Harm Reduction Services and Interventions in Catalonia: Current Status and Lessons Learned

Xavier Majó Roca

2 Territory: 32.000 km2 Population: 7.000.000 Own language and culture

Barcelona

3 Law 20/1985 of July the 25th, on prevention and treatment of addictive behaviour:

– Drug addiction is an ordinary disease – It does not make differences between legal and illegal drugs regarding care provision

4 ADMISSION TO TREATMENT

6500 6000 5500 5000 4500 4000 Heroin 3500 Cocaine 3000 Alcohol 2500 Cannabis 2000 1500 1000 500 0

1 6 9 4 5 0 995 003 0 199 1992 1993 1994 1 199 1997 1998 199 2000 2001 2002 2 2 200 2006

Font: SIDC. Subdirecció General de Drogodependències. Departament de Salut 5 Yearly breakdown of the percentage of AIDS Cases by transmission group and sex (1981- 2004)

6 Source: EMCDDA

7 Causality of deaths among men and women between 29 and 39 years in Catalonia 1983-2003

8 Source: EMCDDA

9 Deaths related to acute adverse reaction to drugs (overdose) in Barcelona city

180 160 140 120 100 80 60 40 20 0 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2

Source: ASPB 10 Source: 11 EMCDDA 12 PEOPLE ON MMT

Annual breakdown

8931 8945 8858 9500 8480 8334 8441 8500 7915 7320 7500 6274 6500 5116 5500 4500 3709 3500 2698 2500 1500 500 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

13 Syringe exchange programmes: Overall syringes distributed: 12.105.275 (*)

1600000 1.418.183 1.423.023 1400000 1.298.691 1.396.000 1200000 963.674 1000000 930.571 934.416 790.478 713.381 932.995 832.419 700.000 800000 733.431 609.263 717.552 600000 471.901 418276 402.341 533.314 400000 390.750434.715 267.297 259.745 331.182 411.628 261.455 200000 85.193 179.982 0 34.163

6 97 98 2 3 04 05 995 99 00 00 1993 1994 1 1 19 19 1999 2000 2001 2 2 20 20 2006 2007*

14 Catalan Health Department: Areas of work

• Prevention • Treatment • Harm reduction • Social rehabilitation and back-to-work programmes • Legislation • International cooperation

15 Drug addiction care and treatment network

Drop in: 12 (4 scr) Mobile units: 7 ( 1 scr) Street outreach teams: 6

Drug treatment Therapeutic C. Detox units: centres 11 Units: 14 Beds: 64 62 Places: 238

Social rehabilitation centres: 30 day centres and social Dual Diagnosis Units: 3 rehabilitation schemes Crisis Units: 1 111 Places on rehabilitation 16 appartments • What we learned

– Addiction is a chronic disease (diabetis, asthma, hypertension,...) – Treatment is effective but only abstinence based treatment: Low contact and retention in treatment – Injecting drug users are exposed to very important health risks (HIV, Hepatitis C & B, overdoses,...) – Success care with a drug users is not only abstinence – The longest the time you are in contact with the drug user the better the outcome: Put in place services & strategies to keep in touch with them

17 HARM REDUCTION INTERVENTIONS IN CATALONIA – Opioid substitution therapy: Methadone – Syringe exchange programmes – Prisons: NSP and methadone in all prisons and all wings – Outreach work: Street work, Mobile units, Peer involvement,… – Low threshold centres (drop in) with social and health care – BBV tests & counselling + HBV/HVA vaccinations – Supervised consumption rooms – Health care workshops for active drug users: Safe injecting, safer sex, overdose prevention and treatment – Promotion and suppot of drug users and patient organisations – Heroin trial 18 Characteristics of the interventions:

– Put in place a variety of care services to fit the different types of drug users and the different maturing moment of every drug user. To decide becoming abstinent and succeed takes time – Services should be friendly and non judgemental – Establish multiple and half way aims (not only abstinence) – Include drug users in decision taking and implementation. They also have know-how

19 PEOPLE ON MMT

Annual breakdown

8931 8945 8858 9500 8480 8334 8441 8500 7915 7320 7500 6274 6500 5116 5500 4500 3709 3500 2698 2500 1500 500 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

2005: About 1.000 in prisons (10-15% of all inmates) 20 ACTIVE CASES IN MMT USER PROFILE

• Sex : Man (84%) • Median age : 25-39 years old • Level of studies : – Primary studies not completed (12,5%) – Graduat escolar (27,8%) – Primary studies (39,1%) – FP1 / FP2 / BUP / COU (12,9%) • Working situation : – Contracte indefinit / compte propi (15%) – Contracte temporal (16,5%) – Unemployed (45,8%) • Median Methadone dosage: 62 mg • Retention in program: 30,45 months 21 14000 12000 10000 13613 8000 7571 6000 4000 Nombreusuaris 4168 1881 2000 1093 1429 866 0 257 Heroin Cocaine Admissions to treatment for the first time Admissions to treatment Drug users in treatment Estimation of problem drug users

22 Font: Sistema d’Informació de Drogues de Barcelona MMT CHARACTERISTICS • Accessibility • Flexibility • Plurality

23 24 MMT IN OFFICES OF PHARMACY

ACTIVE CASES

1000 900 947 800 932 700 777 600 460 500 331 984 974 400 300 200 65 100 0 1998 1999 2000 2001 2002 2003 2004 2005

25 Syringe exchange programmes: Overall syringes distributed: 12.105.275 (*)

6 97 98 2 3 04 05 995 99 00 00 1993 1994 1 1 19 19 1999 2000 2001 2 2 20 20 2006 2007*

26 Kits and syringes distributed. Break down by distributing agent

Drop in with Community Consumption Pharmacies rooms 22% Primary Care 28% Centres 8%

Hospitals 1%

Slot machines 2%

Drug treatment Street work 23% centres Drop in 2% 14% 27 Prisons IDUs in prison is a higher risk group than IDUs in the community with a lower provision of prevention services. Since many IDUs become prisoners, prison counter the effort made in the community The same as in the community (WHO): •Opioid substitution therapy: Methadone •Syringe exchange programmes •BBV tests & counselling + HBV/HVA vaccinations •Free treatment for HIV+ and HVC + patients •Health care workshops for active drug users: Safe injecting, safer sex, overdose prevention

and treatment 28 SPAIN: NUMBER OF PEOPLE ON METHADONE AND PERCENTAGE OF THE TOTAL INMATE POPULATION

29 SPAIN: NUMBER OF PRISONS PARTICIPATING AND NUMBER OF SYRINGES EXCHANGED

30 PrevalencePrevalence ofof HIVHIV infectioninfection inin thethe CatalanCatalan prisonsprisons (Source:( Dep of Justice)

35 29,77% 30

20 15,75% 15

0 1999 2000 2001 2002 2003 2004 2005 2006

31 PrevalencePrevalence ofof HVCHVC infectioninfection inin thethe SpanishSpanish prisonsprisons (Source:( Ministry Interior)

32 OTHER HARM REDUCTION SERVICES

33 12 drop in centres

34 5 supervised consumption rooms (one with smoking room)

35 7 mobile units

36 7 street work teams

37 6 teams provide health prevention trainings: •Safer sex, •Safe injecting, •Overdose prevention

38 Working opportunities for active drug users

39 40 41 Lessons learned

All these services and strategies help: • to increase contact & retention with users • to decrease risk health behaviour • to improve their health situation • to minimize social exclusion • It facilitates referral to drug treatment

42 18 OPEN DRUG SCENES

• Sant Cosme El Prat del Llobregat • La Mina Sant Adrià del Besós • Sant Roc Badalona • Font de la Pólvora (Vila-roja) Girona • Bonavista/Camp Clar Tarragona • Les 600 vivendes Constantí • Sant Pere Roda/Barri Montserrat Terrassa • Casc Històric. Lleida • Parc de la Marquesa/El Gornal L’Hospitalet • Les Farreres/Can Espinós Gavà • Barri de Sant Josep Obrer Reus • Zona Franca Sants/Montjuïc (Barcelona) • El Raval Ciutat Vella (Barcelona) • Barri de Porta Nou Barris (Barcelona)

43 MANAGEMENT OF PUBLIC NUISANCE IN THE OPEN DRUG SCENES

“Everything can not be solved but we can decrease and improve many problems” Coordination scheme: Local drug policy officials, local service drug workers, police, local residents (and drug users) What helps drug users: Opiate substitution therapy Syringe exchange programmes Drop in centres with consumption rooms Street work What helps the community: Drop in centres with consumption rooms Street work Police Picking up syringes and cleaning: users and town council cleaning teams 44 REACH A HIGH LEVEL POLITICAL CONSENSUS:

• Not use drugs for political aims what prevent from getting stuck in ideological (and moral) discussions and focus on scientific based and pragmatic approaches

Two parliamentarian (1996 and 2006) agreements passed by unanimity of all political parties

45 THANK YOU