Four factors influenced SBIRT sustainability: presence of program champions, availability of funding, systemic change and effective management of SBIRT provider challenges.

CONCLUSIONS

The US Substance Abuse and Mental Health Services Administration's Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program was adapted successfully to the needs of early identification efforts for hazardous use of alcohol and illicit drugs. SBIRT is an innovative way to integrate the management of substance use disorders into primary care and general medicine. Screening, Brief Intervention and Referral to Treatment implementation was associated with improvements in treatment system equity, efficiency and economy.

Substance use outcomes following treatment: Findings from the Australian Patient Pathways Study

BACKGROUND AND AIMS

Our understanding of patient pathways through specialist Alcohol and Other Drug treatment and broader health/welfare systems in Australia remains limited. This study examines how treatment outcomes are influenced by continuity in specialist Alcohol and Other Drug treatment, engagement with community services and mutual aid, and explores differences between clients who present with a primary alcohol problem relative to those presenting with a primary drug issue.

METHOD

In a prospective, multi-site treatment outcome study, 796 clients from 21 Alcohol and Other Drug services in Victoria and Western Australia completed a baseline interview between January 2012 and January 2013. A total of 555 (70%) completed a follow-up assessment of subsequent service use and Alcohol and Other Drug use outcomes 12-months later.

RESULTS

Just over half of the participants (52.0%) showed reliable reductions in use of, or abstinence from, their primary drug of concern. This was highest among clients with meth/amphetamine (66%) as their primary drug of concern and lowest among clients with alcohol as their primary drug of concern (47%), with 31% achieving abstinence from all drugs of concern. Continuity of specialist Alcohol and Other Drug care was associated with higher rates of abstinence than fragmented Alcohol and Other Drug care. Different predictors of treatment success emerged for clients with a primary drug problem as compared to those with a primary alcohol problem; mutual aid attendance (odds ratio = 2.5) and community service engagement (odds ratio = 2.0) for clients with alcohol as the primary drug of concern, and completion of the index treatment (odds ratio = 2.8) and continuity in Alcohol and Other Drug care (odds ratio = 1.8) when drugs were the primary drugs of concern.

CONCLUSION

This is the first multi-site Australian study to include treatment outcomes for alcohol and cannabis users, who represent 70% of treatment seekers in Alcohol and Other Drug services. Results suggest a substantial proportion of clients respond positively to treatment, but that clients with alcohol as their primary drug problem may require different treatment pathways, compared to those with illicit drug issues, to maximise outcomes.

Implementation of public policy on alcohol and other drugs in Brazilian municipalities: comparative studies

One of the challenges with respect to public health and the abuse of alcohol and other drugs is to implement policies in support of greater co-ordination among various levels of government. In Brazil, policies are formulated by the Secretaria Nacional de Políticas sobre Drogas (SENAD - State Department for Policies on Drugs) and the Ministério da Saúde (MS - Ministry of Health). This study aims to compare implementation of policies adopted by SENAD and MS at the municipal level. Three municipalities were intentionally selected: Juiz de Fora having a larger network of treatment services for alcohol and drug users; Lima Duarte, a small municipality, which promotes the political participation of local actors (COMAD - Municipal Council on Alcohol and Drugs); and São João Nepomuceno, also a small municipality, chosen because it has neither public services specialised to assist alcohol and other drugs users, nor COMAD. Data collection was conducted through interviews with key informants (n = 19) and a review of key documents concerned with municipal policies. Data analysis was performed using content analysis. In Juiz de Fora, there are obstacles regarding the integration of the service network for alcohol and other drug users and also the articulation of local actors, who are predominant in the mental health sector. In Lima Duarte, while there is a link between local actors through COMAD, their actions within the local service network have not been effective. In São João Nepomuceno, there were no public actions in the area of alcohol and drugs, and consequently insufficient local debate. However, some voluntary, non-governmental work has been undertaken. There were weaknesses in the implementation of national-level policies by SENAD and the MS, due to the limited supply of available treatment, assistance and the lack of integration among local actors.

Navigating the Alcohol Treatment Pathway: A Qualitative Study from the Service Users' Perspective

AIMS

Provision of effective treatment for dependent drinkers has been identified as a priority in England yet evidence suggests that access is problematic and there are low levels of retention. This qualitative study explores how the alcohol treatment system is experienced by service users, identifying barriers and facilitators that influence treatment outcomes.

METHODS

A total of 20 semi-structured face-to-face interviews were conducted with patients from community alcohol treatment services in three London boroughs in 2012. Interviews were undertaken one year after initially entering treatment. A thematic analysis was conducted, with the results further abstracted to relate them to specific aspects of the treatment journey.

RESULTS

Patients journeys were characterized by a perceived lack of control leading to help-seeking, with treatment outcomes influenced by an individuals' self-efficacy and the capabilities and skills of staff in actively engaging and supporting patients on the journey. A focus of services on the detoxification process and fragmented care pathways impacted negatively on engagement.

CONCLUSIONS

Current alcohol care pathways require significant levels of motivation and self-efficacy to navigate that few patients possess. Pathways need to better reflect the capacity and capabilities of patients to be successful in supporting recovery.

Implementation of a clinical pathway may improve alcohol treatment outcome

This article describes the design, implementation, and evaluation of a clinical pathway system in a two-cohort quasi-experimental study before and after implementation, controlling for confounders. The main outcome measures were retention in care and sensible alcohol use (defined as abstinent or drinking no more than 21 standard drinks per week). Patients with harmful alcohol use or dependence as their primary problem who were seeking psychosocial treatment at one of four alcohol clinics in Denmark participated in the study. After implementation of the clinical pathway system, which incorporated a structured intake, a referral and independent follow-up system, checklists, audit, and feedback, there was no change in length of stay, but significantly more patients had a good clinical outcome (stopped or moderated their consumption) at the end of treatment (OR = 1.9; 1.2–3.1). The study documents the feasibility of using a clinical pathway framework, incorporating a local monitoring system, checklists, audit, and feedback to enhance treatment quality and improve outcomes for alcohol use disorders.

Should brief interventions in primary care address alcohol problems more strongly?

BACKGROUND

Brief interventions have well-established small effects on alcohol consumption among hazardous and harmful drinkers in primary care, and national large-scale programmes are being implemented in many countries for public health reasons.

METHODS

This paper examines data from reviews and draws upon older brief intervention studies and recent developments in the literature on motivational interviewing to consider the capacity of brief interventions to benefit those with problems, including those with severe problems.

RESULTS

Effects on alcohol problems have been shown much less consistently, and evidence cannot be claimed to be strong for any outcomes other than reduced consumption. Combinations of advice and motivational interviewing are a promising target for evaluation in trials, and more detailed studies of the conduct of brief interventions are needed.

CONCLUSIONS

We propose that brief interventions in primary care may be more effective if they offer appropriate content in a person-centred manner, addressing patient concerns more directly.

Monitoring Utilization of a Large Scale Addiction Treatment System: The Drug and Alcohol Treatment Information System (DATIS)

Client-based information systems can yield data to address issues of system accountability and planning, and contribute information related to changing patterns of substance use in treatment and, indirectly, general populations. The Drug and Alcohol Treatment Information System (DATIS) monitors the number/types of clients treated in approximately 170 publicly-funded addiction treatment agencies in Ontario. The purpose of this study was to estimate the caseload of addiction treatment agencies, and describe important characteristics of clients, their patterns of service utilization and trends over-time from 2005 to 2010. In 2009–2010, 47,065 individuals were admitted to treatment. Since 2005–2006, there has been an increase in adolescents/youth in treatment, and a decrease in the male-female gender ratio. Alcohol problems predominated, but an increasing proportion of clients used cannabis and prescription opioids. DATIS is an evolving system and an integral component of Ontario’s performance measurement system. Linkages with healthcare information systems will allow for longitudinal tracking of client health-related outcomes.

Drug, sex and age differentials in the use of Australian publicly funded treatment services

Context:

Little is known about the proportion of the Australian population using alcohol or other drugs who may seek treatment. There is a need to have some additional estimates of population morbidity which reflect harms associated with use.

Objective:

To determine Australian population rates of publicly funded community based specialised alcohol and other drug treatment and in-patient hospital care by those ‘at risk’, by drug type, sex and age.

Design and setting:

The design is secondary data analysis of publicly available datasets. We use the latest available complete data on Australian general population incidence of alcohol, cannabis amphetamines and ecstasy use (2007 National Drug Strategy Household Survey) and nationally collected administrative data on publicly funded specialised alcohol and other drug treatment services (2006–2007 Alcohol and Other Drug Treatment Services National Minimum Dataset) and public hospitals (2006–2007 National Hospital Morbidity Minimum Dataset) to calculate rates of drug treatment and in-patient hospital care per 1000 Australians. ‘At risk’ for alcohol is defined as being at risk of short term harm, as defined by the National Health and Medical Research Council (2001). ‘At risk’ for illicit drugs is defined as those exposed to potential harm through at least weekly use of cannabis, amphetamines and ecstasy use.

Results:

Risky alcohol consumption followed by recent cannabis use appears to lead to most harm. Greater harm seems to be experienced by males rather than females. Younger adults (15–19 years) and older adults (40+ years) seem also to experience the highest rates of harm.

Conclusions:

It is possible to derive population estimates of harms associated with licit and illicit drugs use. Treatment rates vary across drug type, gender and age. Alcohol and cannabis are the substances whose use leads to the greatest demand for services. Ecstasy appears to generate few presentations for treatment. Publicly available data can be used to estimate harms associated with the use of particular substances. Such estimates are best interpreted in the light of other ways of estimating harms.

The impact of retail practices on violence: the case of single serve alcohol beverage containers

INTRODUCTION AND AIMS

This paper examines the role that sales of single serve alcoholic beverages plays in violent crime in surrounding areas. Increasingly a target of regulatory measures, this is the first study to systematically assess the impact of single serve containers on neighbourhood violence.

DESIGN AND METHODS

The relative proportion of shelf space in each liquor establishment in San Bernardino, CA devoted to single serve alcohol containers was surveyed. Assuming that this is a rough indicator of the amount of sales derived from single serve containers, we use this indicator as a measure of the impact of specific retail practice on violence around the outlet.

RESULTS

Results show that the average proportion of shelf space devoted to single serve containers in the unit of analysis, the US Census Bureau block group, was positively related to violent crime, net of overall retail availability of alcohol and relevant social and economic indicators often used to predict violent crime rates in such units.

DISCUSSION AND CONCLUSIONS

These findings suggest that if the city were to make the voluntary ban on single serve container sales mandatory, violence in the surrounding areas would decline, all other things being equal. This study provides a much more grounded and specific justification for enacting such policy changes and once again shows the utility of alcohol policy for the reduction of crime and violence.

The World Health Organization Substance Abuse Instrument for Mapping Services

This paper describes the rationale for and development of the World Health Organization Substance Abuse Instrument for the Mapping of Services (WHO-SAIMS), a new procedure for assessing, monitoring, and evaluating treatment systems for substance use disorders in all UN Member States. The paper begins with a description of the information needed to understand the structure and function of drug and alcohol service systems. A conceptual model is presented to show how service system policies and characteristics impact on population health. Five kinds of research are then reviewed to suggest how the nature and impact of alcohol and drug services can be evaluated: 1) systems mapping studies; 2) assessments of service needs; 3) monitoring system development; 4) analysis of system performance; and 5) comparative studies. Although the WHO-SAIMS has a primarily descriptive function that will allow for gaps in service delivery and areas for system improvement to be identified, it can also be used for monitoring and process evaluation to allow countries to identify changes in the system over time and to assess the extent to which system improvement strategies have been implemented.

On the Idea of Treatment Systems

This article addresses certain problems associated with the use of a system approach in studying the organisation and character of treatment for alcohol and drug problems. There are three main approaches of system concept use. The first concerns what could be called the dream of rationality, which tends to have the structure of an attempt to reform a present state of affairs. It is guided by a traditional system concept, which claims that systems consist of interrelated parts and constitute wholes. The second type of use is characterised by an ad hoc approach inasmuch as the actual use of the system concept is primarily to delimit populations of treatment services, rather than of treatment systems. The third approach can be called the extensive system approach since it emphasises the inclusion of a large number of relations that to some extent make the boundaries of the system less distinct. While all three approaches stand out as reasonable and relevant research strategies, their different limitations may nevertheless make it worthwhile to consider some alternatives. I suggest that a possible alternative approach can be found in a market perspective. This suggestion is premised on the specific context of current alcohol and drug treatment organisation in Sweden. However, it is not impossible that similar circumstances could also be present in other countries.

Client characteristics within the Chilean National Youth Addiction Treatment Demonstration System

In the context of an evaluation of a national demonstration program for youth addiction treatment in Chile, a sociodemographic and substance use profile of children and adolescents accessing services through this new program was developed. Information regarding sociodemographic factors, substance use, and problem severity; services used; and unmet needs was retrospectively gathered for all clients (685) admitted between January 1 and June 30, 2006. Thirty-two treatment centers (91.4%) provided data. The client population profile reflected severe psychosocial circumstances (e.g., 61.4% early exit from school). Of the population, 64.9% were classified in the highest substance risk level. The primary drug reported was cocaine-paste-base (52.7%). Comparisons to similar data in other countries illustrate the more severe profile of this Chilean treatment sample. The results suggest the need for increased outreach and comprehensive intersectoral approaches. Monitoring and evaluation should become part of the culture of the national drug treatment system in Chile and other countries.

Social aesthetics and the management of addiction

PURPOSE OF REVIEW

One of the main causes of nonadherence is that the goals and forms of addiction treatment are not sufficiently attractive. To study the attractiveness of treatment in clinical practice inevitably means to enter the field of social aesthetics. The call for the implementation of social aesthetics in practice results in a shift of paradigms in the treatment of patients suffering from dependence syndromes.

RECENT FINDINGS

The main themes in the literature covered by the article focus on the role of social aesthetics in medicine in general, as well as on the attractiveness of addiction treatment, in particular.

SUMMARY

When treatment objectives and programmes become more attractive the result will be reduced drop-out rates, and in turn an increase of treatment effectiveness. Transferring theory of social aesthetics to clinical practice, the Anton Proksch Institute's Orpheus Programme is concerned with opening up spaces and creating atmospheres in which it becomes possible for the individual addicts to realise their possibilities. The challenge in the therapeutic process is not only to recognise the significance of the disorders' pathology but also to find ways out of the imagined impossibilities by opening up new possibilities and uncovering resources of the suffering human.

For the Marginalized or for the Integrated? A Comparative Study of Addiction Treatment Systems in Sweden and the United States

This article compares the roles of two different addiction treatment systems, one in Stockholm county, surrounding the Swedish capital, and the other in a county in Northern California, in relation to marginalized and socially integrated misusers. It investigates: (a) whether the Swedish treatment system, as suspected, treats more marginalized clients than the American system, (b) where in the two systems those with stronger or weaker social ties show up, and (c) what kind of formal and informal pressures the socially marginalized and more integrated groups experience. The analyses are based on structured interviews with two representative samples of clients/patients entering different parts of the treatment systems (926 persons in the Californian county in 1995, 1,865 persons in Stockholm county 2000–2001). The Stockholm county treatment system has a much higher share of marginalized persons than the Californian, and a large proportion in California, almost one third, has both a job and a stable housing (15% in Stockholm). The Stockholm clients were considerably older. Drug use was connected with a marginalized position in both countries, and particularly so in Stockholm. The socially integrated in Stockholm stood out as the group with the highest share of alcohol-dependent persons, the highest Addiction Severity Index (ASI) alcohol scores, and the highest amount of heavy drinking. In both sites, the marginalized had more treatment experience and were more often found in inpatient treatment. There was a somewhat clearer social division in the U.S. system than in the Swedish. Some reasons for this are discussed, including the relation of the treatment system to other handling systems.

Alcohol-induced psychotic disorder and delirium in the general population

BACKGROUND

Epidemiological data on alcohol-induced psychotic disorder and delirium (alcohol-induced psychotic syndrome, AIPS) are scarce.

AIMS

To investigate the epidemiology of AIPS, the risk factors for developing AIPS among people with alcohol dependence, and mortality associated with alcohol dependence with or without AIPS, in a sample drawn from the general population of Finland.

METHOD

A general population sample of 8028 persons were interviewed with the Composite International Diagnostic Interview and screened for psychotic disorders using multiple sources. Best-estimate diagnoses of psychotic disorders were made using the Structured Clinical Interview for DSM-IV Axis I Disorders and case notes. Data on hospital reatments and deaths were collected from national registers.

RESULTS

The lifetime prevalence was 0.5% for AIPS and was highest (1.8%) among men of working age. Younger age at onset of alcohol dependence, low socioeconomic status, father's mental health or alcohol problems and multiple hospital treatments were associated with increased risk of AIPS. Participants with a history of AIPS had considerable medical comorbidity, and 37% of them died during the 8-year follow-up.

CONCLUSIONS

Alcohol-induced psychotic disorder is a severe mental disorder with poor outcome.

Drug Policy and the Public Good: a summary of the book

Drug Policy and the Public Good was written by an international group of scientists from the fields of addiction, public health, criminology and policy studies to improve the linkages between drug research and drug policy. The book provides a conceptual basis for evidence-informed drug policy and describes epidemiological data on the global dimensions of drug misuse. The core of the book is a critical review of the cumulative scientific evidence in five general areas of drug policy: primary prevention programmes in schools and other settings; health and social services for drug users; attempts to control the supply of drugs, including the international treaty system; law enforcement and ventures into decriminalization; and control of the psychotropic substance market through prescription drug regimes. The final chapters discuss the current state of drug policies in different parts of the world and describe the need for future approaches to drug policy that are coordinated and informed by evidence.

The Use of Health Information Technology in Publicly-Funded U. S. Substance Abuse Treatment Agencies

Drug and alcohol treatment agencies are challenged to improve their infrastructure to meet growing technological and organizational demands. Health care reform and increased emphasis on performance monitoring in the United States are leading to improvements in health information technology. We assess literature to: (1) survey opportunities for health information technology for publicly-funded substance abuse treatment; (2) describe the use of electronic medical records in U.S. substance use treatment programs; (3) identify barriers and facilitators to implementing technology in substance abuse treatment programs; and (4) discuss applications of these concepts to private and international substance abuse treatment. Although these technologies hold promise to improve outcomes in the areas of cost-effectiveness, provider time savings, and quality improvement, substantial barriers exist to implementing health information technology in substance abuse treatment programs. Increased incentives, evidence, and implementation guidance can facilitate health information technology infrastructure improvement in substance abuse treatment to increase competitiveness in the U.S. health care market and improve the quality of care.

Packages of care for alcohol use disorders in low- and middle-income countries

In the fourth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Vivek Benegal and colleagues discuss the treatment of alcohol use disorders.

Understanding addiction--mediators and moderators of behaviour change processes: an introduction

We provide an introduction into a highly important research area for the improvement of preventive and therapeutic measures in the field of substance use disorders: a better understanding of core mediators and moderators of change processes, especially during critical phases like onset, progression, cessation and relapse. Based on a brief description of 12 papers on related projects we detail relevant research issues like the role of impaired cognitive control functions or the narrow "window of opportunity" for early interventions during adolescence.