| Definition and concepts |
Definitions:
The coverage of treatment interventions for substance use disorders is defined as the number of people who received treatment in a year divided by the total number of people with substance use disorders in the same year. This indicator is disaggregated by two broad groups of psychoactive substances: (1) drugs, (2) alcohol and other psychoactive substances.
Whenever possible, this indicator is additionally disaggregated by type of treatment interventions (pharmacological, psychosocial and rehabilitation and aftercare services). The indicator is accompanied and can be analysed together with contextual information such as prevalence of alcohol and drug use disorders and availability coverage, i.e. Service Capacity Index for Substance Use Disorders (SCI-SUD) that reflects the capacity of national health systems to provide treatment for substance (alcohol, drugs and other psychoactive substances) use disorders, in terms of the proportion (%) of available health system elements in a given country from a theoretical maximum.
Concepts:
The central concept of “substance abuse” in the SDG health target 3.5 implies the non-medical, hazardous, harmful or dependent pattern of use of psychoactive substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or affect. The concept of “substance use disorders” includes both “drugs use disorders” and “alcohol use disorders” according to the International Classification of Diseases (ICD-10 and ICD-11).
The term “drugs” refers to controlled psychoactive substances as scheduled by the three Drug Control Conventions (1961, 1971 and 1988), substances controlled under national legislations, new psychoactive substances (NPS) and some other that are not controlled under the Conventions, but may pose a public health threat. “Alcohol” refers to ethanol - a psychoactive substance with dependence producing properties that is consumed in ethanol-based alcoholic beverages or their surrogates.
People with substance use disorders are those with harmful patterns of substance use or substance dependence. Harmful pattern of substance use is defined in the ICD-11 as a pattern of use of substances that has caused damage to a person’s physical or mental health or has resulted in behaviour leading to harm to the health of others. According to ICD-11, dependence arises from repeated or continuous use of psychoactive substances. The characteristic feature is a strong internal drive to use psychoactive substance, which is manifested by impaired ability to control use, increasing priority given to use over other activities and persistence of use despite harm or negative consequences.
Within this context treatment interventions for substance use disorders include any structured intervention that is aimed specifically to a) reduce substance use and cravings for substance use; b) improve health, well-being and social functioning of the affected individual, and c) prevent future harms by decreasing the risk of complications and relapse. These may include pharmacological treatment, psychosocial interventions and rehabilitation and aftercare. All evidence-based used for treatment of substance use disorders are well defined in WHO and UNODC related documents. Though hazardous substance use is not included in the concept of “substance use disorder”, such patterns of substance use are important targets for prevention interventions in health systems, and such interventions are included in the overall scope of comprehensive health system responses to “substance abuse” as defined in SDG 3.5.1 indicator.
Pharmacological treatment refers to evidence-based interventions that include administration of pharmacological agents or medicines in the context of different treatment modalities and interventions, including withdrawal management; treatment of alcohol use disorders with baclofen, naltrexone, acamprosate and disulfiram; management of opioid dependence with opioid agonists (methadone, buprenorphine) and antagonists (naltrexone); and prevention and management of opioid overdose with naloxone (WHO/UNODC International Standards for the treatment of drug use disorders, 2020 and WHO Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders, 2023 ).
Psychosocial interventions refer to programs that address motivational, behavioral, psychological, social, and environmental factors related to substance use and have been shown to improve quality of life and well-being, reduce psychoactive substance use, promote abstinence and prevent relapse. For different substance use disorders, the evidence from clinical trials supports the effectiveness of treatment planning, screening and brief intervention (SBI), counselling, peer support groups, cognitive behavioral therapy (CBT), motivational interviewing (MI), community reinforcement approach (CRA), motivational enhancement therapy (MET), family therapy (FT) modalities, contingency management (CM), counselling, insight-oriented treatments, housing and employment support among others. (UNODC/WHO International Standards for the Treatment of Drug Use Disorders, 2020 and WHO Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders, 2023).
Rehabilitation and aftercare (Recovery Management and Social Support) refers to interventions that are based on scientific evidence and focused on the process of rehabilitation, recovery and social reintegration. (UNODC/WHO International Standards for the Treatment of Drug Use Disorders, 2020 and WHO Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders, 2023).
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| Data sources |
Numerator (people who received treatment):
Treatment registries are the main source of data for the number of people receiving treatment. They are expected to cover the entire national territory and be linked to all relevant agencies providing treatment services.
Denominator (people with substance use disorders):
To estimate the number of people with drug use disorders, the sources include:
- Household surveys
- Surveys among people using substances – using for instance respondent driven sampling
- Indirect methods such as capture/recapture or multiplier benchmark method
Surveys should be nationally representative, with a sample size sufficiently large to capture relevant events and compute needed disaggregation, and they should be based on a solid sample design. The use of indirect questions for network scale-up methods in household surveys is encouraged.
When data at the national level are not available, estimates on the number of people with drugs use disorders produced by the Institute for Health Metrics and Evaluation (IHME), and published through the Global Burden of Disease (GBD) study, can be used for the denominator of the indicator.
To estimate the number of people with alcohol use disorders, preferred data sources are population-based surveys targeting the adult population (15+ years) and using standardized diagnostic instruments. International surveys such as World Health Survey (WHS), WHO STEPwise approach to surveillance (STEPS), Gender, Alcohol, and Culture: An International Study (GENACIS), and The European Cancer Anaemia Survey (ECAS) represent good practices.
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| Comment and limitations |
The two main challenges in terms of computing the SDG 3.5.1 indicator are the limited availability of household surveys on substance use and the under-reporting of use among survey respondents.
Data reported from household surveys are one of the sources of information on of the number of people with substance use disorders. There are issues of under-reporting for certain psychoactive substances, in countries where stigma is associated to substance use and when a considerable proportion of the drug or alcohol using population is institutionalized, homeless or unreachable by population-based surveys. Additionally, being a relatively rare event, household surveys on substance use disorders require a large sample and can be costly. In order to address these issues, additional approaches (e.g. scale up methods) are increasingly used in household surveys to address undercount issues. These can be used in conjunction with special studies and/or additional information, in order to obtain reasonable estimates via indirect methods, such as benchmark/multiplier or capture-recapture methods.
Given these challenges, often national officially produced estimates on the number of people with drug use disorders are not available. In this context, additional sources are considered, such as the estimates produced by the Institute for Health Metrics and Evaluation (IHME), and published through the Global Burden of Disease (GBD) study. Data on treatment of drug use disorders is more widely available at the national level, as it relies on administrative records.
An additional step in data validation and country capacity building for monitoring treatment coverage for substance use disorders will be implemented during the next couple of years for in-depth data generation in a sample of countries from different regions and representing different levels of health system development. A rapid assessment tool for in-depth data generation is in the process of development by WHO.
The indicator stresses on type, availability and coverage of services but does not necessarily provide information on the actual quality of the interventions/services provided. To address this, the proposed treatment indicator is accompanied with contextual information on availability coverage produced by WHO and using Service Capacity Index for Substance Use Disorders (SCI-SUD) that reflects the capacity of national health systems to provide treatment for alcohol and drug use disorders, in terms of the proportion (%) of available service elements in a given country from a theoretical maximum.
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