Organised by Italy with the support of the UNODC Prevention Treatment and Rehabilitation Section, the Pompidou Group of the Council of Europe, the European Union and the World Health Organization
Giovanna Campello, Chief UNODC Prevention, Treatment & Rehabilitation Section: How is the concept of recovery is included in the international standard for the treatment of drug use disorders? It is a process through which individuals address substance use disorders, actively manage their continued vulnerability to such disorders and develop a healthy and meaningful life. Very first contact in outreach worker, maybe a mobile unit or low threshold or outpatient services treatment. Or maybe evidence-based pharma treatment. Either in patient or out patient. Recovery management happens once patients have been stabilized – stopped or reduced their drug use. Health wellbeing and social functioning has already improved. Want to maintain gains and reduce chance of relapse. In the standards you see different ways of organising treatment. Many of us will find ourselves in this approaches. E.g. one-stop shop approach or the community-based network approach or even the case management approach. Essential elements of recovery-oriented rehabilitation and social management. You continue the care of the physical and mental health of that person. Recovery-oriented continuum of care – supports abstinence and reduced level of drug use. We are moving from fire fighting to a long term game in promoting health and wellbeing of people who use drugs.
Next speaker: (no translation)
Vladimir Poznyak, Unit Head, Alcohol, Drugs and Addictive Behaviours (ADA), Department of Mental Health and Substance Use, WHO: We all aim (I am a psychiatrist by background) and all want our patients to stop using drugs, stop using alcohol and live a healthy life. Unfortunately for many is not an achievable goal. Then the question is what to do with these people? Do we exclude them? From the therapeutical process or they are the same human beings that have the same right to healthcare and continue their way of treatment which is not only that aims at full abstinence. It is defined as a process that sometimes takes many years which can eventually bring full recovery. Sometimes we need to make sacrifices and care for them. Recently we did a review of scientific evidence of different treatment approaches. The term recovery is very poorly defined. If you look at the literature on effectiveness of what is now accumulated you will find a lot of difficulties in finding the evidence. The concept is not well defined and the interventions are difficult to define clearly, that makes the whole field need to invest much more in defining recovery and its different components. However, I want to share the definition of rehabilitation from the WHO: “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”. Rehabilitation requires a supporting environment, treatment options that respect values and preferences of people, decriminalisation of drug use and possession. Why? If we are talking about criminalisation, we are saying that all our patients should go to prison. They suffer from drug use disorders and they use drugs. Is it really a principle that can be used effectively. What is important is that governments address their commitments to UNGASS 2016, and civil society organisations work with people with drug use disorders, working toward recovery with v good results. Engage people with lived experiences into the designing and implementation of programs which hopefully aim to full recovery.
Next speakers: (no translation)
Massimo Canu, Department for Antidrug Policies Expert: (…) second point is that a drug addict has a low self-esteem, poor confidence and takes drugs and has dependency on drugs to give them a sense of confidence. Therefore we have to consider the human being at the centre of our programs and plans and the measures to be taken our multi dimensional in order to treat the person. Neurocognitive aspects are to be considered as well and we know that this is very important. We know there is a psychological need to take new drugs because there is no self control. Physical dependency is linked to withdrawal syndrome and then we have pathological dependency and we have to consider the social wellbeing of the patient as a whole and we know the person is unique and has relational, social, familial ties and therefore we have to look at all these different levels. Healthy relations are important involving all the people and mutual relations. We consider that family and school should support the individual development. Parents as human beings have many resources and can help their children preventing some problems and supporting them before the dependency has developed too much. Therefore it is important to promote the right to qualified access to treatment and through all processes to guarantee the personal development of the individual. We are convinced that the health services really promote diversified services at community level in order to maintain health and good general conditions.
Moderator: He reminded us of the importance of school and family which are central elements of prevention. The integral model that we have – the public/private approach and synergy which can be considered an example of a good practice for other countries. Now we give the floor to Monica.
Monica Barzanti, Comunitalia: Today I’m here to represent Comunitalia, representing historical Italian communities affected by pathological dependencies since the 70s. of course over time they evolved because they had to adapt to social changes such as decrease in level of perception of dangerousness of use of drugs. On the other hand the steady increase in cases of diagnosis because the challenges posed by this kind of situation was very important. Beyond the differences between the communities, we share similar values – working practices and experiences gained directly in the field. We think that the development of dependency from substance is an attempt to fill in a void, to respond to basic unmet human needs such as a desire for a meaningful life or a quality interpersonal relationship or also for recognition of the value of the person that exists. This is dramatic in a relationship. All this lack of the basis for which the dramatic experience of dependency can develop. That’s why the added value in therapeutic communities is the relationship because actually the condition of dependency depends on quality relation with other people. People experience desperate loneliness and are not able to enjoy relation with other people, to be happy with we. They remain isolated by other people. That’s why the close and meaningful relation that can be created with educator and peer group and the individual are crucial to start an maintain and continue the process. Recovery is not a goal or a status, it is a process that can continue over time and reach different levels according to the situation. This meaningful relation are established in therapeutic community continue afterward and that is key to open the person to change. To welcome change in life and to start to be open to other people and to get out of feeling lonely. Also, the collaboration between private and public services which are so expanded in Italy. We have more than 600 public services and more than 900 communities and the collaboration between them is fundamental. But it is important that they continue with full recognition. Another important thing that the therapeutic community in Italy included over time is a holistic approach. We believe in 2 many pillars – one is prevention and the other is rehabilitation or recovery as we want ot call it. They are very close to each other. So prevention is something that aims to implement drug policy in a way that can guarantee the wellbeing of the general population as well as hinder drug use in order to avoid the scourge of pathological dependencies. Universal prevention aims to prevent the use of drugs and guarantee the general wellbeing of the population. Young people are at risk of impulsive behaviour. We give importance and value to indicated prevention, also to early intervention in order to avoid people getting sick or falling into difficult situations. To avoid overdoses and to improve the quality of life as much as possible. The other pillar of our intervention is rehabilitation – this means for us a pathway to the recovery of the person oriented to overcoming pathological dependency. This is a tailor made program. Each therapeutic pathway should be human centred. The treatment should always be socially oriented reintegration. The aim is to give the person back to society and in order to achieve this goal we have to equip the person with skills and tools to successfully reintegrate into society. Also meaningful friendships and human relationships can consolidate this process.
Moderator: I wish to stress that rehabilitation recovery is a long process that cannot be taken for granted. It is a complex process. Now I wish to give the floor to Guido.
Guido Faillace, Federazione Italiana Operatori Dipartimenti e Servizi Dipendenze, FeDerSeD: We have the possibility of monitoring these patients. 86% of these patients is over 40 years of age and the rest is below 25. Therefore we have a lot of services that obviously are important for us. As I said the patients are mostly male but women present specific and often hard problems. The critical role of local public health system which needs upgrading after years of investment cuts. They provide a range of services for prevention treatment and rehabilitation. It is extremely important to insist on the multi faceted approach – this is the winning aspect. We have doctors, social workers, so as to provide a wide as possible response to this problem. The substance use disorder requires an approach in line with primary health care including care accessibility, including ease of access upon the first contact. We need to provide the best possible care and have a systemic approach. In Italy access is free, everyone can come without being reported by doctor. A coordination between the various health professionals is essential – we have a wide network throughout the system and obviously we have also the specific characteristic of longevity and continuity of care. This is essential to continually improve the skills offered and in this way we can improve the existing models, fighting stigma and supporting social rehabilitation. We have tried to understand why patients didn’t address to these services – one is stigma. This causes a delay in seeking help and an unexpressed need. This has social roots and is a problem of guilt, lack of self-esteem. Social rehabilitation requires responses that are person-centred. There is an explicit need for treatment which si a public health priority. Delayed treatment delays a persons clinical situation, prognosis, may increase criminal record and mortality rate. We need to stress the health and social costs so we must also consider the determinants of health – namely income, social status, social network, employment and work conditions, physical environment, early childhood etc. we need both this network of public services but we also need a strong network of accredited services.
Lorenzo Camoletto, Coordinamento Nazionale
Comunità Di Accoglienza, CNCA: The issue we have decided to tackle is the right to recovery. An integrated and pragmatic approach in light of the results of national conference on addiction. The organisation I represent is a wide network over 50% of services present make reference to our network. In Italy almost half of the treatment centres refers to CNCA. Here you can see the challenges that we need to rise up to – they change quite quickly. There are some new issues e.g. older people with drug problems who continue to be assisted by centres of addiction, comorbidity, new psychoactive substances, also have consumption related to migration, and people that use drugs in prison. EU drug strategy plan from 2020-2025 it is very clear that there is the issue of drug supply reduction, prevention. All the challenges we need to face need a clear evaluation of this. Vertical – between different thresholds; Cross-cut: various areas (mental health, social services etc.); Horizontal: public, non-private sectors and user unions. We need to reduce damage which must be part and parcel of the basic system. We should better cooperate in terms of better mental health services which are linked to addiction. As already said we should make public and private entities collaborate in the most effective way. Also based on the viewpoint of addicts, and we must also involve the associations of consumers of this substances. The social impact assessment required by law 106, 2016 is both an opportunity and a challenge for the service provider. It is essential to implement shared approaches and methodologies which could help policy makers to make strategic choices. This is essential if we want to overcome mere ideological perspectives and approaches. There is no approach that are better than the other – they must co-exist. We should start holding a different dialogue with all the entities involved.
Giuseppe Mammana, Comitato italiano delle Comunità
e dei servizi per le dipendenze: The committee I represent has a network of services that has 53 different operational centres. The services provided are residential services, centres for professional reintegration. They are inspired by the principle of recovery as developed by the U.S. and spread to other counties. The concept of recovery is about treatment, cure and improvement of living conditions so people can take back control over their lives. Recovery is not just the immediate removal of symptoms, but the acceptance of this problem. Rehabilitation is conducive to recovery and obviously this is useful because the psychosocial measures such as motivation to treatment and training on coping methods are essential as the drugs are. We need to protect addicts and prepare our patient and semi-residential programs that are sufficiently protective in scope. We need to guarantee freedom of access for these addicts and the members of their families .recovery is also essential in the field of severe forms of addiction. This is useful for this measures. We need to manage addiction so as to include the quality of life of these patients and the quality of life of all these patients is essential. People must be trained to have new skills which is essential for training and planning of new environments. Rehabilitation takes place in present times but is designed to improve the living of these people in the future. We need to define new recovery measures, both in patient and semi residential ones. This is essential for an early diagnosis. We require the active cooperation of patients. We train professionals in the field and provide doctors and psychiatrists that should increase the skills of these people and in the field of recovery the assessment based on evidence is essential.
Biagio Sciortino, Coordinamento Nazionale INTERCEAR: Thank you, I am the national representative of the 17 regions of Italy and we have 344 entities that belong to INTERCEAR. Here you see the beds available, you can have the document and revise it at leisure. We see it is very important to work together private and public and it is important to look at prevention, recovery from the very beginning and then also work at community level. But families are also very important – very quickly I would like to look at flexibility. Why flexibility? Addiction and drug use has changed. Flexibility is an essential pathway for appropriate care because it has to be focused on person specific needs. This is a main pillar. Clinical appropriateness – what do you mean? The future care of the person in achievable measurable goals. There fore accredited facilities should be able to provide a diagnosis and provide action. Sooner the person is taken care of, the better the person’s integration. Public and private integration is important here. Last but not least we need homogeneity of care. People must be able ot receive the guarantee to have access to homogenous treatment. I want to say many other things but time is short, thank you for attention.
Massimo Canu, Department for Antidrug Policies Expert: We are present in European federation so we are a federation member – we started working in the 80s. Human beings have a great potential – this should be the starting point for drafting any effective plan. Who are we? We are 44 centres working in Italy in the different regions. In 2022, we welcomed 7900 people, 4000 with addiction problem. 5% of our patients have been victims of violence, 21% are subjected to alternative measures of detention, 40% cocaine/crack, 9.67% cannabis etc. so the person is at the centre of the global vision. I would like to dwell on time at community level. We are just providing all the appropriate measures – people need community treatment and space of time to take care of themselves and each other and to understand what happened in their lives. Time is short thank you so much. We will continue the collaboration in Venice. Thank you.