Atlas Uso SPA OMS

8/19/2019 Atlas Uso SPA OMS

1/156

ATLAS on substance use (2010)Resources for the prevention and treatmentof substance use disorders


2/156


3/156

ATLAS on substance u


4/156

WHO Library Cataloguing-in-Publication Data

Atlas on substance use (2010): resources for the prevention and treatment of substance use disorders

1.Substance-related disorders - epidemiology. 2.Substance-related disorders - drug therapy. 3.Substance-rcontrol. 4.Substance abuse. 5.Substance-related disorders - rehabilitation. 6.Health policy. 7.Health personn

ISBN 978 92 4 150061 6 (NLM classication: WM 270)

© World Health Organization 2010

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Heal1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Reqor translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to


5/156

The global burden of disease attributable to alcohol and illicit d

by any m easure; it am ounts to 5.4% of the total burden oto the latest W H O estim ates (W H O , 2009a). A nother 3.7%

of disease is attributable to tobacco use. A nd disorders

substance use –including alcohol, drug and tobacco dependence –ar

conditions ultim ately responsible for the largest proportion of the glo

attributable to substance use.

Effective strategies and interventions exist to prevent and treat sub

H ow ever, effective im plem entation of such strategies and intervent

health system levels, including policy fram ew orks, the organizatio

treatm ent system s, and provision of prevention and treatm ent in

care and other settings.

W H O ’s key functions include m onitoring health situations and asses

years the W H O D epartm ent of M ental H ealth and Substance A buse

of ATLA S reports on global resources for m ental health and neurolo

W H O project ATLA S-SU used a sim ilar m ethodology to collect, com

inform ation from countries on resources that are available for

treatm ent of substance use disorders. This report has been devel

that inform ation and provides a general overview of the availabilit

prevention and treatm ent services for substance use disorders ar

particular focus on low - and m iddle-incom e countries.

The data presented in this report indicate that m ental health se

providers of treatm ent for substance use disorders in less-resourc

incom e countries, specialized services play a signi cant role in

substance use disorders through a broad range of providers. Spe

im portant for consolidating and developing expertise and hum an reso

the health and w ell-being of persons w ith substance use disorder

–requires easily accessible and affordable services for those in ne

less resourced countries specialization forhealth professionals in sub

FOREWORD


6/156

ATLAS on substance use (2010) — Resources for the prevention and t reatment of substance use disordersATLAS on substance use (2010) — Resources for the prevention and t reatment of substance use disorders

are expected to im prove the coverage and quality of prevention and tr

for substance use disorders in low - and m iddle-incom e countries. Thto contribute to bridging the gap betw een population needs an

particularly in health care system s.

Im proving the coverage and quality of prevention and treatm ent interv

use disorders requires w ell-developed and w ell-governed health ca

educated and trained hum an resources, nancial resources that are

population needs, supportive policy and legislative fram ew orks, a

appropriate essential m edicines. This publication is W H O ’s rst attem

areas at global level w ith inform ation collected from 147 countries fr

representing 88% of the w orld population.

The data presented is this report are based on results of the que

focal points identi ed in W H O M em ber States, and on the effo

ensure validity of data. There are m any challenges in collecting and

of inform ation, from the boundaries of prevention and treatm ent

countries to ensuring a com m on understanding of the term s and

data collection tools. It is acknow ledged that these challenges resu

presented data. H ow ever, the focus of the report is on presenting

available resources for treatm ent and prevention of substance use

W H O regions, and in groups of countries w ith different levels of eco

In each subsequent round of data collection, all efforts w ill be m ade t

and com parability of the data so that trends can be m onitored in

prevention and treatm ent resources for substance use disorders a

hope that this report w ill be useful to a w ide range of stakeholde

engaged in international efforts to im prove the prevention and tre

use disorders in low - and m iddle-incom e countries.

D r Shekhar Saxena

D irector

D epartm ent of M ental H ealth and Substance A buse

D r Vladim ir Poznyak

C oordinator

M anagem entofSubstance A buse


7/156

Foreword

Acknowledgements

Executive summary

Introduction

Methodology

Chapter 1. Psychoactive substance use: epidemiology and

burden of disease

1.1 A lcohol

1.2 Illicit drugs

1.3 Epidem iology of psychoactive substance use and burden of dis

1.4 M ain psychoactive substances used in the treatm ent populatio

1.5 Substance use m onitoring and surveillance

Chapter 2. Health services

2.1 Treatm ent of substance use disorders w ithin health services

2.2 G overnm ent adm inistration and budget of treatm ent

services for substance use disorders

2.3 Financing treatm ent services for substance use disorders

2.4 Treatm ent settings for alcohol and drug use disorders

2.5 Treatm ent services and coverage of alcohol and drug use

disorder treatm ent

2.6 N um ber of beds and length of stay

2.7 C are for special populations

Chapter 3. Pharmacological treatment

3.1 Pharm acological treatm ent of alcohol and drug use disorders

3 2 Policy fram ew ork and guidelines forthe pharm acological

CONTENTS

Foreword

Acknowledgements

Executive summary

Introduction

Methodology

Chapter 1. Psychoactive substance

burden of disease

1.1 A lcohol

1.2 Illicit drugs

1.3 pidem iology of psychoactive sub

1.4 M ain psychoactive substances us

1.5 Substance use m onitoring and su


.1 Treatm ent of substance use disor

.2 G overnm ent adm inistration and b

services for subs tance use disord

.3 Financing treatm entservices for s

.4 Treatm ent settings for alcohol and

.5 Treatm ent services a nd c overage

disordertreatm ent

.6 N um ber of beds and l ength of sta

.7 C are for special populations

Chapter 3. Pharmacological treatm

3.1 Pharm acological treatm ent of alco

3 2 Policy fram ew ork and guidelines f


8/156

ATLAS on substance use (2010) — Resources for the prevention and t reatment of substance use disordersATLAS on substance use (2010) — Resources for the prevention and t reatment of substance use disorders

Chapter 5. Policy and legislation

5.1 A lcohol and drug treatm ent policy in public health perspective

5.2 Policy fram ew orks and special legislative provisions

5.3 The crim inal justice system and substance use disorders

Chapter 6. Prevention

6.1 Effective prevention of substance use disorders

6.2 A dm inistration and budget

6.3 Availability and coverage of prevention services

6.4 Prevention services in special populations and harm reduction

6.5 Screening and brief intervention program m es

6.6 G roups and agencies involved in prevention of substance use d

References

List of nominated focal points

List of countries according to WHO region

List of countries according to the World Bank list of economies


9/156

This report w ould not have been possible w ithout the assistan

points in W orld H ealth O rganization (W H O ) M em ber State

and shared their know ledge and experience on the curren

country resources for the prevention and treatm ent of subs

The contribution of the focal points is gratefully acknow ledged. The l

points in countries responding to the ATLA S survey is provided at t

This report w as produced in the fram ew ork of ATLA S-SU proje

the M anagem ent of Substance A buse team of the D epartm ent o

Substance A buse of W H O headquarters in collaboration w ith W H O

ATLA S-SU project builds on the m ental health ATLA S project and

developm ent of the global inform ation system on resources for prev

of substance use disorders.

The ATLA S-SU project is im plem ented under the overall direction

Shekhar Saxena and B enedetto S araceno provided vision and gui

The principal w riting of this report w as done by D aniela Fuhr and

m ain contributors included Vladim ir Poznyak and A lexandra Fleisch

com pilation and statistical data analyses w ere carried out by D anie

The data collection from countries and the production of this report

possible w ithout the collaboration of the W H O regional of ces and t

country of ces. Key collaborators from W H O ’s regional of ces, w ho a

contributions at different stages of the developm ent of the report,

W H O A frican R egion: C arina Ferreira-B orges, Therèse A goussou an

W H O R egion of the A m ericas: M aristela M onteiro and Linda C astag

W H O Eastern M editerranean R egion: Khalid S aeed

W H O European R egion: Lars M øller and A nne-M ajlis Jepsen

W H O South-East A sia R egion: Vijay C handra

W H O W estern Paci c R egion: X iangdong W ang and N ina Rehn-M en

ACKNOWLEDGEMENTS


10/156

ATLAS on substance use (2010) — Resources for the prevention and t reatment of substance use disorders

of A delaide, A ustralia; M aria E lena M edina-M ora, N ational Institute

de la Fuente, M exico; R obin R oom , A ER C entre for A lcohol Polic

Point A lcohol & D rug C entre, Fitzroy, Victoria, A ustralia; School o

U niversity of M elbourne, A ustralia; C entre for Social R esearch on

Stockholm U niversity, Sw eden; and Tim Stockw ell, C entre for A d

B ritish C olum bia; D epartm ent of Psychology, U niversity of Victoria

D uring the developm ent of this report, a num ber of people con

capacities. D aniele Zullino and D elphine S reekum ar, D epartm ent o

U niversity, Sw itzerland, provided their assistance w ith data entry

W orld P sychiatric A ssociation and Tarek G aw ad from the Internationa

M edicine assisted w ith identifying the relevant data sources from so

their m em ber associations.

D avid B ram ley edited the report, and Irene Lengui developed grap

of the report. Em ily B aron assisted w ith the production of graphs.

Teresita N arciso and M ylène Schreiber provided valuable adm inist

preparation of the report.

Finally, W H O gratefully acknow ledges the nancial support of the Va

G overnm ent (Spain) for the developm ent and publication of this repo

2010 Fram ew ork Collaborative A greem ent betw een W H O and the V

G overnm ent (Spain), the H ealth A uthority, Valencian H ealth A gency


11/156

EXECUTIVE SUMMARY

BackgroundThis report provides for the rst tim e com parable global inform ation

range of resources required for the prevention and treatm ent of sub

by draw ing together inform ation from 147 countries that represe

population.

A questionnaire w as developed to m easure a w ide range of different

the prevention and treatm ent of substance use disorders at countr

o adm inistrative and nancial resources such as the presence of

funding and w ays of nancing treatm ent and prevention servic

o health service resources such as the availability and coverage of

services, the presence of pharm acological treatm ent, the num

length of stay for treatm ent;

o hum an resources such as the involvem ent of health profession

of substance use disorders, and the presence of other instit

institutionalized groups providing care for persons w ith substan

o policy and legislative resources such as the presence of d

legislative provisions for prevention and treatm ent of substanc

o resources for prevention of substance use disorders, such as avai

of different prevention services, im plem entation of screening a

in prim ary care, and presence of harm reduction program m es;

o inform ation resources such as know ledge of epidem iological as

use in the country, and know ledge of treatm ent service deliver

Key findings


12/156

ATLAS on substance use (2010) — Resources for the prevention and treatment of substance use disorders

o Psychoactive substance accountable for treatm ent dem and

From the m ajority of countries in every W H O region 1 but one, alcoho

the m ain psychoactive substance responsible for dem and for trea

of the A m ericas, treatm ent dem and w as chiefl y due to cocaine.

o N um ber of deaths and disability-adjusted life years lost due to ps

use

G lobally, som e 39 deaths per 100 000 population are attributable

drug use, out of w hich 35 deaths are attributable to alcohol use and

to illicit drug use. The use of alcohol and illicit drugs accounts g

disability-adjusted life years (D A LYs) lost per 1000 population. A pp

per 1000 population are lost due to alcohol use, and approxim ately

due to illicit drug use.


o G overnm ent adm inistration and budget for treatm ent services

The presence of a governm ent unit or a governm ent of cial respo

services for substance use disorders w as reported by 66.2% of c

half of the countries in the survey reported having a speci c budge

treatm ent of substance use disorders.

o Financing of treatm ent services

C ountries identi ed tax-based funding, out-of-pocket paym ents and s

to be am ong the forem ost m ethods of funding treatm ent for a

disorders. A frica appears to be the only region in w hich out-of-po

reported to be the m ain funding m ethod for alcohol and drug us

services.

o Treatm ent setting for alcohol and drug use disorders


13/156

present in over 90% of countries responding to the survey. H ow e

population in need w ith alcohol and drug use disorder treatm ent s

low . For exam ple, in low -incom e countries the m ajority of persons w

use disorders are not covered by the respective treatm ent services

o N um ber of beds and length of stay

A m ong the responding countries, the m edian num ber of beds for

disorders w as 1.7 per 100 000 population (range of 0–52 beds per

The m edian length of stay for alcohol and drug detoxi cation w as

days respectively.

o C are for special populations

Substance use disorder treatm ent services for prisoners w ere rep

surveyed countries, follow ed by substance use disorder treatm en

people (47.6% ) and for injecting drug users (40.0% ). Specialized su

treatm ent services for pregnant w om en and com m ercial sex w orker

present in 31.0% and 25.5% of countries respectively. A pproxim ate

reported having substance use disorder treatm ent services for indi

Specialized treatm ent services for persons w ith drug use disorders

reported in 43.2% of countries. A round a quarter of countries (24

treatm ent services for people w ith both drug use disorders and tub

Chapter 3. Pharmacological treatment

o Policy fram ew ork and guidelines for the pharm acological treatm

disorders

Policy docum ents on the pharm acological treatm ent of substance

reported by 40.2% of countries, w ith E urope reporting the highest p

w ith policy docum ents on the pharm acological treatm ent of subs

G uidelines on the pharm acological treatm ent of substance use diso

by approxim ately half of the surveyed countries (51.8% ).


14/156

ATLAS on substance use (2010) — Resources for the prevention and treatment of substance use disorders

o A dm inistration of opioid agonist pharm acotherapy

Length of treatm ent w ith opioid agonist pharm acotherapy w as repor

in the m ajority of countries, w ith 74.1% of countries reporting no

agonist pharm acotherapy. O ver 55% of countries in the survey repor

syrup/solution for the treatm ent of opioid dependence. A pproxim ate

the survey reported com m encing opioid agonist pharm acotherapy o

o Supervision and prescription requirem ents for opioid agonist ph

Supervision of m ethadone for the treatm ent of opioid dependence w

of countries in the survey. In 60.6% of countries buprenorphine supe

w hile 71.4% of countries required buprenorphine/naloxone superv

M ore than 20% of countries in w hich m ethadone is used reported

special training are allow ed to prescribe m ethadone. In approxim at

surveyed, it w as reported that non-doctors are given the authorit

agonists.

Chapter 4. Human resources

o H ealth professionals

A variety of health professionals seem to be responsible for the m anag

drug use disorders in different countries. The m ajority of countries re

general practitioners and addictologists/narcologists to be the health

involved in the treatm ent of alcohol and drug use disorders.

o Standards of care and supervision for health professionals

A pproxim ately half of the countries in the survey (47.6% ) repo

standards of care for health professionals w orking w ith persons

disorders. The low est proportions of countries w ith standards of care

regions of South-East Asia (20.0% ), A frica (20.9% ) and the Eastern M

The clinical supervision of nurses w as reported in 57 1% of cou


15/156

surveyed countries reported the presence of N G O s focusing on re

and drug use disorders. N G O s involved in treatm ent of alcohol dis

disorders w ere reported from 54.5% and 59.9% of countries respe

A lcoholics A nonym ous w as reported to be active in the m ajority o

N arcotics A nonym ous w as reported to be active in approxim ately h

the survey (56.7% ), and C ocaine A nonym ous in 11.5% of countries

“Ex-addicts”or “recovering addicts”w ere reported to provide form al

substance use disorders in 59.9% of countries in the survey, and thi

be m ost com m on in high-incom e countries. The highest proportion

providing care for persons w ith substance use disorders w as repor

countries (44.7% ). R eligious groups or N G O s based on religious gro

care for substance use disorders are reported m ost com m only am

higher m iddle-incom e group (79.3% ).

Chapter 5. Policy and legislation

o Policy fram ew orks and special legislative provisions

The m ajority of countries in the survey (68.0% ) reported having

abuse policy, w ith 100% of high-incom e countries reporting that

highest proportion of countries in the survey reporting substance a

the European R egion (93.2% ). The A frican R egion (32.6% ) reported

of countries w ith substance abuse policies.

Special legislation for the com pulsory treatm ent of substance use di

from 42.5% of countries in the survey. O f these countries, 30% rep

legislation for the com pulsory treatm ent of both alcohol and drug us

G overnm ent bene ts for persons w ith alcohol and drug use diso

from 40.6% of countries in the survey. The W estern Paci c (78.6%

for drugs) and E urope (69.0% for alcohol, 70.5% for drugs) reporte

proportions of countries providing governm ent bene ts for persons

use disorders.

o The crim inaljustice system and substance use disorders


16/156

ATLAS on substance use (2010) — Resources for the prevention and treatment of substance use disordersATLAS on substance use 2010 — Resources for the prevention and treatment of substance use disorders

Chapter 6. Prevention

o A dm inistration and budget

In 72.4% of countries in the survey, one or m ore governm ent u

the prevention of substance use disorders w ere reported. H alf of

survey (50.0% ) reported having a budget line in the annual budget

substance use disorders. The low est proportion of countries report

in A frica (30.2% ).

o Availability and coverage of prevention services

School-based program m es, com m unity-based program m es, and w o

for the prevention of substance use disorders w ere reported by 77.9

of countries respectively. H ow ever, coverage of the population

based program m es, com m unity-based program m es, and w orkplace

prevention of substance use disorders appears to be low . For exam

countries indicated that the coverage of school-based program m es

substance use disorders w ould be provided for less than half of the

o Prevention services in special populations and harm reduction

The m ost com m only reported prevention program m es w ere those fo

at risk (45.2% of countries), follow ed by prevention program m es f

for people living w ith H IV/A ID S (41.1% ), for pregnant w om en (32

sex w orkers (29.5% ) and for m inority groups (17.8% ).

The presence of needle/syringe exchange program m es differs w ithi

of countries, com m unity-based needle/syringe exchange program

Som e 6.6% of countries reported having syringe exchange program

o Screening and brief intervention program m es

Screening and brief interventions im plem ented in prim ary health ca

harm ful alcohol use and for drug use w ere reported by 47.9% and

respectively. The A m ericas and the W estern Paci c reported the h

countries w ith screening and briefinterventions forharm fulalcoholu


17/156

INTRODUCTION

Dimensions of psychoactive substance use and dependeThe use of alcohol and other psychoactive substances alters bo

ultim ately, the structure of the brain by the altered stim ulation of part

central nervous system . M ood, perception and consciousness are a

psychoactive substances, w hich can infl uence the capacity of person

their drug use. The result can lead to physical and psychological d

the person to continue taking the drug despite adverse consequenc

im pairm ent and loss of physical health, people w ith alcohol and dru

suffer severely from psychological and psychosocial problem s, int

loss of em ploym ent, dif culty in participating in education, and lega

G iven the com plexity of substance use disorders and their effects on

aspects of the person, treatm ent and prevention of alcohol and dru

involve a range of treatm ent and prevention m odalities w hich m ay be

of settings. Treatm ent m odalities m ay involve pharm acological tre

include other com ponents of health care, such as psychological sup

as w ell as rehabilitation to respond to the stage of the illness and t

of the person w ith the substance use disorder. D elivery of adequat

for persons w ith alcohol and drug use disorders requires a w ell f

and prevention system that has the capacity to respond to the nee

What constitutes resources for the treatment and preventuse disorders?The effective prevention and treatm ent of substance use disorders re

of a range of resources at the national or subnational level. R esource

nancial capital of national authorities to fund treatm ent and pre

substance use disorders, but also include hum an and institutionaliz

the availability of health care staff and nongovernm ental organizati

in the delivery of care and treatm ent for the population in need. Wsetting, clinical m anagem ent of substance use disorders m ay involve

and treatm ent approaches; treatm ent m ay also be differentiated b

classes of pharm acological drugs used for detoxi cation or for the

and drug dependence. O ther resources include the know ledge o

aboutthe epidem iologicalsituation in the country regarding substan


18/156

ATLAS on substance use (2010) — Resources for the prevention and treat ment of substance use disorders

signi cant prevention and treatm ent gap suggests a shortage o

treatm ent and prevention of substance use disorders. G iven the co

health resources, both low -incom e and high-incom e countries can

detailed aw areness of w hat resources are being m ade available

substance use disorders, so that this can be com pared to other hea

m odels of resource distribution (as m ay be used in other countries,

of this, the ATLA S-SU project seeks to m ap those resources at n

global levels to highlight the speci c resources available for treatm e

substance use disorders. A s such, it represents an essential tool fo

health professionals and policy-m akers in helping to assess the pri

increasing the quality of care for people w ith substance use disorde

inform ation about the resources available for the treatm ent and pre

use disorders in all W H O regions has been collected and analys

regional and global com parisons possible. A structured description o

and treatm ent resources for substance use disorders is also a pre

detailed assessm ent of treatm ent system s, and for im proving treat

system s for substance use disorders at national, regional and globa

The objective of the ATLAS-SU project and the structure The objective of the ATLA S-SU project w as to collect, com pile, ana

basic inform ation from W H O M em ber States on the follow ing r

required for substance use treatm ent and prevention:

o adm inistrative and nancial resources such as the presence of

funding and w ays of nancing treatm ent and prevention servic

o health service resources such as the availability and coverage of

services, the presence of pharm acological treatm ent, and the

length of stay for treatm ent;

o hum an resources such as the involvem ent of health profession

of substance use disorders, and the presence of other instit

institutionalized groups providing care for persons w ith substan

o policy and legislative resources such as the presence of dif

legislative provisions for prevention and treatm ent of substanc

o resources for prevention of substance use disorders, such as avai

ofdifferentprevention services im plem entation ofscreening a


19/156

disorders are presented in chapter 3. C hapter 4 covers hum an re

provides inform ation about the health w orkforce for substance use

legal resources for people w ith substance use disorders are discusse

concluding w ith resources for the prevention of psychoactive substa

Each chapter begins w ith an expert introduction before data from t

are presented. D ata from the ATLA S-SU survey are presented grap

charts. Salient ndings are described, and notes and com m ents on

The raw data on w hich the ATLA S-SU report w as prepared w ill be av

online database on the w eb site of the M anagem ent of Substanc

at W H O (w w w .w ho.int/substance_abuse/en). This w ill enable m ore

be conducted.


20/156


21/156

o Stage 5: D ata m anagem ent.U pon receipt of nal questionnaire

into a statistical package (SPSS 16). For the ease of statist

questions w ere regrouped. A n identi er w as applied to the

country to facilitate disaggregation of data by W H O region and b

of econom ies (based on the W orld B ank list of econom ies of 2

divided according to gross national incom e per capita. A ccordin

these groups are low -incom e countries (having a gross national

less), low er m iddle-incom e countries (U S$ 936 to U S$ 3,705), h

countries (U S$ 3,706 to U S$ 11,455) and high-incom e count

over). Lists of countries by W H O region and by the W orld B ank

provided at the end of this report.

o Stage 6: Statistical analyses of data and presentation of data. Fre

and m easures of central tendency w ere calculated as approp

disaggregated according to W H O regions and different incom e

To illustrate the inform ation obtained, data w ere exported into M

to produce bar and pie charts.

o Stage 7: D ata availability on a searchable database. D ata w isearchable database (i.e. to a global inform ation system ) on the W

the global inform ation system indicators of the A TLA S project

presented according to country and W H O regions.

Representativeness and limitations of dataThe questionnaire w as developed in 2007, and sent out to the count

2008. D ata w ere obtained from all W H O regions, although not all Ww ithin the regions responded to the survey questionnaire. D ata pre

report refl ects inform ation from countries w hich responded to the su

of 193 countries took part in the ATLA S-SU project and subm itted

covering 76% of all W H O M em ber States and 88% of the w orld p

for som e questions the denom inator w as below the overall num b

received. N um bers in the respective categories (i.e. region and incom

if no m ore than 15% of countries responded to the survey question

In the W H O A frican R egion 43 countries responded to the ATLA

(93% coverage of countries in the region), in the W H O R egi

21 countries responded (58% coverage of countries in the region),

M editerranean R egion 14 countries responded (67% coverage of co

in the W H O European R egion 44 countries responded (83% covera


22/156


23/156

CHAPTER 1. PSYCHOACTIVE SU

USE: EPIDEMIOLOGY AND BURD

DISEASE

1.1 Alcohol

Jürgen Rehm and Jayadeep Patra

A lcohol is possibly the oldest psychoactive substance used by m anki

C urrently, it is also the m ost prevalent psychoactive substance, alth

the w orld adult population abstains. G lobally, 46% of all m en and 73%

from alcohol, and m ost of these persons have not consum ed an

during their entire lives. There are huge variations in abstention aroverw helm ing m ajority of people in a belt stretching from N orthern A

M editerranean, South C entral A sia and South-East Asia to the islands

for reasons often attributable to religion and culture. In other parts

Europe, less than 20% of the population abstains on average.

The level of abstention is relatively strongly associated w ith the lev

capita consum ption. Total adult per capita consum ption is highest in

Europe w here total adult per capita consum ption ranges from 15 and is low est in N orthern A frica, the Eastern M editerranean, South

East Asia and the Indonesian islands w here also the m ajority of the

The burden of disease attributable to alcoholThe burden of disease attributable to alcohol w as based on th

A ssessm ent (C R A ) m ethods (R ehm , Klotsche & Patra, 2007; R ehm

w ere also used in the W H O R eport on G lobal H ealth R isks to comfactors (W H O , 2009a). In 2004, 7.6% of the global burden of dis

attributable to alcohol consum ption am ong m en and 1.4% to consum

N europsychiatric disorders, including alcohol use disorders, acco

disability-adjusted life years (D A LYs)1 caused by alcohol (R ehm et al

ATLAS on substance use (2010) — Resources for the prevent ion and treat ment of subst ance use disorders


24/156


im pact from alcohol. The least alcohol-attributable harm can be found

M editerranean and in the southern part of A sia, especially in countrie

M uslim populations. In evaluating these num bers it should be recog

these data are based on the C R A of the year 2000, in w hich the d

alcohol on infectious diseases such as tuberculosis w as not suf ci

the G lobal B urden of D isease study had few er categories w hich re

som e of the im pact of alcohol (e.g. on pancreatitis) (R ehm & M ath

of alcohol-attributable infectious disease categories w ould change

extent (R ehm et al., 2009a; R ehm & Parry, 2009). Even w ithout c

of alcohol on infectious diseases, harm ful use of alcohol is one o

contributors to the global burden of disease (W H O , 2009a) and m

ranked third behind childhood underw eight and unsafe sex.

Alcohol use disorders and global estimatesA lcohol use disorders com prise alcohol dependence and the har

G lobal estim ates for alcohol use disorders are based on epidem io

assess these disorders through diagnostic assessm ent instrum ents a

disorders through international disease classi cation system s suchC lassi cation of D iseases (IC D ) and the D iagnostic and Statistic

D isorders (D SM ) (Kehoe, R ehm & C hatterji, 2007; R ehm et al., 200

The highest prevalence rates of alcohol use disorders in the popul

parts of Eastern and C entral Europe (highest prevalence rates of alc

som e countries reaching up to 16% ), in the A m ericas (prevalence ra

in this region reaching up to 10% ), South-East Asia (prevalence

10% ) and in som e countries in the W estern Paci c (prevalence ratreaching up to 13% ). In India, for exam ple, in spite of high abstent

all w om en abstaining from alcohol, a pattern of frequent and heavy

am ong those w ho drink, resulting in high rates of alcohol use disor

(Prasad, 2009; R ehm et al., 2009b).

Psychoactive substan


25/156


1.2 Illicit drugs

Louisa Degenhardt

Illicit drugs are used by only a m inority of the global population. The U

on D rugs and C rim e (U N O D C ) estim ated that betw een 172 and 250

15–64 years had used an illicit drug at least once in 2007 (U N O D C ,

by far the m ost com m only used illicit drug (3.3–4.4% of the populatio

w ith the highest prevalence in N orth A m erica, W estern Europe and O

m illion people aged 15–64 years w ere estim ated to have used am phw ith the highest levels in South-East Asia. An estim ated 16–21 m illion

(0.4% –0.5% ) w ith use concentrated in N orth A m erica, follow ed by

Europe, and S outh A m erica. The num ber of opiate users w as estim

w ith the m ain drug traf cking routes out of A fghanistan having the

(U N O D C , 2009).

Those w ho use drugs once or tw ice have, at m ost, a very sm all

and m ortality, w ith the concentration of harm s occurring am ong tregularly. The com m only used expression “problem atic drug use”

corresponding to the W H O ’s International C lassi cation of D isea

“harm ful drug use”and “drug dependence”(W H O , 1993).

Risk factors for drug dependenceStudies exam ining the level of risk for dependent use am ong life

lim ited, but studies in the U SA and A ustralia have suggested thapeople w ho ever use an illicit drug m ight m eet criteria for depen

(G lantz et al., 2008; H all et al., 1999). The extent of this risk varie

w ith greater risks for drugs w ith a rapid onset and shorter duration o

by sm oking or via injection carries greater dependence risk (A nthon

1994; Volkow et al., 2004; M cKetin, Kelly & M cLaren, 2006).

Risk factors for drug dependence m ay differ betw een countries, altho

directly exam ined this (D egenhardt et al., 2010). A study of initiation toto dependence in the W H O W orld M ental H ealth Surveys found a r

w ere com m on to the developm ent of illicit drug dependence am on

et al., 2010): earlier onset of drug use; using m ore types of illicit dru

age 15 years of externalizing (e.g. conduct disorder) and internaliz

(e g depression)(D egenhardtetal 2010) These ndings are consis



26/156

( ) p

that, globally, 11–21 m illion people injected drugs1 in 2007 (M ath

2007, U N O D C estim ated that there w ere betw een 18 and 38 m

users”(i.e. injecting drug users or problem users of opioids, coca

(U N O D C , 2009). “Illicit drug dependence”w as assessed in the W

H ealth S urveys, in 27 countries in ve W H O regions (Kessler &

signi cant geographic variation in rates of illicit drug use (D egenh

drug dependence (D em yttenaere et al., 2004), and higher rates of

developed countries (Kessler & Ü stün, 2008). These differences m ay

of actual differences, as w ell as cultural differences in the un

preparedness to report, illicit drug use and related problem s in surv

To date, no estim ates of the prevalence of speci c form s of drug de

m ade regionally and globally, and few countries have m ade estim a

types. This is a m ajor gap in know ledge that severely lim its our capac

based decisions about the extent of need for interventions to addre

Interventions show n to be effective differ in im portant w ays acr

opioid pharm acotherapy being the m ainstay of treatm ent for hero

psychosocial interventions being m ore appropriate for cannabis

dependence. There is a need to im prove our understanding of these questions about illicit drug use and dependence in order to im p

respond, nationally and globally.

1 Injecting drug use: use of a drug by injection, w hich may be intravenous, intramuscular or subcutaneous.



27/156

1.3 Epidemiology of psychoactive substance usedisease

(Figures 1.1–1.7)

Background o Estim ates of the num bers of deaths and the am ounts of loss of

diseases, including the use of alcohol and illicit drugs are pro

B urden of D isease project w hich w as initiated during the 1990

o A lcohol and drug-attributable D A LYs represent a m easure of ov

quantifying m ortality and m orbidity due to alcohol and illicit drug u

m easure. The burden of disease expressed in D A LYs quanti es

current health status of the population and an ideal situation w h

old age in full health (W H O , 2009a).

Salient findingsPrevalence of alcohol and drug use disorders in the populatioprevalence) o A cross countries, the point prevalence of alcohol use disorders (i

15 years and over) is generally higher than the point prevalence

in the sam e population and is generally higher am ong m en than

o G lobal prevalence rates of alcohol use disorders w ere estim at

to 16% , w ith the highest prevalence rates to be found in Easte

o A m ong m ales, the point prevalence of alcohol use disorders fo

to be highest (i.e.≥6.4% ) in E astern E uropean countries, in par

countries in the A m ericas. A m ong fem ales, the highest estim a

of alcohol disorders (i.e.≥1.6% ) w ere found in Eastern Europ

selected countries in the A m ericas and in the W estern P aci c.

o A m ong m en and w om en, the estim ated prevalence of alcohofound to be low est in the A frican and Eastern M editerranean re

o G lobal prevalence rates of drug use disorders w ere estim ated

3% , w ith the highest prevalence rates found in the E astern M e



28/156

Number of deaths and disability-adjusted life years lost o G lobally, approxim ately 39 deaths per 100 000 population are a

and illicit drug use, out of w hich 35 deaths are attributable to deaths to illicit drug use.

o The highest num bers of deaths due to alcohol and illicit drug

Europe w here 70 deaths per 100 000 population are attributab

approxim ately ve deaths per 100 000 to illicit drug use.

o In alm ost all regions, num bers of deaths attributable to alcoho

those for illicit drug use. In the Eastern M editerranean R egion, hper 100 000 population are attributable to illicit drug use, an

deaths per 100 000 population are attributable to alcohol use.

o U se of alcohol and illicit drugs accounts for alm ost 13 D A LYs los

w orldw ide. A pproxim ately 11 D A LYs per 1000 population are lo

and approxim ately tw o D A LYs are lost due to illicit drug use.

o D A LYs lost due to alcohol and illicit drug use w ere found to b(approxim ately 23 D A LYs lost per 1000 population) and the A m

18 D A LYs lost per 1000 population).

o In the Eastern M editerranean R egion m ore D A LYs are lost due t

D A LYs lost per 1000 population) than due to alcohol use (appr

lost per 1000 population).

o The num ber of D A LYs lost due to alcohol and illicit drug use varieH igher m iddle-incom e countries w ere found to have the greate

lost due to alcohol and illicit drug use (24 D A LYs lost per 100

alcohol use and approxim ately three D A LYs lost due to illicit dr

Notes and comments o Prevalence estim ates for alcohol and drug use disorders a

com parable across countries and regions of the w orld. Prevafrom the G lobal B urden of D isease study (W H O , 2004).

o A lcohol use disorders included in the G lobal B urden of D isea

alcohol dependence and harm ful use of alcohol. D rug use diso

G lobalB urden of D isease analysis included opioid dependenc



29/156


30/156


31/156

Alcohol

Illicit drug use

D A L Y s

p e r 1 0 0 0

p o p u l a t i o n

W e s t e r n P a

S o u t h - E a s t A s i a

E u r o p e E a s t e r n M e d i t e r r a n e a n

A m e r i c a s

A f r i c a 0

5

10

15

20

25

FIGURE 1.7DALY LOST BY ALCOHOL

AND ILLICIT DRUG USE, BY

INCOME GROUP, PER 1000,

2004

D A L Y s

p e r 1 0 0 0

p o p u l a t i o n

H i g h H i g h e r - m id

L o w e r - m i

L o w 0

5

10

15

20

25

30

FIGURE 1.5

DEATHS ATTRIBUTABLE TO

ALCOHOL AND ILLICIT DRUG

USE, PER 100 000,

BY REGION, 2004

D e a t h s

p e r 1 0 0

0 0 0

p o p u l a t i o n

W o r l d W

e s t e r n P a c i fi c


E u r o p e E a s t e r n M e d i t e r r a n e a

n

A m e r i c a s

A f r i c a 0

10

20

30

40

50

60

70

80



32/156

1.4 Main psychoactive substances used in the trpopulation

(Figures 1.8–1.9)

Backgroundo N om inated focal points in countries w ere asked to report th

substances accountable for entry into treatm ent.

Salient findings o In the m ajority of countries (53.9% ) alcohol w as identi ed as th

substance at entry into treatm ent. A lcohol w as reported to be th

substance responsible for treatm ent dem and in the m ajority

region, w ith the exception of the A m ericas.

o The m ajority of countries in the R egion of the A m ericas (50%

be the m ain psychoactive substance at treatm ent entry.

o In the Eastern M editerranean R egion, alcohol and cannabis w

m ajority of countries as being m ost frequently the m ain psyc

at treatm ent entry. O pioids w ere reported as the m ain psych

treatm ent entry in 20% of countries in the Eastern M editerrane

o In the A frican R egion, cannabis appears to be the m ost fre

substance at treatm ent entry in approxim ately 40% of countrie

o In the South-East A sia and E uropean regions, opioids w ere id

frequent psychoactive substance behind the dem and for trea

26.5% of countries respectively.

o In the W estern Paci c R egion, cannabis and am phetam ine-type s

reported to be the m ost frequent psychoactive substance acco

entry in 16.7% of countries.

o N o country in the survey identi ed inhalants, sedatives or pres

m ain psychoactive substance at treatm ent entry am ong person

o In contrastto high incom e and higherm iddle incom e countries c



33/156

o The question aim ed to identify the single m ost com m on psy

behind substance use disorders that cause entry into treatm e

com bination of m ultiple psychoactive substances accountable fpatients –such as the com bined use of alcohol and other psyc

not speci cally exam ined.

o O ther m ain psychoactive substances in the treatm ent popula

regional-speci c psychoactive drugs. A num ber of A frican cou

the m ain psychoactive substance at treatm ent entry w as kha

under this category.

o Treatm ent data m ay not necessarily correlate closely w ith data

the respective disorder and underlying substance use in popula

m ay be infl uenced by w hat treatm ent is available, and m ay al

group w ith substance use disorders w ho seek treatm ent, and t

treatm ent. A n exam ple is the Eastern M editerranean R egion w h

identi ed alcohol as being the m ost com m on substance at tre

the low er rates of alcohol use in these countries (see section 1


34/156



35/156

LO W

P e r c e n t a g e

o f c o u n t r i e

s

n= 24

33.3%

45.8%

4.2%0% 0%

0% 0%

8.3%

0%

8.3%

LO W

P e r c e n t a g e

o f c o u n t r i e

s

n= 20

50.0%

25.0%

0%

5.0%

H IG H E R ‐ M I D D

L E

P

e r c e n t a g e

o f c o u n t r i e s

n= 22

63.3%

9.1%

22.7%

0% 0% 0%

0%

4.5%0% 0%

P e r c e n t a g e

o f c o u n t r i e s

n= 23

4.3% 4.3%

0%

56.5%

Alcohol

Cannabis

Cocaine

ATS

Inhalants

Sedatives

Hallucinogens

Opioids

Prescribed opioidsOther

FIGURE 1.9

MAIN PSYCHOACTIVE SUBSTANCE ACCOUNTABLE FOR TREATMENT ENTRY IN COUNTRIES, BY INCOME GROUP, 2008



36/156

1.5 Substance use monitoring and surveillance

(Figures 1.10–1.15)

Background o N om inated focal points in countries w ere asked about the pres

collection system s that collect epidem iological data on alcohol

treatm ent data from health system s in their respective areas. N

regarding the existence of inform ation at subnational level.

o Epidem iological data can be obtained through national surveilla

can be com posed of national surveys collecting inform ation on

am ong the adult or the adolescent population.

o Treatm ent data relating to alcohol and drug use can be obtained

delivery data collection system s that com pile adm ission and

num ber of outpatient contacts and sim ilar service inform ation

system .

Salient findings o Less than 50% of countries reported having national data collecti

epidem iological data or treatm ent data.

o The regions w ith the highest proportion of countries (approxim

national epidem iological data collection system s for alcohol anA m ericas and Europe.

o The low est proportions of countries reporting national surveys

use am ong adolescents w ere in A frica (5–7% ), in E astern M ed

20% ) and in South-East A sia (less than 20% ).

o Treatm ent data on both alcohol and drug use disorders appe

collected in the A m ericas and in E urope, w ith around 65–77% regions reporting the collection of treatm ent data. C ollection

alcohol and drug use disorders seem s to be balanced across r

Eastern M editerranean and S outh-East A sia regions w here h

countries indicated collection of treatm ent data on drug use th


sychoactive substan


37/156

Notes and comments o N ational epidem iological data collection system s m ay focus on

exclusively. H ow ever, epidem iological data collection system sof health issues m ay not have been detected by this survey.

o Inform ation on alcohol and drug use am ong youth can be collec

going to school. A num ber of countries reported national schoo

w ay of collecting inform ation on alcohol and drug use am ong y

o N ational data collection system s on epidem iology and treatm e

and substance use disorders appear to be lacking. This is elow -incom e and low er m iddle-incom e countries, w hich m ay ha

effective responses.


38/156


39/156

CHAPTER 2.HEALTH SERVICES

2.1 Treatment of substance use disorders within services

Thomas F Babor and Kerstin Stenius

OverviewSince the end of the Second W orld W ar there has been a consistent

m edical, psychiatric or social services for individuals w ith subst

particularly in the m ore af uent parts of the w orld w here disorder

illicit drugs are prevalent (M äkelä et al., 1981). In low -incom e and

countries, specialized treatm ent services are often lacking and the

system s are not prepared to m anage patients w ith substance us

good evidence that treatm ent can reduce the health burden attributaand possibly the am ount of alcohol and drugs consum ed in a coun

alone cannot com pletely solve the alcohol or drug problem (B abor e

M ann, 2000; R euter & Pollack 2006).

A ttem pts to build service system s that adequately respond to subst

the population face several challenges. W hile epidem iological know

it is still incom plete in m any countries, m aking it dif cult to estim

type of treatm ent that is needed in a particular country. C onsequentare often established w ithout any overall planning or a general con

present and future population needs. Treatm ent services tend to be

suf cient coordination betw een different services. Access to treatm e

to location, nancial resources and type of substance. Services are

in a w ay that increases stigm a and at tim es they m ay lack the neces

hum an rights.

ATLAS-SU dataThe ATLA S gures presented in this chapter provide a global view

treatm ent services and system s w ithin the six W H O regions. A s suc

source of inform ation about how treatm ent for substance use diso

organized atnationaland regionallevels A lthough tw o thirds ofthe W



40/156

health plays a m ore im portant role in treatm ent provision in low -i

both alcohol and drugs). The availability of both inpatient and ou

m uch higher in the m ore af uent countries, even if there is a relativem any of these countries. There is a large difference betw een the l

incom e countries in the m edian num ber of beds available for alcoho

In addition, specialized treatm ent for people w ith substance use dis

diseases is often not delivered, w ith the data show ing a lack of tr

persons w ith H IV/A ID S, especially in the W H O A frican R egion.

Towards a public health modelAs suggested by these data, countries differ m arkedly in the extent, o

of the health services provided to persons w ith substance use diso

has been a considerable am ount of clinical research on speci c thera

little attention has been devoted to the optim al am ount, type and or

necessary to m eet the public health needs of a particular country.

com parative research and descriptive studies have begun to fo

issues as availability, accessibility, coordination, service quality, co

degree of coerciveness (B abor, Stenius & R om elsjo, 2008). M uchbe characterized in term s of system qualities, w hich are de ned

different facilities and levels of care, and by the extent of integrat

of services, such as prim ary health care, m ental health, and m utu

(G ossop, 1995; Klingem ann, Takala & H unt, 1992; 1993; Klingem an

A ccording to a public health m odel proposed by B abor, Stenius

treatm ent policies affect system qualities by specifying not only

located (e.g. separate alcohol and drug services, or com bined alcohw ith or w ithout m ental health services), but also how they are orga

System qualities include equity (the extent to w hich services are

accessible to all population groups), ef ciency (the m ost appropr

and econom y (the m ost cost-effective services). These qualities

general effectiveness of a system of services. W hen they are availa

persons w ith substance use disorders, the cum ulative im pact of t

translate into population health bene ts, such as reduced m ortality a

as bene ts to social w elfare, such as reduced unem ploym ent, disand health care costs.

These considerations suggest the need for a public health view of

one that avoids an exclusive focus on expensive residential, m edic

in favour of a broader system of services that includes selfhelp o


41/156

ConclusionH ealth services for substance use disorders form a vital part

responses to the burden of disease and disability resulting from subW hile inform ation on the structure and functioning of these service

the developm ent and m odi cation of service system s, this info

available in low -incom e and m iddle-incom e countries. The ATLA

this report not only represent an im portant rst step in the develop

on treatm ent services at an international level but they also point

com prehensive m ethods of data collection and analysis. C ontinued e

friendly treatm ent service data could provide a basis for im proved

could stim ulate system reform in countries attem pting to m axim izefor persons affected by substance use disorders.


ATLAS on subst ance use 2010 — Resources for the prevention and treatment of substance use disorders


42/156

2.2 Government administration and budget of treservices for substance use disorders

(Figures 2.1–2.4)

Background o N om inated focal points w ere asked about the presence of a spe

or the presence of a governm ental of cial in their countries resp

use disorder treatm ent services.

o In addition, focal points w ere asked to provide inform ation abo

speci c budget line in the annual budget of the governm ent w h

for actions directed tow ards the treatm ent of substance use di

Salient findingsGovernment unit for substance use disorder treatment service

o A governm ent unit or a governm ent of cial responsible for sutreatm ent services w as reported by 66.2% of surveyed count

of these countries (50% ), the governm ent unit w as taking car

use disorder treatm ent services together. Separate governm

treatm ent services and drug use disorder treatm ent services ex

only. Few countries (7% ) reported having a governm ent unit for

use disorders only. N o country in the survey reported having on

focusing on the treatm ent of alcohol use disorders.

o The presence of governm ent units for the treatm ent of alcohol a

appears to be least likely am ong countries in the A frican R egio

o There seem s to be an effect of country incom e level on the pres

units for substance use disorder treatm ent services across diff

of countries. C ountries in the higher incom e groups report m o

presence of governm ent units for substance use disorder trea

countries in the low er incom e groups.

Budget line for treatment services o Less than half of the countries reported having a budget line

directed tow ards the treatm entof substance use disorders


43/156

o There is no clear country incom e effect on the presence of budg

use disorder treatm ent services across different incom e group

o The m ajority of low -incom e countries appear to nance sub

treatm ent services through an integrated budget line (i.e. a

reserved for nancing m ental health, alcohol and drug use

services together). The presence of an integrated budget line

w ith increasing country incom e.

Notes and comments o A third of responding countries reported having no governm en

substance use disorder treatm ent services. A governm ent unit r

health treatm ent services w hich includes substance use disord

still be present in such countries.

o B udget lines speci cally allocated to the treatm ent of substance

to be absent, even in higher m iddle-incom e and high-incom e c

o The presence of a budget line does not m ean that inform ation

am ount of nancial resources that are ultim ately allocated to su

treatm ent services.



44/156

For alcohol and drug use disorders together

For alcohol use disorders only

For drug use disorders onlyFor alcohol and drug use disorders separately

FIGURE 2.1

PROPORTION OF COUNTRIES

WITH A GOVERNMENT UNITRESPONSIBLE FOR TREATMENT

OF SUBSTANCE USE DISORDERS,

BY REGION, 2008

W o r l d W e s t e r n P a c i fi c


E u r o p e E a s t e r n M e d i t e r r a n e a n

A m e r i c a s

A f r i c a

41.8%

70.0%

78.6% 79.2%80.0%

73.4%

66.2%

n = 1 4 5

FIG

PRWIRE

OFBY

H i g h H i g h e r - m i d d l e

L o w e r - m i d d l e

L o w

78.8%72.4%

68.3%

50.0%

n = 1 4 5

For mental health, alcohol and drug usedisorders together

For alcohol and drug use disorders together

For alcohol use disorders only

For drug use disorders only

For alcohol and drug use disorders separately

32.6%

52.4%

42.8%44.3%

70.0%66.6%

45.8%


45/156

2.3 Financing treatment services for substance u

(Figures 2.5–2.8)

Background o N om inated focal points w ere asked to rank the three m ost

nancing m ethods for the treatm ent services of alcohol and d

their countries.

o D ifferent sets of gures are presented in this section:

• Figs. 2.5 and 2.7 present the forem ost m ethods in coun

treatm ent of alcohol and drug use disorder treatm ent serv

• Figs. 2.6 and 2.8 indicate the relative im portance of the

m ethods in countries of funding the treatm ent of alcohol an

presenting this inform ation across different incom e groups

Salient findingso C ountries identi ed tax-based funding, out-of-pocket paym en

insurance as being am ong the forem ost m ethods of funding tre

w ell as drug use disorders.

o In A frica, approxim ately 40% of countries reported out-of-pocke

m ain funding m ethod for alcohol and drug use disorder treatmthe regions, how ever, out-of-pocket paym ents w ere also repo

nancing m ethod for alcohol and drug use disorder treatm ent fr

of countries in the A m ericas (approxim ately 41% ) and in Eastern

for alcohol disorder treatm ent, 45% for drug use disorder treat

o A high proportion of countries in E urope reported that social

tax-based funding w ere the forem ost m ethods of nancing alcoh

services (47% and 42% respectively) and drug use disorder treaand 45% respectively).

o The bar graphs presenting the relative im portance of the th

nancing m ethods for alcohol and drug use disorder treatm ent

tax based funding outof pocketpaym ents and N G O s appeart



46/156

o The biggest proportion of high-incom e countries nance alcohol

treatm ent services through tax-based funding and social health

alcohol and drug use disorder treatm ent services through soseem s to increase w ith increasing country incom e.

Notes and commentso In m any countries, no single nancing m ethod for substance us

services seem s to be used exclusively. C ountries appear to com

to fund treatm ent for substance use disorders.

o In low -incom e and low er m iddle-incom e countries, treatm ent s

nanced prim arily w ith out-of-pocket paym ents. A num ber of

and drug use disorders and their fam ilies m ay, how ever, not ha

resources to pay for substance use disorder treatm ent. This m

treatm ent for a large part of the population.


47/156



48/156

FIGURE 2.6

THREE MOST COMMON METHODS IN COUNTRIES OF FUNDING THE TREATMENT OF ALCOHOL USE DISORDERS, BY INCOM

Main met

Second m

Third me

WO R L D

P e r c e n t a g e o f c o u n t r i e s

E x t e r n a l g r a n t

N o n g o v e r n m e n t a l o r g a n i z a t i o n

P r i v a t e i n s u r a n c e

S o c i a l h e a l t h i n s u r a n c e

O u t - o f - p o c k e t p a y m e n t

H y p o t h e c a t e d t a x

O t h e r

T a x - b a s e d f u n d i n g

0%

50 %

40 %

30 %

20 %

10 %

Main me

Second m

Third me

LO W

P e r c e n t a g e o f c o u n t r i e

s







O t h e r


0%

50 %

40 %

30 %

20 %

10 %

E


49/156

Main me

Second m

Third me

H IG H E R ‐ M I D D

L E








O t h e r


0%

50 %

40 %

30 %

20 %

10 %

Main me

Second m

Third me

H IG H








O t h e r


0%

50 %

40 %

30 %

20 %

10 %


50/156

FIGURE 2 8


51/156

FIGURE 2.8

THREE MOST COMMON METHODS IN COUNTRIES OF FUNDING THE TREATMENT OF DRUG USE DISORDERS, BY INCOME

Main met

Second m

Third me

WO R L D








O t h e r


0%

50 %

40 %

30 %

20 %

10 %

Main me

Second m

Third me

LO W








O t h e r


0%

50 %

40 %

30 %

20 %

10 %



52/156

Main me

Second m

Third me

H IG H E R ‐ M I D

D L E








O t h e r


0%

50 %

40 %

30 %

20 %

10 %

Main me

Second m

Third me

H IG H








O t h e r


0%

50 %

40 %

30 %

20 %

10 %


53/156

2.4 Treatment settings for alcohol and drug use

(Figures 2.9–2.12)

Background o N om inated focal points w ere requested to indicate the m

treatm ent settings for persons w ith alcohol and drug use disord

In the context of this report, the treatm ent settings w ere: s

services for alcohol and drug use disorders, m ental health ser

services (such as treatm ent delivered in district hospitals), primother treatm ent services.

o D ifferent sets of gures are presented in this section:

• The pie graphs (Figs. 2.9 and 2.11) present the m ost com m on

for the treatm ent of alcohol disorders and drug use disord

• The bar graphs (Figs. 2.10 and 2.12) indicate the relative imm ost com m on treatm ent settings in countries, presenting th

different incom e groups of countries.

Salient findingso N om inated focal points in countries reported a variety of tre

persons w ith alcohol and drug use disorders. W ith few exce

settings are used for the treatm ent of alcohol and drug use diso

incom e groups of countries.

o In the m ajority of responding countries (39.8% ), m ental health s

com m on treatm ent setting for alcohol use disorders.

o A higher proportion of countries reported specialized treatm en

m ain setting for the treatm ent of drug use disorders (51.5% )

disorders (34.6% ).

o A pproxim ately 10% of countries in the survey reported prim ary

m ost com m only used setting for treatm ent of alcohol and drug

o In high incom e countries specialized treatm entservices forthe t



54/156

Notes and comments o Treatm ent of alcohol and drug use disorders in surveyed countr

treatm ent settings w ith m ental health services and specializservices as m ain providers of treatm ent for people w ith a

disorders. The role of prim ary health care is still lim ited.

o The m ajority of low -incom e countries identi ed m ental health se

setting for alcohol and drug use disorder treatm ent. The im porta

services as the m ost com m on treatm ent setting for alcohol an

appears to decrease w ith increasing country incom e, w hich is

the treatm ent of drug use disorders.

o The im portance of specialized treatm ent services in treating a

disorders gains in im portance as a country’s incom e level rises

o B ecause the m ajority of focal points for the ATLA S survey are w o

system , there m ay have been a tendency to overem phasize the

system in provision of treatm ent for substance use disorders.

Specialized treatment servicesWORLD


55/156

FIGURE 2.10

THREE MOST COMMON SETTINGS IN COUNTRIES FOR THE TREATMENT OF ALCOHOL USE DISORDERS, BY INCOME GROU

Main locat ion [n= 133)

Second most common [n= 112)

Third most common [n= 96)

WO R L D


O t h e r P r i m a r y h e a l t h c a r e

M e n t a l h e a l t h s e r v i c e

G e n e r a l h e a l t h s e r v i c e

S p e c i a l i z e d t r e a t m e n t s e r v i c e

0%

1 0 0 %

80 %

30 %20 %

10 %

60 %

70 %

50 %

40 %

90 %

LO W

FIGURE 2.9

MOST COMMON SETTING IN COUNTRIES

FOR THE TREATMENT OF ALCOHOL USEDISORDERS, 2008

n = 1 3 3

Mental health serv ices

Specialized treatment services

General health services

Primary health careOther

9.8%1.5%

34.6%

39.8%

14.3%

WORLD



56/156

Main locat ion [n= 36)

Second most common [n= 31)


LO W E R ‐ M I D D

L E






0%

1 0 0 %

80 %

30 %

20 %

10 %

60 %

70 %

50 %

40 %

90 %

Main locat ion [n= 29)Second most common [n= 26)


H IG H E R ‐ M I D

D L E






0%

1 0 0 %

80 %

30 %20 %

10 %

60 %

70 %

50 %

40 %

90 %

H IG H

Specialized treatment servicesWORLD


57/156

FIGURE 2.12

THREE MOST COMMON SETTINGS IN COUNTRIES FOR THE TREATMENT OF DRUG USE DISORDERS, BY INCOME GROUP, 2

Main locat ion [n= 136)Second most common [n= 116)

Thi rd mos t common [n= 102)

WO R L D






0%

1 0 0 %

80 %

30 %20 %

10 %

60 %

70 %

Documents

Atlas Uso SPA OMS