The Barcelona Model - Addiction care resources in Barcelona by Oleguer Parés. The city of Barcelona has had since 1987 consecutive action plans for drugs • They are always based on actual data, derived from the drug information system

1. The Barcelona Model
Addiction care
resources in Barcelona
Agència de Salut Pública de Barcelona
Barcelona Public Health Agency
Oleguer Parés
opares@aspb.cat

2. This story begins with a catastrophe:
the heroin epidemic in Spain in the late 80s
• New problem, beginning in late 70s
• Heroin concentrated in deprived
neighborhoods
• White heroin (better for injected use)
dominated the market
• Conditions worsened by HIV/AIDS
epidemic
• Confused ideology and public image
• Lack of specialized centers and
personnel
• Most users rebuffed by health care
system
Observed and estimated problematic heroin use incidence rates, Spain (1971-2005)
Sanchez-Niubò (2009) Addiction

3. Pragmatic model
• Heavy drug use produces physiological and
psychological changes that override the
“choice”
• Addiction depends on drug pharmacology
and way of use
• Social o genetic susceptibility
• Drug use continues in absence of pleasure or
health and social consequences
• Social and therapeutic programs
Sceptical or moral model
• Addicts are drug users by voluntary choice
• Addiction as the excuse to keep using drugs
irresponsively
• Initial voluntary choice
• Most addicted people stop use by themselves
• Punitive laws
• Lack of investment in medical research and
treatment
Models of Addiction

4. Drug addiction Action Plan
Barcelona 1988-2020
• The city of Barcelona has had since 1987 consecutive action
plans for drugs
• They are always based in actual data, derived from the drug
information system
• They define comprehensive actions for all actors and not
only for addiction treatment centers
• They are approved by the City Council, searching for consensus
(politic drug group)
• The action plan relies on the participation of:
• different areas of the City Council (economic, social, health,
police, culture… departments)
• NGOs, professional colleges, syndicates, neighbors
associations

5. Catalonia Health
Department
Public Health Secretary
Drug dependencies
General
Sub-Directorate
Planification general
management
CATSALUT
Catalan health service
Barcelona Health
Consortium
Barcelona Public Health
Agency
Barcelona
City Council
Organization chart
Drug addiction services governance
Barcelona Public Health
Agency
Open tender
to manage municipal drug
addiction centers
Barcelona Public Health Agency funding:
 60% Barcelona city council
 40% Catalan Government

6. Key issues in each period
20152010200520001995199019851980
First needle and syringe
program
Methadone made
availableHeroin epidemic peaks
in Spain
First CAS
Take-home
naloxone
First integral
CAS
First SIF
Mobile SIFMobile methadone clinic
Supervised drug use in
open scene
First Drug Addiction
Action Plan
First pharmacy
siringe exchange

7. Prevention programs for teens and youth
 Indicated prevention
 Servei d’orientació sobre drogues (Drug guidance service)
 Selective prevention
 Programa Salut als Barris (Neighborhood health program)
 Universal Prevention
 De marca fent esport (Going out doing sports)
 Pase.bcn
 Classe sense fum (Smokefree class competitions)
 Sobre canyes i petes (All about pints and joints)
Indicated
aimed at individuals who
are experiencing early signs
of substance abuse
Selected
aimed at
subgroups at risk
Universal
aimed at the
entire population

8. DRUG ADDICTION
CENTERS
BARCELONA 2018

9.  15 centers for addiction treatment (CAS)
 4 hospital units for detoxification
 1 therapeutic community (CECAS)
 1 day care center
 9 consumption rooms (19 + 4 booths)
 2 CR in harm reduction facilities (one mobile)
 6 CR in Integrated Drug Addiction Centers
 1 consumption room for inhaling
 13 therapeutic flats managed by NGOs
 65 pharmacies and 5 health care centers with syringe
exchange programs
 34 pharmacies with methadone program
Main resources for drug Addiction in Barcelona

10. Barcelona Model: Integral drug addiction centers
(Harm reduction + Treatment)
Prochaska and DiClemente's Stages of Change Model
Action
Active modification of
behaviour (eg starting a
treatment).
Maintenance
Sustained change. New
behaviour replaces old.
Contemplation
Aware problem exists but
no action in mind.
Relapse
Fall back to old patterns
of behavior.
Pre-
Contemplation
No intention of changing
behaviour.
Preparation
Intent on taking action to
address the problem.
Treatment
Alcohol, opiates, cocaine, cannabis, other drugs
and dual diagnosis programs
Health care
Psychological care
Socio-educational care
Therapeutic groups
Family support
Emergency care
Harm Reduction
First contact
Safe injection materials
SIF
Skills to reduce risks
Wound care
Health and social care referral
Community outreach
Low-threshold methadone
Stages of change
(addiction as a chronic and recurrent disease)
Services provided

11. The portfolio of services
Treatment program
• Psychopharmacological treatments, group and individual psychotherapy:
• Alcohol, cocaine, cannabis and opioid programs
• Dual diagnosis program
• Hospital or outpatient detoxification treatments
• Individual Treatment Plan (ITP):
• Clinical assessment. Organic, mental, social and educational diagnosis.
• Care to families. Relapse prevention and discharge follow-up
• Referral, coordination and monitoring with other health resources:
• Primary Care, mental health centers, acute care hospitals, etc

12. Font: Sistema d’informació de drogues de Barcelona (SIDB). Agència de Salut Pública de Barcelona.
Treatment demands by substance, 1997 - 2015
0%
10%
20%
30%
40%
50%
60%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
%oftreatmentdemandbysubstance
Opioid Cocaine Cannabis Alcohol Other

13. The portfolio of services
Socio-educational program
 Social and occupational rehabilitation workshops
 Linguistic and cultural diversity
 Promotion of healthy leisure time
 Legal counselling
 Referral and coordination with different external resources:
 Women programs
 Social services, prisons, minors, etc.
 Health education programs for people who use drugs
 Overdose prevention workshop, venipuncture workshop, safe sex, etc.

14. The portfolio of services
Harm reduction program
 Supervised consumption rooms
 Provision of sterile equipment and collection of used
material
 Overdose prevention workshop
 Infectious diseases: HIV, HCV screening, HBV vaccination
 Directly observed treatment for different diseases
 Brief motivational interventions to adhere to treatment
 Evaluation and establishment of basic needs (shelter,
food supplement) and referral to social services

15. Community activities
 Health educators:
 Link PWID with drug addiction services
 Contact with neighbors and community
agents
 Track syringes at public spaces
 Coordination with:
 Local police
 Social services educators
 Cleaning services
 Social and occupational
rehabilitation workshops

16. Consumption rooms history
1992 Olympic Games: Drug use dropped off from
inner city to Can Tunis open scene
First open scene
2002 Can Tunis open scene shut down, July 2004
2003 SAPS opening (downtown)
Political plan to open 3 consumption
rooms in the city
2004 Baluard opening (downtown)
2005 Mobile consumption room opening (Zona Franca)
Integral drug addiction Center
(treatment + harm reduction) Vall d’Hebron
2009-11 Opening of 4 integral drug addiction centres
© Sergi Reboredo

17. Different models of DCR in Barcelona
Integrated DCR - CAS Baluard

18. Different models of DCR in Barcelona
Hospital based – Vall d’Hebron

19. Different models of DCR in Barcelona
Mobile Unit

20. Syringes Exchange Program
Barcelona, 1996-2015
Font: Sistema d’informació de drogues de Barcelona (SIDB). Agència de Salut Pública de Barcelona.
218.539
273.939
372.033
476.582
660.632
859.236
1.022.710
1.071.185
718.871
462.771
363.252
329.678 343.490 328.180
299.243
231695
176.606 177.162
234.091 241.144
297.690
344.330
0
200.000
400.000
600.000
800.000
1.000.000
1.200.000
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Given syringes Returned syringes

21. 0
2.000
4.000
6.000
8.000
10.000
12.000
14.000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Ciutat Vella Sants-Montjuïc Nou Barris Sant Andreu Sant Martí
Monthly mean of syringes collected from public spaces, by area.
Barcelona 2004-setembre 2016
CAS Baluard opening
CAS Fòrum opening
CAS Vall Hebron opening
Opening CR other CAS
Font: Sistema d’informació de drogues de Barcelona (SIDB). Agència de Salut Pública de Barcelona.
Opening CR Lluís Companys

22. CAS Lluís
Companys
CAS Baluard
CRD Robador
Syringes collected in public spaces
Barcelona city center, January 2017

23. Annual number of visits to the consumption room by center and year
Barcelona, 2006-2016
0
10.000
20.000
30.000
40.000
50.000
60.000
70.000
80.000
90.000
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
CAS Baluard (inj) CAS Baluard (inh)
SAPS CAS Vall Hebron
MU Zona Franca CAS Forum

24. CAS BALUARD
CAS LA MINA
2024 clients
2903 clients
621 clients
7 km

25. Annual number of overdose deaths
Barcelona, 1990-2016
139
159 160
151
128
150
141
122
113
121
101
87
74
84
73
80
85
66
48
84
70
60 64
55
34
42
54
0
20
40
60
80
100
120
140
160
180
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
Numberofoverdosedeaths
Four out 100
opioid overdose
are fatal

26. The Barcelona Model
Addiction care
resources in Barcelona
Agència de Salut Pública de Barcelona
Barcelona Public Health Agency
Oleguer Parés
opares@aspb.cat