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PUBLIC-PRIVATE GOVERNANCE IN DRUG-USERS REHABILITATION AND RECOVERY Claudio Leonardi, MD PhD Member of Italian Council of the Department of Antidrug Policies at Italian Presidency of the Council of Ministers Member of the Expert Group on Treatment and Rehabilitation United Nations Office on Drugs and Crime (ONU) President of the Italian Society on Drug Addiction Pathologies (S.I.Pa.D.) Department Director for Coordination of Inpatient and Outpatient Facilities and of Drug Addiction Centers - Local Public Health Organization (ASL Rome 2) We are going to talk about 1 • The Italian Network 2 • Managing Opioid Addiction Italian Experience 3 4 • Public & Private Governance of Addicts • Conclusions The Italian Network Health Minister Regional Health Assessorship Welfare Minister Regional Welfare Assessorship Local Health Authority (ASL) G.P.s Public Health System DPA National Dept. for Antidrug Policies funding Alcohol Unit 550 Drug Addiction Centers in Italy Opiates Unit Psycho-rehabilitative Unit 1,200 Therapeutic Communities (mostly private) Department of addiction Prevention Unit Street Unit Single Drug Addiction Centers Gambling Unit Eeating Disorder Unit Treatments Drug Addiction Center Pharmacological Detox Treatments Psychologists Pharmacological Mid Term Treatments Social workers Pharmacologists Nurses Pharmacological Long Term Treatments Prison Health System Psychological Support Ser.T. Directors Psychotherapy Ser.T. Physicians Socio-rehabilitative Support Toxicologists Internal Medicine Psychiatrists Other spec.s ITALY: Heroin Addiction Therapy AGONIST METHADONE PARTIAL AGONIST BUPRENORPHINE PARTIAL AGON/ANTAGONIST BUPREN/NALOXONE ANTAGONIST NALTREXONE DUAL DRUG DEPENDENCY MOST HEROIN ADDICTS ALSO ABUSE OTHER DRUGS LIKE COCAINE, ALCOHOL, BENZODIAZEPINES, STIMULANTS AND OPIOIDS PRESCRIBED DUAL DIAGNOSYS DRUGS DIRECTLY CAUSES MENTAL ILLNESS MENTAL ILLNESS DIRECTLY CAUSES DRUGS USE AND ABUSE (SELF MEDICATION) DRUG USING LIFESTYLE INDIRECTLY CAUSES MENTASL ILLNESS MENTASL ILLNESS HANDICAPS INCREASES VULNERABILITY TO DRUG USE AND ABUSE COMMON FACTORS PREDISPOSES TO BOTH PROBLEMS DIFFERENT OPIATES AFFECTS HEROIN AND OTHER DRUGS ABUSE CAUSE PROGRESSIVE BRAIN AND MIND IMPAIRMENT AND INTERMITTENT WITHDRAWAL METHADONE MAINTENANCE REMOVES INTERMITTENT WITHDRAWAL AND MAY IMPROVE DEPRESSIVE MOOD BUPRENORPHINE MAINTENANCE REMOVES INTERMITTENT WITHDRAWAL AND IMPROVE DEPRESSIVE MOOD ITALY: Number of Treatments YEAR 2015 ± 90.000 ITALY Methadone & Buprenorhine Treatments Ratio 1 BUPRENORPHINE TREATMENT BENEFITS OF PHARMACOTHERAPY (1) THE BENEFITS OF MAINTENANCE THERAPY ARE IMPRESSIVE ALL THE BRAIN MOOD AND COGNITIVE FUNCTIONS PSYSICAL HEATH IMPROVES SEXUAL FUNCTION IMPROVES MORTALITY IS REDUCED OFFENDING BEHAVIOUR IS REDUCED SOCIAL STABILITY IMPROVES COMORBIDITY ARE STABILIZED FAMILY RELATIONSHIPS IMPROVE ACCOMODATION AND WELFARE IMPROVE CRIME BEHAVIOUR REDUCED BENEFITS OF PHARMACOTHERAPY (2) THE BENEFITS OF DETOXIFICATION THERAPY REVERSING NEUROADAPTATION PROMOTING UPTAKE OF POST DETOX TREATMENT PSYSICAL HEATH IMPROVES SEXUAL FUNCTION IMPROVES MORTALITY IS REDUCED OFFENDING BEHAVIOUR IS REDUCED SOCIAL STABILITY IMPROVES COMORBIDITY ARE STABILIZED FAMILY RELATIONSHIPS IMPROVE ACCOMODATION AND WELFARE IMPROVE CRIME BEHAVIOUR REDUCED HOWEVER, COMPLETION WITHDRAWAL IS DIFFICULT FOR MOST!!! RELAPSES •OLD “DRUGS” FRIENDS •PLACES •RITUALS BEHAVIOUR •FAMILY •NO WORK PROTECTION ENVIRONMENT CAN BE BETTER? Brief History of Care Interventions in Residential Therapeutic Community Yesterday Today The same approach for each Diversified approach type of psychotropic according to the different substance substances of abuse Rigidly drug free program Use of pharmacotherapies as an integral part of the No substance in any phase of rehabilitation program the rehabilitation program Physical and temporal area wider and open to the Closed structure with strong territory, integrated with away from public service social and public health services Yesterday Today Eeach one is different and is Everyone must be treated treated in a personalized way equally Authority exercise is not placed from above, but based Community operator was on interactive relationship. proposed as authorities Prevails a non-judgmental attitude, or punitive damages, based on listening and dialogue Yesterday Today Now the goal is integration in The target was referring to the social and health network specific parameters: The perspective changing Withdrawal Time from linear to circular and Autonomy needs a more comprehensive Integrating social and work assessment JOINT VENTURE PUBLIC & PRIVATE Mission impossible to achieve about 15 years ago to the absolute incompatibility ideal and ideological between therapeutic program in community and drug treatment, with methadone in particular DEVIL AND HOLY WATER JOINT VENTURE PUBLIC & PRIVATE Designing to three hands: Health, Social, Community without a priority and in synergy Fairness in the various phases of the contact: – – – – – – – Process Reception Diagnosis Pharmacotherapy Stabilization Evaluation Tools Follow-up STRENGTHS Mutual cooperation Continuity of care Strong integration Management in a unique and exclusive environment Diagnostic residential Flexibility in the interventions Multiprofessional teamwork Pharmacotherapy as an integral part of community treatment Informal individual counseling OUR EXPERIENCE From 2001 to 2014 Reception Phase (Public towards Private or Private towards Public) Treatment plan shared (Public & Private) Individual pharmacological plan (progressive decrease) Psychological and community containment phase during pharmacologic decrease Drug Free Phase Orientation phase towards the community programmes in Ce.I.S. or others OUR DATA 320 subjects welcomed 272 programmes completed on average in 3 months 192 subjects in various Ce.I.S. programmes Follow-up for two years with drug free status Final Conclusions Multi-factorial health disorder Relapsing and remitting chronic condition Drug Dependence Treatable Best treated by pharmacological and psychosocial interventions together 1. WHO/UN-ODC. Principles of drug dependence treatment. Discussion paper. March 2008. GOALS Permanent staff monitoring Remodeling cognitive maps Motivational stop Place of awareness and care (orientation) Knowledge expansion (use of logic) Pharmacotherapy decrease in a protected environment Addiction management and acting out (comorbidity). Reshaping family relationships Stabilization and rewrite identity Rapid resocialization 26