A Public HealthSocial Welfare Perspective on Alcohol and Drug Treatment Systems

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A Public Health/Social Welfare Perspective on
Alcohol and Drug Treatment Systems

• 9th International Symposium on Substance Abuse
  Treatment Kerstin Stenius, Stakes SoRAD
• Based on a paper by T. Babor, K. Stenius A.
  Romelsjö

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Expanding treatment need for allocation
guidelines

• Treatment has expanded in developed countries
  after WWII but often in a fragmented and
  arbitrarian way. Today, effects of allocation
  decision or relative cuts of resources threaten
  those that are worse off
• In many developing countries treatment resources
  are scarce prioritising is important

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Broadening the focus

• From focus on effects on individuals of single
  interventions or episodes of care in one setting
• To impact on population of treatment systems and
  multiple episodes
• Looking at treatment from the populations and
  the clients/patients point of view, where
  treatment potentially canmplay a small or large
  part in a long and complex process with many life
  influences (Orford 2006 see research on natural
  recovery)

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Purpose of presentation

• To analyse how treatment system can be
  conceptualised from public health/social welfare
  point of view
• To discuss what kind of research that could be
  undertaken from this perspective

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FROM EFFECTIVENESS TO POPULATION EFFECTS

• Most treatment research is designed to
  investigate efficacy and effectiveness of
  treatment episodes
• Treatment can a) reduce alcohol and drug use, b)
  improve psychiatric, medical and employment
  outcomes, c) reduce risk of overdose, crime, HIV
  infection.
• Treatment of drug abuse may have supply side
  effects (e.g., NTORS, DATOS)
• Treatment of heavy drinkers may affect the social
  ecology of drinking subcultures

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Research on population effects of alcohol
treatment

• Mann et al (1992) increases in the proportion
  of alcoholics in treatment linked to decreases in
  liver cirrhosis morbidity
• Holder and Parker (1992) - increases in treatment
  linked to declines in cirrhosis mortality
• Smart and Mann (2003) increases in AA
  membership and amount of treatment linked to
  decreased alcohol problems

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Research on treatment system

• 1) service system changes tend not to be driven
  by scientific findings
• 2) there is great diversity across and also
  within countries in the organization of services
  
• 3) some organizational models may be more
  equitable, efficient and effective than others
  but we know very little about it

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Can we bring together

• 1. Knowledge of the varying nature of the alcohol
  and drug problems in (different groups of) the
  population and how they may at some point benefit
  from treatment
• 2. A conceptualisation of the treatment system
  and a list of quality requirements on that system
• 3. Measures of public health and social welfare
  to evaluate how the system functions

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Alcohol and drug problems

• Ranging from dependence, problem use or abuse to
  alcohol and drug related problems problem areas
  can be physical health, mental health, various
  social areas, criminal justice problems
  everything from chronic and serious conditions to
  brief episodes, minor or passing problems
• The individual careers are often not predictable

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The complexity of the system

• Due to the mixed nature of the problematic
  consequences a wide field of actors are involved,
  treatment services are often complex, fragmented
  and heterogeneous

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Treatment Service System

• A coherent and organized entity
• An arrangement of facilities, programs, personnel
  designed to function in a coordinated way
• A collection of resources (facilities, programs,
  personnel), tasks (care, cure, control) and
  linking elements that make it possible to
  coordinate resources to accomplish key tasks
• Includes linkages between specialized care and
  other types of services, such as mental health,
  general medicine, social welfare, criminal
  justice and mutual help organizations

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General medicine
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SYSTEM Resources . Facilities . Programs .
Staff Qualities f.i. Equity Efficiency Economy
Treatment policies Allocative Regulatory
Effectiveness as
Population Health Welfare
Moderating Factors Cultures Drinking/drug
use Case Mix Social Capital
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Service System Qualities

• Equity acceptability, appropriateness,
  accessibility to population subgroups
• Efficiency integration of services to meet
  population needs referral, diagnosis, detox,
  rehab, after-care
• Economy organization of available services to
  minimize cost and maximize effectiveness

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Public Health

• Physical, mental and social well-being and the
  equal distribution of health within the
  population
• Measures alcohol and drug related mortality,
  morbidity, disability and its distribution in the
  population

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Social welfare

• From a social point of view social stability,
  social integration etc (cf for instance Lorenz
  1994)
• From the individuals point of view Needs
  fulfilment (ex. Allardts having, loving, being),
  capabilities (autonomy, freedom, knowledge),
  resources (ex.vis Levnadsnivåundersökningen),
  respect (cf Julkunen 2006)
• Measures alcohol and drug related poverty,
  family violence and child protection,
  unemployment, homelessness, crime, compulsory
  treatment?, marginalisation etc.

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Need of system research

• Functioning systems will affect the populations
  health and welfare
• Orients planning back to the 60s

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Types of studies

• Treatment system mapping
• Needs assessement
• System analysis
• System monitoring
• Comparative analysis