Evaluation of

1
Evaluation of

• Cyprus Action Plan
• Guidelines for Best practice
• NGO drug services and prevention

• Christian Haasen, Heike Zurhold, Peter Degkwitz,
  Uwe Verthein, Agorastos Agorastos

2
Objectives of the three activities

• Evaluation of the National Drug Action Plan
  (2004-2008)
• Identification of the actions performed those
  not performed
• Characterise the best achieved and most
  problematic objectives and actions
• Development of evidence-based guidelines for best
  practice in drug treatment and prevention
• Evaluation and assessment of
• Non-governmental drug services, the prison drug
  services and the prevention network
• Contribute to an improvement of the therapeutic
  continuum
• Recommendations for the improvement of
• NGO drug services, prison services and prevention
  programmes

3
Action Plan on Drug Demand Reduction and on
Supply Reduction 2004-2008

• Results of the evaluation

4
Background

• The evaluation of the Action Plan is one
  objective explicitly stated in the Action Plan
• The evaluation covered
• Detailed analysis of what was envisaged in the
  Action Plan
• Systematic assessment of what was planned and
  what was achieved
• For the evaluation, the different areas of
  intervention have been resorted in a more
  structured way
• Pillars prevention, drug treatment, harm
  reduction, supply reduction
• Strategic actions have also been resorted
• To the category instruments across the pillars
• This covers monitoring, evaluation and research,
  coordination and cooperation, and the legal
  framework

5
Results - Prevention

• 8 different environments with specific objectives
• School, family, army, working, health,
  communication, recreation, and community
• 59 actions are specified for prevention
• 37 actions have been performed, mostly in the
  school, army and family environment
• Results achieved
• 27.761 pupils from different types of schools
  participated in about 40 prevention programmes
  provided in 2006 and 2007
• Health Visitors provided information and
  counselling to parents and the Social Welfare
  Services operates a Family Guidance Centre
• 5800 members of the army member have been trained
  in drug prevention since 2004
• For occupation of children and young people
  Multi-Purpose Centres or Information Centres are
  provided
• To reduce road accidents due to alcohol 76.055
  breathalyser tests have been carried out between
  2004 and 2007

6
Results - Treatment

• Major objective is to guarantee specialised
  treatment and universal access to treatment
• 11 actions have been planned
• 10 actions have been performed or partly
  performed
• Results achieved
• Expansion and diversification of drug treatment
  services
• Implementation of new programmes
• Specific offers addressing adolescent have been
  developed
• New health care programmes in prison have been
  implemented
• In 2008 maintenance treatment has started in two
  cities

7
Results Harm Reduction

• The Action Plan mentioned only 3 actions related
  to harm reduction
• Two actions are partly and one action is
  completely performed
• Results achieved
• Testing for HIV and hepatitis is provided
• Vaccination programmes for hepatitis are
  available
• Initiation of provision of clean syringes and
  needles
• Limitations
• Insufficient actions in the field of harm
  reduction
• Availability of syringe exchange programmes still
  low

8
Results Supply reduction

• The main actions are directed to the control of
  drug trafficking and to prevent money laundering
• 34 actions mainly directed to drug trafficking
• All essential actions have been performed
• Results achieved
• The system for the control of drug trafficking is
  reinforced and works effective
• Electronic recording and monitoring of drug
  trafficking, selected checks at airport and
  ports, mapping neighbourhoods for drug dealing
• In the field of money laundering additional
  infrastructure has been implemented
• Continuous exchange of information on methods and
  operations between MOKAS and DLEU, electronic
  analyses of databases

9
Results Strategic instruments

• Monitoring, evaluation and research
• All 7 actions specified have been performed
• A regular monitoring of the national drug
  situation has been established and related
  reports are provided annually
• Coordination and cooperation
• All 3 actions related to cooperation have been
  partly performed
• Committees for the coordination of drug and
  supply issues have not been fully established on
  a formal and regular basis
• One action for coordination has been performed
• Cyprus being presented in European and
  international groups dealing with drug
  trafficking, organised crime, police cooperation
  and precursors
• Legal reform
• 4 out of 7 actions have been performed
• The Narcotest for drug screening of drivers is
  expected to be implemented next year
• All actions related to the introduction of drug
  courts have not been performed

10
General results

• The four-year period is rather short to achieve a
  change in the drug markets and drug behaviours
• Results in relation to general objectives
• The number of treated clients increased from 300
  in 2003 to about 800 in 2008
• Life-time prevalence of intravenous drug use
  remains stable on a high level (gt80 of heroin
  using clients)
• Life-time prevalence of needle-sharing among
  heroin users increased from 20 to about 50
• Drug possession increased from 169 cases in 2003
  to 419 cases in 2007
• Alcohol-related accidents have decreased
  noticeably from 3800 accidents in 2003 to 2300
  accidents in 2007
• Accusations for drunk-driving have increased
  disproportionally from 1050 to 7900

11
Recommendations for the planning of the national
drug policy

• Balancing of different approaches to the drug
  problems
• In the Action Plan prevention and supply
  reduction were given priority
• In the future prevention, treatment, harm
  reduction and supply reduction should have
  equivalent importance
• Define objectives more precisely
• Objective should be as concrete and measurable as
  possible
• For instance Overall objective is to extend
  maintenance treatment, related actions are to
  extend the number of treatment places by xxx, or
  to reach the number of xxx clients with this
  treatment
• Develop more focussed and priority-driven actions
  
• For instance priority is given to prevention for
  high-risk groups
• Standard operations of further action plans
• Monitoring, evaluation and research

12
Guidelines

• For best practice in drug treatment and
  prevention programmes

13
Framework for guidelines

• Based on international evidence for effective
  interventions
• Guidance
• On how effective, evidence-based and high quality
  interventions should be designed
• For an optimisation of the care for drug users
• Drug treatment
• Core standards independently from the type of
  intervention
• Guidelines for main treatment modalities
• Guidelines for primary prevention of substance
  abuse

14
General principles of care

• Accessibility
• Within a continuum of care, problem drug users
• should have access to treatment services
  through multiple entry points
• Specialised drug and treatment services should
• provide low-threshold access where drug
  users
• can easily self-refer

• Targeting special subgroups
• who are less attracted by the care system such
• as adolescents, migrants, women etc.
• Engage special qualified staff who are age-,
• gender-, and cultural sensitive

• Assessment
• Identification of the clients problems and
  needs
• by either basic or comprehensive assessment
• Aim is to determine the severity and urgency
  of
• the problems and the most appropriate type
  of
• intervention for the client

15
General principles of care (2)

• Treatment engagement and retention
• Best practice includes
• Rapid intake to treatment, motivational
  enhancement, the active involvement of the client
• intensive ongoing support and an empathic
  attitude of professionals
• Responsiveness and flexibility of the
  treatment programme is associated with more
  positive
• outcomes for clients

• Care planning and coordination
• Care planning is the process of setting goals
  and interventions based on the assessment
• Clients have to be fully engaged as partners
  and owners in the delivery of their care
• Coordination requires a care plan which is
  specific in the goals, time-limited and revised
• periodically to respond to the clients
  changing situation

• Monitoring
• Monitoring and evaluation of the performance
  and outcome of drug services provided to clients
• are part of the quality assurance
• Monitoring of the care and outcome has to be
  carried out continuously and on basis of
• standardised tools

16
General principles of care (3)

• Evidence for continuity of care suggests that
• Drug treatment is not an event, but a process
  usually involving engagement with different drug
  treatment services, perhaps over many years
• Service users gain cumulative benefit from a
  series of treatment episodes
• Optimised treatment usually involves retaining
  clients in drug treatment for a minimum of three
  months
• After this period treatment begins to have
  generalised long-term benefit
• Best improvements in client outcomes are likely
  to be made in the first six months of treatment

17
Guidelines for different interventions

• Information and advice
• Should be available to all substance abusers on
  an open-access basis
• Settings in general healthcare or social care
  settings, as well as in specialised drug services
  and prisons
• Harm reduction
• to reduce health-related risks, especially spread
  of blood-borne viruses and overdoses
• Should include needle exchange services,
  counselling, testing for infections, vaccination
  and hepatitis B, C and HIV infection
• Maintenance treatment
• Should be in line with the WHO guidelines 2008,
  controlled by rules regulations
• Methadone should be considered the optimal
  treatment, with buprenorphine as a further option
  for some patients
• To increase treatment retention flexible dosing
  structures, without restriction on dose levels
  and the duration of treatment
• Settings primary care system, specialised units
  for drug treatment, prisons

18
Guidelines for different interventions (2)

• Psychosocial interventions
• Evidence-based psychosocial interventions
  include cognitive-behavioural therapy (CBT),
  coping skills training, relapse prevention
  therapy (individual or group-based cognitive
  behavioural approach), motivational
  interventions, contingency management
• Setting part of all main interventions and
  treatment modalities
• Detoxification
• Ensure 24-hour medical care provided by a
  multidisciplinary team
• Specialised substance misuse units are more
  likely to have better treatment outcomes than
  general psychiatric wards
• Aftercare
• Delivered by outpatient drug treatment units to
  support clients after leaving structured
  treatment
• Clients are offered a range of interventions to
  address their drug and alcohol-using behaviour
  and their functioning (e.g. housing, employment,
  family etc)
• Setting in all regional drug treatment agencies

19
Guidelines for primary prevention

• Evidence for effective prevention has not been
  confirmed for all settings
• Primary prevention in the school setting is
  effective if
• Interactive methods are used based upon the model
  of social influence and target at the development
  of life skills and competencies
• Small interactive programmes with limited number
  of participants and programmes targeted at
  younger pupils of up to 13 years do best
• Primary prevention in the family setting is
  effective if
• Training of children, parents and the family is
  combined
• Methods are used to improve competences of
  problem solving, education and family coherence
• Guidelines
• Prevention should be directed at strengthening
  peoples own responsibility for their health
• Programmes on healthy and unhealthy lifestyles
  are desirable
• Local continuation of a prevention is important
  to enhance the sustainability

20
Evaluation of the non-governmental drug
services, prison drug services and prevention
programmes
Results and recommendations
21
Objectives

• Evaluation of concepts, programmes and
  functioning (system, utilisation, clients)
• Assessment of quality and efficiency of drug
  services and prevention programmes
• Methods
• Personal interviews with staff of all evaluated
  programmes
• Analysis of available data and reports

22
Treatment and Prevention in Cyprus
In 2008 21 different drug treatment services in
Cyprus, 13 of them are provided by NGOs 16
organisations provide primary prevention

• Nicosia 307,100 inhabitants
• 7 prevention, 6 NGO drug services
• Limassol 223,600 inhabitants
• 3 prevention, 2 NGO drug services
• Larnaca 130,100 inhabitants
• 4 prevention, 3 NGO drug services
• Pafos 74,900 inhabitants
• 2 prevention, 2 NGO drug services

23
KentheaSix prevention and counselling stations

• Provision of assessment, counselling,
  motivational enhancement and prevention
• Unspecific target group
• In practice, main activities are directed to
  prevention
• Low number of clients in counselling (41 clients
  in 2007)
• Some stations do not seem to cover the needs of
  the community and have insufficient specific
  training for drug counselling

• Recommendations
• Modification of the counselling concept
• Specification of the target groups
• Systematic assessment of the needs for
  counselling and prevention

24
KentheaPrevention Centre Larnaca

• Implementation of universal prevention for broad
  spectrum of target groups
• Main prevention programmes Standing on my own
  feet and Communication in the family
• Annual Pancyprian congresses for teachers,
  parents, adolescents
• In 2007 102 workshops for adolescents, 130 for
  parents

• Recommendations
• Become more focused on structured interactive
  programmes
• Differentiate between activities and programmes
• Reduce one-day activities because of low
  effectiveness

25
TolmiFour outpatient Therapeutic Communities

• Properly designed with regard to objectives,
  target groups, and therapeutic processes
• Target group of adult alcohol and drug users is
  reached with the 12-month programme
• Number of clients decreased since 2007 (from 151
  in 2006 to 81)
• The rooms are partly not adequate for group
  sessions

• Recommendations
• Increase occupancy by easing access for drug
  users in maintenance treatment
• Strict time-limit for motivational counselling (8
  weeks) has to be reconsidered
• Introduce electronic documentation (PCs are
  available)

26
Agia SkepiInpatient Therapeutic Communities for
male drug addicts

• Setting and structure of the 12 months programme
  is well established
• Target group long-term, drug users (mainly
  heroin addicts)
• 18 staff members (10 FTEs), huge building (space
  for 45 clients)
• Intensive and strictly ruled treatment programme
  (10 group sessions per week, no contacts to the
  outside world)
• In 2007 34 clients, 44 drop-out rate
• Electronic documentation, standardised instruments

• Recommendations
• Reflect structure, intensity and length of the
  treatment programme to improve occupancy (and
  outcome)
• Allow direct referrals from all available drug
  services (after detox)
• Strict rules are only reasonable in the beginning
  of treatment

27
Agia SkepiCounselling Station

• Target group adult drug users (legal and illegal
  substances)
• Objective is to motivate drug users for drug-free
  treatment, preparation for TC Agia Skepi
• Brief intervention is well structured and time
  limited
• Introduction of (obligatory) outpatient
  rehabilitation for TC completers

• Recommendations
• Employ additional staff to meet demands
• Allow referral of clients to substitution
  treatment (not only detox)
• Offer the rehabilitation programme on voluntary
  basis
• Develop concept for counselling and treatment for
  women

28
Life Education CentresPrimary Prevention by
mobile classrooms

• Mentor programme is well established and
  evaluated
• Directed to 6-12 years old pupils
• Mobile classrooms offer interactive education
  carried out during school lessons
• Specially trained tutors and teachers provide the
  programme

• Recommendations
• Continue with the programme
• Evaluation of long-term effects of the Mentor
  programme

29
PrisonDrug services

• Care for drug users in prison is provided by
  Mental Health Care team, introduced in 2004
• Medical-based withdrawal treatment is delivered
  without the prescription of methadone or
  buprenorphine
• Vaccination for hepatitis B and counselling
  related to infectious diseases
• Psychosocial drug treatment on basis of different
  group sessions
• Only one social worker for more than 600 prisoners

• Recommendations
• To provide qualified (opiate-assisted) withdrawal
  treatment
• To introduce maintenance treatment in prison
• To introduce specific relapse prevention
  programmes for the preparation for release

30
ASPISPrimary Prevention

• Objective is to promote everyday skills for
  adolescents (12-18 yrs)
• Main programme is Standing on my own feet
  (focussed on developing the pupils personal and
  social skills)
• Every year a one-day conference with interactive
  workshops

• Recommendations
• To continue with main programme
• Consider the need for modification to reduce
  drop-out of participants
• Long-term evaluation of the programme

31
Lions-Quest FoundationPrimary Prevention

• Promotion of the evaluated US programme Quest
  for adolescents
• The topic Skills for adolescents addresses
  pupils of 10-14 years
• Only 10 of trained teachers have used the
  programme
• Manual 10 handbooks only available in English

• Recommendations
• Promote implementation in schools
• Translation of the most important handbooks
• Evaluation of acceptance and efficacy

32
Pafos Anti-Drug AssociationPrimary Prevention

• Profile of the association is not very clear
• Engaged in broad variety of issues (fundraising,
  networking, )
• Closely linked to NGO drug services of Tolmi and
  Kenthea
• Workshops and seminars in 2007 mainly addressed
  to parents

• Recommendations
• To reframe profile and objectives

33
Mikri ArktosYouth Board of Cyprus Primary
Prevention

• Provision of various universal prevention
  activities in school and community setting
• Broad target group pupils, teachers,
  adolescents, parents, general population,
  municipal authorities
• Objective to enhance life-skills of young people,
  improve functioning of the family, train
  multipliers in programmes and tools
• In 2007, 134 workshops with 550 participants

• Recommendations
• Plan to expand the prevention programmes should
  be based upon needs assessment in the districts
• Evaluated and evidence-based prevention should be
  allowed to be carried out during school lessons

34
Sykana and FarosLarnaca Primary Prevention

• Focus on students and teachers
• Structure of the prevention programmes remains
  unclear
• Faros main activities such as sport, theatre
  performances etc. did not demonstrate scientific
  evidence

• Recommendations
• Role and function of the two NGOs have to be
  reframed
• Justify the need for two organisations which
  appear to be similar
• Discontinue ineffective prevention measures

35
General conclusions

• Evaluation of NGO drug services
• Not all comply with quality standards
• Lack of systematic documentation and reporting
• Prison
• Medical care is not available for 24 hours
• Opiate assisted treatment required (detox and
  maintenance)
• Evaluation of prevention programmes
• Not all correspond to evidence for effective
  prevention
• There is a need for a systematic prevention
  policy
• The balance between drug services provided as
  well as prevention activities and the needs in
  the communities has to be reflected!

36
Final recommendations

• Drug services have to be operated and funded on
  basis of quality standards checked and controlled
  by the CAC
• Setting, structure and processes
• Qualification of staff
• Quality assurance and documentation
• Prevention activities have to be coordinated and
  to comply with the National Drug Action Plan
• Prevention activities have to be evaluated as to
  their long-term effects with regard to substance
  use behaviour (incidence and prevalence) and
  funded accordingly