Kosten und Nutzen der Substitutionsbehandlung

Research has shown clearly that a drug addict who is in treatment costs less to society than those who are on the street or in prison. Data vary from country to country and also depend on the kind of treatment provided. Some of these data will be discussed.

Furthermore, I would like to raise the question why this information plays little or no role in the development of drug policies. I see three major factors:

• The moral issue

• The stream of money

• The insecurity of treatment providers

The first point regards the moral issue. Just some remarks that a lot of us hear everyday:

• „All addicts should be forced to get clean“

• „It is their own fault that they are in deep shit, so why should we use tax money to help them“

• „If they want to die, let them die, we can save money!“

• „Treatment does not work, just lock them up in prison“

• „Why use money on drug addicts, which should be used to give better care to old people who built up our country“

• Etc.

All these remarks are not based on scientific data, but appeal to basic emotions: drug addiction is bad, a sign of weakness, something which disrupts society, a threat to quality of life. And when people feel threatened, the first reaction is more law enforcement. We see this with the anti-terror reactions: more control, more police, tougher laws etc.

Anybody who comes with the argument that treating drug addict is more cost-effective then putting them in prison, will have a hard time to overcome the general emotions felt in society.

The second issue is the stream of money.

When we say that treatment of drug addicts is cost effective, it basically means that gains are made in the criminal justice system, on public order measures, insurance money and hospital costs, while the extra investments for more and better treatment come from the health system. These two systems are not interrelated, so a gain in one area is not felt as a compensation for extra investment in the other area. As long as the streams of finances are independent of each other, it is not very likely that any argument of cost effectiveness will get through.

The third issue relates to the practitioners. Many of us see how patients relapse time and time again. Whenever we are criticised for not being effective, it hits an open nerve so to speak. Are we really effective? Could we do better? Do we set our goals too high? This makes us insecure. Just to say bluntly that treatment works and saves society a lot of money, is something that many of us don't do and don't like to do either. In this respect, it is probably also important to realize that most of us look at our patients as human beings who need help rather than looking at our patients and treatment as a commercial product, an investment with a certain value of return.

So, what can we do to include the cost effectiveness question in such a way that we feel comfortable with it, that it leads to more and better treatment and in the end to more people who receive the treatment they need?

I would suggest a number of concrete actions:

1. Know about the data on cost effectiveness.

There are many studies, but it would be advisable not to complicate matters too much and stick to concrete data from your own country. The COBRA study could be a good source in this respect.

Keep it simple: Thus, for every euro spent on treatment, more than 7 euros in future costs are saved.

2. Change moral issues into more pragmatic discussions.

It is a reality, that in our society every life counts, whether someone is of old age, born with a handicap, cancer patient or someone who is addicted to drugs. I am happy to live in a society where we treasure ALL life. Given the reality that people are addicted to drugs, we better make the best of it. If we provide them with good quality treatment we reduce criminal involvement and medical complications and thus save a lot of money in the law enforcement field and hospital costs. The more people in treatment, the more money we save! And not only that, we also give them and their families to opportunity to improve quality of life and participate in society again.

3. Make sure your treatment is of a high standard.

And here I come to my favourite topic: improving the quality of substitution treatment. As you may know, I am the coordinator of Euro-Methwork. In the last decade, Euro-Methwork has devoted a lot of time and energy in assisting practitioners all over Europe in improving the quality of their work. We have organised training sessions and workshop, we have published documents and we have developed an extensive website.

Our publications were amongst others the European Methadone Guidelines, A Training Manual and a booklet on Buprenorphine. In these publications we provide scientific data in combination with practical suggestions on how to make changes in the daily work. All the documents are on our website as PDF files and many were translated from English into other languages in order to reach as many people as possible. Our website also has an extended database with addresses of substitution programmes all around Europe. This database was made in order to facilitate for patients who wish to travel and receive their medication in another country during their stay.

Finally, Euro-Methwork is involved in training. Recently, we have started a very successful project in cooperation with essex: ZEUS. In the first half of 2006, 40 German doctors were trained in Amsterdam to become certified Euro-Methwork trainers. The training took place on weekends, where we worked very hard, using different kind of modules and paid a lot of attention to effective methods to teach practitioners to do a better job. Besides the hard work, we made sure that the trainees would have sufficient time to communicate with one another. Feedback we received was very positive in terms of what they learned and also that they had a great time. When learning takes place in a pleasant and entertaining environment it is always much more effective. Now, the 40 new German Euro-Methwork trainers are busy in organizing their own training here in Germany. They put in practice what they have learned in Amsterdam and I am sure they will contribute greatly to further ameliorating the quality of substitution treatment in Germany. Soon, Germany will be an example to other European countries in terms of how to develop and carry out effective treatment for drug addicts.

With this new development of training so many practitioners in Germany, the climate amongst practitioners will soon change: they will be self assured and know that what they do makes a difference. Anytime the question is raised whether substitution treatment is cost effective, they will be able to answer without any hesitation: Yes it is effective, give us all the support you can and we will keep on doing our important work, save lives, improve quality of life of our patients and save society a lot of money!