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

Drug treatment service procurement: A systematic review of models, goals, and outcomes

Aim: To explore the goals and outcomes of public procurement of drug treatment services in OECD countries. The study explores how these complex services are procured and delivered. Methods and data: A systematic review of the literature (1990-2020) identified four partly overlapping models of drug treatment service procurement that are here labelled traditional, value-based, outcome-based, and innovative. Results: Even though different forms of drug treatment services procurement are common, only 12 empirical studies that focused on procurement were found. The four models differ in their approaches to design and performance specifications and the role of competition and collaboration in the co-creation of value. Conclusions: Competition and incentives improve neither the efficiency nor the quality or the outcomes of complex drug treatment services. Whereas many studies focus on payment mechanisms, there are important research gaps that relate to the co-creation of value with and for the service-users and other stakeholders.

Estimating the Prevalence of Mental and Substance Use Disorders: A Systematic Approach to Triangulating Available Data to Inform Health Systems Planning

OBJECTIVE

To estimate the prevalence of specific mental and substance use disorders (MSUDs), by age and sex, as a first step toward informing needs-based health systems planning by decision-makers.

METHODS

We developed a conceptual framework and a systematic methodology for combining available data sources to yield prevalence estimates for specific MSUDs. Data sources used included published, peer-reviewed literature from Canada and comparable countries, Canadian population survey data, and health administrative data from British Columbia. Several well-established methodologies including systematic review and meta-analyses of published prevalence estimates, modelling of age- and sex-specific distributions, and the Global Burden of Disease severity distribution model were incorporated in a novel mode of triangulation.

RESULTS

Using this novel approach, we obtained prevalence estimates for 10 MSUDs for British Columbia, Canada, as well as prevalence distributions across age groups, by sex.

CONCLUSION

Obtaining reliable assessments of disorder prevalence and severity is a useful first step toward rationally estimating service need and plan health services. We propose a methodology to leverage existing information to obtain robust estimates in a timely manner and with sufficient granularity to, after adjusting for comorbidity and matching with severity-specific service bundles, inform need-based planning efforts for adult (15 years and older) mental health and substance use services.

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.

Relationships between age at first substance use and persistence of cannabis use and cannabis use disorder

Background

From a secondary prevention perspective, it is useful to know who is at greatest risk of progressing from substance initiation to riskier patterns of future use. Therefore, the aim of this study was to determine relationships between age at first use of alcohol, tobacco and cannabis and patterns of cannabis use, frequency of use and whether age of substance use onset is related to having a cannabis use disorder (CUD).

Methods

We analysed data from Ireland’s 2010/11 and 2014/15 National Drug Prevalence Surveys, which recruited 5134 and 7005 individuals respectively, aged 15 years and over, living in private households. We included only those people who reported lifetime cannabis use. Multinomial, linear and binary logistic regression analyses were used to determine relationships between age of substance use onset and patterns of cannabis use, frequency of use and having a CUD.

Results

When compared to former users, the odds of being a current cannabis user were found to be reduced by 11% (OR = 0.89; 95% CI: 0.83, 0.95) and 4% (OR = 0.96; 95% CI: 0.92, 1.00) for each year of delayed alcohol and cannabis use onset, respectively. Among current users, significant inverse linear relationships were noted, with increasing age of first use of tobacco (β = − 0.547; P < .001) and cannabis (β = − 0.634; P < .001) being associated with a decreased frequency of cannabis use within the last 30 days. The odds of having a CUD were found to be reduced by 14% (OR = 0.86; 95% CI: 0.78, 0.94) and 11% (OR = 0.89; 95% CI: 0.82, 0.98) for each year of delayed tobacco and cannabis use onset respectively in analyses which examined survey participants aged 15–34 years.

Conclusions

Among people who report past cannabis use, it is those with a more precocious pattern of early use of substances, including alcohol, and especially tobacco and cannabis, who are more likely to report ongoing, heavy and problematic cannabis use. Secondary prevention initiatives should prioritise people with a pattern of very early onset substance use.

The evolution of addiction treatment and harm reduction programs in Iran: a chaotic response or a synergistic diversity?

BACKGROUNDS AND AIMS

Iran has 2.1 and 1.8% of its 15-64-year-old population living with illicit substance and opioid use disorders, respectively. To address these problems, Iran has been developing a large and multi-modality addiction treatment system, spanning the time before and after the Islamic Revolution.

METHODS

Iran's current drug treatment scene is a combination of services, ranging from medical/harm reduction services to punitive/criminal justice programs. Included in this array of services are drop-in centers providing low-threshold harm reduction services, such as distribution of sterile needles and syringes; opioid maintenance treatment clinics providing methadone, buprenorphine and opium tincture; and abstinence-based residential centers. We will review the evolution of this system in four phases.

RESULTS

In 1980, Iran's revolutionary government shut down all voluntary treatment programs and replaced them with residential correctional programs. The first shift in the addiction treatment policies came 15 years later after facing the negative consequences. Addiction is viewed as a disease, and new voluntary treatment centers offering non-agonist medications and psychosocial services were established. With an increased number of people who inject drugs and HIV/AIDS epidemics, in the second shift an extensive move towards harm reduction strategies and opioid-maintenance programs has been implemented to reduce HIV-related high-risk behavior. The emergence of a methamphetamine use crisis creating an increased number of socially marginalized addicted people resulted in public and political demands for stricter policies and ended in the third shift starting in 2010, with extended compulsory court-based residential programs. Currently, there is a new shift towards reducing the severity of criminal penalties for drug use/sales and promoting proposals for opium legalization.

CONCLUSION

Iran's evolutionary experience in developing a large addiction treatment program in a complex combination of medical/harm reduction and punitive/criminal justice addiction treatment can be examined in its political, clinical and pragmatic context.