World Health Organization guidelines for the treatment of substance use disorders and comorbid conditions<span class="pie

To the distinguished delegates of the Congress and colleagues, it is a great pleasure and honor for me to present to this audience. I only regret the fact that I cannot deliver my presentation in Spanish.

I would like to start with some acknowledgments to my colleagues from the World Health Organization (WHO), who, in different ways, have collaborated in the collection of materials for this presentation.

I will begin with some figures in relation to the consumption of psychoactive substances in the world. Alcohol continues to be the substance of greatest acceptance and consumption, with almost two billion alcohol users in the last 12 months, followed by tobacco that, according to the latest estimates of the WHO, is used by 1.1 billion smokers in the world. For psychoactive drugs, around 255 million people used psychoactive drugs during the last 12 months according to the global estimates made for 2015.

In terms of prevalence and distribution of substance use disorders, the estimated numbers of people with different types of substance use disorders reflect the same proportions that we observe for exposure to or consumption of psychoactive substances. Approximately 250 million people in the world suffer from alcohol use disorders with a much higher rate in men than in women (7.2 percent versus 1.3 percent in women), about 30 million people live with drug-use disorders. In addition, according to the latest global estimates, 12 million people in the world are injecting drug users.

There is an important co-occurrence of the use of different substances in individuals, and according to the research data coming from the United States the use of alcohol and prescription drugs among tobacco users is much higher than in the general population. These statistics allow us to suggest to health professionals to focus on the use of tobacco as the first question to ask by health professionals before coming to a deeper exploration of the use of other psychoactive substances.

There is a high prevalence of mental disorders among drug users. In the United States, some studies show that fifty percent of people with mental disorders have comorbid substance use disorders. There are studies that show a significant association between mental and substance use disorders, also in Europe, and research data in this area was recently summarized by the European Monitoring Center for Drugs and Drug Addiction. The consumption of psychostimulants is much higher in patients with schizophrenia, compared to the general population. Lifetime prevalence of major depressive disorder reach 32% among cocaine users, compared to 8-13 percent of those who are not using cocaine.

Individuals with some severe psychotic disorders have an increased risk of substance use; they smoke almost five times more often than the rest of the population; they have a four times higher risk of heavy drinking as well as of heavy use of marijuana, and, in general, of almost any recreational drug use. Lifetime prevalence of non-affective psychoses is above 12 percent among those with substance use disorders.

We cannot ignore that in order to provide care services, from a public health perspective, it is extremely important to know comorbidities of substance use disorders with infectious diseases. The latest global estimates published in 2017 for injecting drug users indicate 18 percent of HIV infection, 52 percent of hepatitis C and 9 percent positive for hepatitis B surface antigen.

My talk is about current WHO guidelines that serve as important technical tools that support clinicians or other health professionals who work with people with substance use disorders to address their comorbidities. They are developed by the well-defined and transparent processes using internationally recognized methods and standards for guideline development to ensure that its guidelines of the highest quality. They are also relevant for different health care systems and settings.

Fifteen years ago, the WHO guidelines were produced by consensus of a group of experts who met for several days to draft recommendations; the process is no longer like that, it complies with the highest international standards.

In some jurisdictions, including the United States, Canada and Australia, there is a crisis of opioid overdose mortality that changed the mortality trends in populations, especially among middle-aged people.

In 2014, the WHO guidelines on community management of opioid overdose were developed with the main objective to help to deal with opioid overdose by engaging those who have high chances to observe opioid overdose. For effective community management of opioid overdose people at high risk should have an access to naloxone, and there should be a possibility for not only health professionals to administer it, without medical prescription. The guidelines have been published and disseminated also within the SOS initiative of UNODC and WHO, and have the ultimate goal of helping to reduce opioid overdose deaths and the mortality due to opioid use.

Another WHO guidelines cover the identification and management of substance use during pregnancy. There is a general trend around the world that the prevalence of use of alcohol and some other psychoactive substances, such as cannabis, and prescribed medicines such as benzodiazepines, has increased among women, especially among those of childbearing age.

That is why WHO, in collaboration with other partners, has produced guidelines on identification and management of substance use in pregnancy. The guidelines also provide recommendations on what to do when substance use disorders have been identified and indicate how to provide treatment to pregnant women with substance use disorders.

Speaking of a comorbidity between substance use disorders and other mental disorders, it is important to mention the mhGAP Intervention Guide with its first edition published by WHO in 2012. It is currently used in over 90 countries and has been translated into more than 20 languages. The second edition of this guide was released a year ago; its recommendations were developed following the strict methodology of the WHO for developing the guidelines. It is designed for the use in non-specialized services and primary care physicians; it includes the identification of depression, psychoses, epilepsy, dementia, suicidal behaviors and disorders related to substance use, including alcohol and drugs. It can be a very useful tool for those who have to deal with mental health disorders and comorbidities in non-specialized health care settings; it is also accompanied by different training materials that have been published this year.

Another important area of WHO normative guidance is an area of hepatitis and HIV AIDS; there is a large burden of hepatitis B and C in populations using drugs, largely due to drug injection and to increase in frequency of high-risk behaviors. The WHO guidelines for this area, which have been developed between 2009 and 2017, cover different aspects, from structural factors and general policies, to more specific guidelines on HIV testing, the use of retrovirals for treatment, as well as the diagnosis and treatment of hepatitis B and C.

Tuberculosis and associated drug use is another public health problem. The 2016 WHO guidelines addresses the diagnosis and management of tuberculosis in drug users.

Smoking remains a major public health issue, also within mental institutions. Much of the work of WHO and Article 14 of the Tobacco Control Convention provide the necessary guidelines for the management of tobacco dependence.

Tools related to the prevention of violence and injuries are another resources that are available.

Finally, I would like to mention the guidelines for education and training of health professionals developed by WHO in 2016.

There are other guidelines addressing comorbidities, which are not developed or published by WHO, but they are available and can be very useful in daily work. Among them let me list the following: the S3 guidelines on comorbidities of mental disorders and alcohol use disorders developed in Germany; the guidelines on diagnosis and management of physical complications of alcohol use disorders developed in the United Kingdom (UK) and updated in 2017, and the UK guidelines on assessment and management of coexisting severe mental illness and substance use disorders; the guidelines of the British Association of Psychopharmacology; the Dual Diagnosis Clinical Guidelines with Clinician Tool Kit and a brief guide for the primary care clinicians on comorbidity of mental disorders and substance use developed in Australia; and, finally, the SAMHSA protocol on substance abuse treatment for persons with co-occurring disorders developed.

What are the challenges for management of comorbid mental and substance use disorders? The first is to eliminate stigma and discrimination in access to public health services; this affects access to resources in communities or societies. There is often an exclusion of the provision of services to patients with comorbidities. Such patients are considered as treatment orphans and there is often inadequate management of their health conditions in health services. Also we often lack sufficient research data to inform management of this type of disorders in different settings.

There are many approaches to service delivery for comorbid conditions, but largely there are two main models: the one of linking services for mental health and substance use disorders, and another – on integrating the services with some programs providing a mix of the above-mentioned two models of service provision.

What are the implications of comorbidity for policies and programs? It is quite direct and perhaps a bit obvious, but at the same time this is not always reflected in the relevant national and international documents. The evaluation, treatment, rehabilitation and social reintegration would be more effective if a comprehensive and integrated approach is adopted for treatment of comorbid mental and substance use disorders. In general, attention to comorbidity of substance use disorders and mental disorders is required as an element of good practice in the treatment of these disorders, and the high level of comorbidity must be taken into account in planning and development of treatment programs and services and training of health professionals.

Thank you.

World Health Organization guidelines for the treatment of substance use disorders and comorbid conditions*