Download The concept of National guidelines for treatment of alcohol and drug

The concept of National
guidelines for treatment of
alcohol and drug problems/
dependence in Sweden 2007
Ulf Malmström
coordinator, PhD
National Board of Health and Welfare
Cyprus May 2009
Why establish norms and
guidelines?
1. Changes in structure and content
2. Diminution in quality
3. Competence problems
4. Poor general knowledge and accumulation
of knowledge
5. Regional differences
6. Increased number of heavy misusers
How to organize the development
of guidelines?
1. Seminars with experts, representatives of
occupational groups, authorities and client
and patient organizations
2. Internal project group and executive group
3. Reference group
4. Expert groups
Substance use disorder care system;
a brief introduction
Treatment of substance use disorders
main responsibility:
-detoxification:
-dual diagnosis:
Local Social Authority
Health Care System
Psychiatric Health Services &
Local Social Authority
-hazardous drinking:
Health Care System &
(identification, intervention) Local Social Authority
Special. in-outpatient.:
Addiction Centres
Expert group 1
Psychosocial treatment and medicinal treatment of drug
misuse and addiction, including care
Expert group 2
Psychosocial treatment and medicinal treatment of
alcohol misuse and addiction, including care
Expert group 3
Discovery and preventive activity
Expert group 4
Markers, diagnostic instruments and systematic
assessment of patients and clients as well as
documentation
Expert group 5
Treatment of pregnant misusers
Target groups and
Intervention/
remedial action
Effect and the
reliability and
performance of the
test 12
Cost of the test
(form etc.)
2005
Accessibility
Persons in the risk
zone or with already
identified alcohol
problems.
Identification of
alcohol problems
(at-risk consumption,
harmful consumption
and addiction).
The instrument is
free of charge
Electronic version
available on the
Internet
AUDIT (questionnaire)
AUDIT is well tested
and quality assured
for identification
Swedish manual
exists
Target groups and
Intervention/
remedial action
Effect and the
reliability and
performance of the
test
Cost of the test
(form etc.)
2005
Accessibility
Persons in the risk
zone or with already
identified alcohol
problems.
Assessment of
Training and system Both instruments
severity of problem
costs
are easily
and assistance needs
accessible
as well as follow-up
respectively of action
and clients and
patients with alcohol
and drug problems.
ASI or DOK
(assessment
instrument)
Validity and reliability
of the ASI-interview
are satisfactory.
Corresponding test of
validity and reliability
has not been made
for DOK
Target groups and
Intervention/
remedial action
Effect
Evidence for effect Economic
assessment
Patients in primary
care and emergency
care that have been
identified with at-risk
alcohol consumption
Reduced alcohol
consumption
Evidence level 1
Brief counselling
Reduced
expenditure for
among others
health services,
social services
and the judicial
system. Scientific
foundation.
Target groups and
Intervention/remedial
action
Effect
Clients and patients
misusing or addicted to
drugs
Psychosocial
treatment in the form
of:
• Cognitive behaviour
therapy focussed on
misuse.
• Brief intervention
/Motivational
Interviewing (MI).
• CRA-treatment.
• Dynamic therapy.
• Family therapy
focussed on misuse
and addiction.
Reduced use
of drugs,
improved
social
situation
Evidence
for effect
Remain in
treatment
longer
Evidence
level 1
Economic
assessment
Comment
Not capable
of
assessment
See chapter 5.
Common to the
methods showing
effects is that
treatment is
characterised by
• Clear structure
• Focus on
misuse and
addiction
• Well-defined
remedial action
• Detailed
guidelines
(manual)
Target groups and
Intervention/remedial
action
Effect
Clients and patients
misusing or addicted to
alcohol
Psychosocial
treatment in the form
of:
•12 Step programme
•Cognitive behaviour
therapy focussed on
misuse.
•Motivation enhancing
treatment.
•CRA-treatment.
•Brief intervention.
•Interactional therapy
•Dynamic therapy
•Family therapy
focussed on misuse
and addiction.
Sobriety
Evidence
for effect
Reduced
consumption
and fewer
days of
misuse.
Improved
quality of
life.
Evidence
level 1
Economic
assessment
Comment
Not capable
of
assessment
See chapter 6.
Common to the
methods showing
effects is that
treatment is
characterised by
•Clear structure
•Focus on misuse
and addiction
•Well-defined
remedial action
•Detailed guidelines
(manual)
Target groups
and
Intervention/
remedial action
Effect
Evidence
for effect
Economic
assessment
Comment
Patients addicted
to alcohol.
Treatment with
akamprosat
(Campral
)
Reduced risk of
relapse.
Reduced need of
alcohol.
More fully sober
days.
Evidence
level 2
Not capable
of
assessment
See chapter 6.
The product may be used in
the treatment of alcohol
addiction generally within
health care in combination with
care that includes medical
counselling, support and
careful follow-up.
Patients addicted
to alcohol.
Treatment with
naltrexon
(Revia
)
Reduced risk of
relapse.
Reduced need of
alcohol.
More fully sober
days.
Evidence
level 2
Not capable
of
assessment
See chapter 6.
See the comment above for
Campral.
Patients misusing
or addicted to
alcohol.
The medicine
disulfiram
(Antabus
) to be
given under
supervision.
Sobriety.
Fewer days spent
in misuse.
Evidence
level 1
Not capable
of
assessment
Chapter 6.
Intake should take place in the
presence of, for example,
personnel or a workmate.
Regular control of liver function
( ref. Medical Products Agency)
Target groups and
Intervention/remedial
action
Effect
Evidence
for effect
Economic
assessment
Comment
Pregnant women with
alcohol and drug
problems in need of
treatment.
Sobriety and
freedom from
drugs
Reduced level
of misuse and
addiction
problems and
thereby reduced
danger of injury
to foetus
Test of
experienc
e
Not capable
of
assessment
See chapter 7.
Different
alternative
treatments with
high evidence
levels exist. (see
previous
recommendations)
•
Treatment is designed
- considering the health of the foetus
- to involve the partner if the woman wishes it
- to investigate and deal with the need of social support
Target groups and
Intervention/action
Effect
Evidence for effect Economic
assessment
Clients and patients
with alcohol or drug
problems and
suspected mental or
somatic illness seeking
assistance from the
social services.
Improved mental or
somatic health as
well as reduced
misuse or addiction
Test of experience
Immediate contact is
to be taken with an
operational unit
within the health
service competent to
assess mental or
somatic illness.
Not capable of
assessment
Target groups and
Intervention/action
Effect
Evidence for effect Economic
assessment
Clients and patients
with a mental illness or
disorder misusing or
addicted to drugs.
Improved mental
health as well as
reduced misuse or
addiction
Evidence level 2
After emergency
measures, treatment
is to be coordinated.
Treatment of one of
the conditions may
not be delayed while
waiting for the other
condition to improve.
Reduced
expenditure for
treatment, health
care, social
service and for the
judicial system.
Scientific
foundation.
Implementation of guidelines
Lectures at conferences, seminars
Refer for consideration
Pamphlet and a guide for implementation
Publication and distribution
Government grants and economical support for
local implementation
Evaluation
Results
A new standard for treatment of alcohol and drug
dependence in both municipalities (social work)
and county councils (health care) is established
Great interest in changing methods towards
evidence-based knowledge
Revision 2009-2010
A new document or ”platform” with information
about:
• how to organize the work
• procedure for reviews of literature
• the role of experts
• which type of data should be included
• how the guidelines should be implemented