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Atlas: substance use in the Eastern Mediterranean Region 2015

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EMRO Technical Publications Series

Atlas: substance use in the Eastern Mediterranean Region 2015

EMRO Technical Publications Series

Atlas: substance use in the Eastern Mediterranean Region 2015

WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean Atlas: substance use in the Eastern Mediterranean Region 2015 / World Health Organization. Regional Office for the Eastern Mediterranean p. .- (EMRO Technical Publications Series; 45) ISBN: 978-92-9022-144-9 ISBN: 978-92-9022-145-6 (online) ISSN: 1020-0428 1. Substance-Related Disorders - prevention & control 2. Substance-Related Disorders – therapy 3. SubstanceRelated Disorders - epidemiology - Eastern Mediterranean Region 4. Alcohol-Related Disorders 5. Health Services 6. Atlases I. Title II. Regional Office for the Eastern Mediterranean III. Series (NLM Classification: WM 270)

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Contents Executive summary....................................................................................... 5 Information systems...................................................................................... 6 1. Introduction................................................................................................ 7 2. Methodology............................................................................................... 7 2.1 Data collection....................................................................................................................................... 7 2.2 Limitations.............................................................................................................................................. 8

3. Substance use and health: situation in the Region.................................. 8 3.1 Sociodemographic characteristics of the Region........................................................................... 8 3.2 Epidemiology ......................................................................................................................................... 8

4. Country responses to the Atlas questionnaire...................................... 16 4.1 Leadership and governance............................................................................................................... 16 4.2 Financing................................................................................................................................................ 22 4.3 Service organization and delivery.................................................................................................... 26 4.4 Workforce............................................................................................................................................. 45 4.5 Information systems........................................................................................................................... 48

5. Comparison of data between Atlas 2012 and Atlas 2015..................... 52 5.1 Leadership and governance............................................................................................................... 53 5.2 Financing................................................................................................................................................ 53 5.3 Service organization and delivery .................................................................................................. 54 5.4 Workforce............................................................................................................................................. 56 5.5 Information systems........................................................................................................................... 57

6. Conclusion................................................................................................. 58 Glossary......................................................................................................... 59 Country fact sheets: substance use disorders............................................................................... 63 Afghanistan.................................................................................................................................................. 65 Bahrain.......................................................................................................................................................... 68 Djibouti........................................................................................................................................................ 71 Egypt............................................................................................................................................................. 74 Iran (Islamic Republic of).......................................................................................................................... 77 Iraq................................................................................................................................................................ 80 Jordan............................................................................................................................................................ 83 Kuwait........................................................................................................................................................... 86 Lebanon........................................................................................................................................................ 89 Libya.............................................................................................................................................................. 92 Morocco....................................................................................................................................................... 95

Atlas: substance use in the Eastern Mediterranean Region 2015

Oman............................................................................................................................................................ 98 Pakistan....................................................................................................................................................... 101 Qatar ......................................................................................................................................................... 104 Saudi Arabia............................................................................................................................................... 107 Somalia....................................................................................................................................................... 110 Sudan........................................................................................................................................................... 113 Syrian Arab Republic............................................................................................................................... 116 Tunisia......................................................................................................................................................... 119 United Arab Emirates ............................................................................................................................. 122 West Bank and Gaza Strip..................................................................................................................... 125 Yemen......................................................................................................................................................... 128

Executive summary

Executive summary The atlas project on substance use is a project conducted by the World Health Organization (WHO) that aims to collect, compile and disseminate information on the availability of resources for the prevention and treatment of substance use disorders. A first assessment of available resources was carried out at the global level1 and at the regional level2. This report presents the latest information on the available resources and services at country level for the prevention and treatment of substance use disorders in the Eastern Mediterranean Region. The information presented in this report is based on an atlas questionnaire that was updated from the previous version and sent to all countries. All of the 22 countries of the Region submitted replies to the atlas questionnaire. Key findings of the report are presented below.

• The regional estimated number of deaths due to drug use disorders in 2012 is 1.8 per 100 000 population, which is almost three times the estimated number of deaths due to alcohol use disorders. • The regional estimated number of disability-adjusted life years (DALYs) due to drug use disorders in 2012 is 253 per 100 000 population.

Leadership and governance • More than half of the countries have a government unit/official responsible for the prevention and treatment of substance use disorders. • More than 60% of the countries have a legislative provision for offering voluntary treatment for drug use disorders as an alternative or in addition to criminal sanctions.

Financing • Specific budget lines for the prevention and treatment of substance use disorders are available at the ministry of health in the majority of the countries. • Government financing is the most common financing method for treatment services for substance use disorders. • In the vast majority of the countries, people with substance use disorders are not eligible to receive government benefits.

Substance use and health: situation in the Region • The estimate of the total alcohol per capita consumption in the Region for 2010 is 0.7 litres of pure alcohol, which is almost nine times lower than the global estimate3. • The prevalence of opioid use varies greatly within the Region but is among the highest in the world in some countries. • Lifetime prevalence of cannabis and amfetamine use among students aged 13– 15 years is 3.5% and 3.3% respectively, with large differences between males and females.

Service organization and delivery • 60% of the countries have specialized treatment facilities for substance use disorders in the capital city, but only 28% have such facilities in areas other than the capital city or other major cities. • Mental health facilities are the most important providers of treatment services for alcohol use disorders.

Atlas on substance use 2010. Resources for the prevention and treatment of substance use disorders. Geneva: World Health Organization; 2010. 2 Atlas: substance use in the Eastern Mediterranean Region 2012. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2012. 3 Global status report on alcohol and health 2014. Geneva: World Health Organization; 2014. 1

Atlas: substance use in the Eastern Mediterranean Region 2015

• Specialized stand-alone facilities are the most important providers of treatment services for drug use disorders. • The regional median number of beds reserved for the treatment of substance use disorders is 0.7 per 100 000 population. • Information on treatment coverage or access to treatment is not known in the vast majority of countries. • Cannabis and opioids are the main substances reported as the primary drugs being used at treatment entry.

Prevention • Community-based prevention programmes for drug use are available in almost 75% of the countries. • Nongovernmental organizations, schools and religous groups are involved in prevention of substance use in more than 75% of the countries. • Most countries have not implemented screening and brief interventions for substance use in primary health care.

Workforce • Psychiatrists, medical doctors, psychologists, social workers and nurses provide treatment for substance use disorders in more than half of the countries. • Postgraduate training programmes for professionals providing treatment are not available in 40% of the countries.

Pharmacological treatment • 50% of the countries have guidelines on the pharmacological treatment of substance use disorders. • Pharmacotherapies for opioid dependence are available in less than 25% of the countries.

Special programmes and services • Needle/syringe exchange programmes are available in one-third of the countries of the Region. • Less than 25% of the countries have special treatment programmes for women, children or adolescents with substance use disorders.

Information systems • More than half of the countries do not have an epidemiological data collection system for substance use. • 45% of the countries do not have a system of data collection based on health services delivery for substance use disorders.

Introduction

1. Introduction The use of alcohol and other psychoactive substances alters brain functions, such as mood, perception and consciousness. It can lead to physical and psychological dependence, coercing a person to continue taking the drug despite adverse consequences. People with substance use disorders may suffer from psychological and psychosocial problems, loss of employment or legal problems. Substance use disorders are chronic mental disorders characterized by remissions and relapses and frequently accompanied by other mental conditions, such as depression or anxiety disorder, or by physical conditions such as HIV/AIDS, hepatitis B and C, and tuberculosis. Given the complexity of their health and social consequences, management of substance use disorders involves a range of prevention, treatment and rehabilitation approaches. Delivery of adequate care and treatment to people with substance use disorders requires a well functioning prevention and treatment system. Pharmacological, psychological and social interventions have been shown to be effective. The WHO atlas project on resources for the prevention and treatment of substance use disorders aims to collect, compile and disseminate information on resources for the prevention and treatment of substance use disorders. A first assessment was conducted in 2011 in order to map resources available in the Eastern Mediterrean Region. The aim of this report is to update that information by providing the regional response to the atlas questionnaire conducted in 2014. The data presented in this report are needed at the country level to assess the current situation and to assist in developing policies, plans and programmes. This report provides the latest information available regarding substance use and

health in the Region; the results of the atlas questionnaire are presented in the following sections: leadership and governance, financing, service organization and delivery, workforce, and information systems. A last section aims to monitor progress between the first assessment in 2011 and the latest information presented in this report. Though changes to the instruments make it challenging to compare certain items directly, some information can be tracked. Finally, country fact sheets providing detailed information for each country are presented at the end.

2. Methodology 2.1 Data collection The atlas project on resources for the prevention and treatment of substance use disorders was launched in 2010 by WHO in an attempt to map resources available worldwide for the prevention and treatment of substance use disorders. The 2015 version of the atlas represents the latest information on resources available. The questionnaire has been updated and contains the following sections: • • • • policy, legislation and financing human resources and training services and interventions health information systems.

The questionnaire was sent to nominated focal points at ministries of health. The focal point was encouraged to consult with experts and gather relevant information to answering questions. Once a completed questionnaire was received, it was screened for incomplete and inconsistent answers. To ensure high quality data, respondents were contacted again and were asked to respond to the requests for clarification and to correct their responses.

Atlas: substance use in the Eastern Mediterranean Region 2015

All of the countries in the Region replied to the atlas questionnaire on substance use.

Findings • The Eastern Mediterranean Region is the least populous among the six WHO regions. • In terms of proportion of population 15 years and under, the Region ranks second. • With almost 50% of the total population in the Region living in urban areas, the Eastern Mediterranean Region ranks fourth among the six WHO regions. • In terms of life expectancy at birth and adult literacy rate the Region ranks fourth.

2.2 Limitations Most of the data presented in this report are based on expert opinion; the designated focal points in ministries of health in consultation with related experts having provided the data for development of the atlas. Scarcity of information was a major challenge in compiling the report. For some items, particularly regarding service organization and delivery, information was not provided. A few components that are essential for a comprehensive treatment package for substance use disorders, namely structured psychosocial interventions, were not surveyed in development of the atlas and therefore the relevant data are missing in the current report.

3.2 Epidemiology 3.2.1 Per capita alcohol consumption Table 2 provides information on recorded and unrecorded per capita alcohol consumption in the Region and in the world for 2010. These data are extracted from the Global status report on alcohol and health 20149. Table 3 provides data on total per capita alcohol consumption by sex.

3. Substance use and health: situation in the Region 3.1 Sociodemographic characteristics of the Region Table 1 provides a brief overview of sociodemographic statistics of the WHO Eastern Mediterranean Region. These indicators are extracted from Framework for health information systems and core indicators for monitoring health situation and health system performance 2014 for the Eastern Mediterranean Region4, except for the “Population proportion under 15” indicator which is extracted from the WHO Global Health Observatory5. Framework for health information systems and core indicators for monitoring health situation and health system performance 2014. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2014. (http://applications.emro.who.int/dsaf/EMROPUB_2014_ EN_1792.pdf?ua=1, accessed 5 March 2016). 5 See http://apps.who.int/gho/data/view.main. POP2020?lang=en, accessed 5 March 2016. 4

Findings • The Region has the lowest alcohol consumption level among all WHO regions. • The regional estimate is almost nine times lower than the global estimate. • More than half of the alcohol consumed is unrecorded, which refers to alcohol that is not accounted for in official statistics on alcohol taxation or sales. • Alcohol consumption among women in the Region is 11 times lower than consumption among men, while at the global level, women drink nearly four times less than men. Data from five countries are available for 2012. Data from five countries are available for 2012, data from one country are available for 2011 and data for one country are available for 2009. 8 Data are available from 2006 to 2013 depending on the country. 9 Global status report on alcohol and health 2014. Geneva: World Health Organization; 2014. 6 7

Substance use and health: situation in the Region

Table 1. Demographic and socioeconomic indicators of the Region Total population (000s), 20136 Urban population (%), 2013 7

618 210 49.5 33 63.5 68.5 8

Population proportion under 15 (%), 2013 Adult literacy rate (15–24 years) (%) Life expectancy at birth (years), 2012

Table 2.Total recorded and unrecorded per capita alcohol (15+ years) consumption in litres of pure alcohol, 2010 Eastern Mediterranean Region Recorded per capita alcohol consumption Unrecorded per capita alcohol consumption Total 0.3 0.4 0.7 World

3.2.2 Prevalence of illicit drug use The data presented in Table 4 are extracted from the latest UNODC annual prevalence of use estimates for population aged 15 to 6410. These data are based on the UNODC annual report questionnaire, UNODC estimates and in some cases governments’ national reports. It should be highlighted that recent information is not available for the majority of the countries of the Region.

4.7 1.5 6.2

Findings for annual prevalence of cannabis use • In most countries of the Region, cannabis is the most common drug used by population aged 15 to 64. • According to UNODC estimates that are available for nine countries in the Region, the regional median annual prevalence is 3.6%. Fig. 1 presents the annual prevalence for these countries. • Compared to the last estimated regional median11, this represents an increase of more than 10%.

Table 3.Total per capita alcohol (15+ years) consumption in litres of pure alcohol by sex, 2010 Eastern Mediterranean Region Female Male Both 0.1 1.2 0.7 World 2.5 9.9 6.2

Table 4. Estimates of annual prevalence of illicit drug use for population aged 15–64 (%) Opioids Afghanistan (2009) Egypt (2006) Islamic Republic of Iran (2010) Kuwait (2004) Lebanon (2003) Libya (2004) Morocco (2011) Pakistan (2012) Saudi Arabia (2006) Somalia (2004) Syrian Arab Republic (2005) Tunisia (2011) United Arab Emirates (2004) 10

Cocaine 0 0.02 0.01 (2008) 0.04 (2005)

Cannabis 4.28 6.24

ATS 0 0.48 0.13

2.92 0.44 2.27 0.17 0.2 0.14 0.08 2.4 0.06 0.16 0.02 0.12 0.02 11

3.1 (2005) 2 (2009)

0.27 (2005)

0.05 (2004) 0.01

4.22 (2004) 3.6 0.3 2.5 (2002) 0.08 0.4

5.35 (2006)

United Nations Office on Drugs and Crime.World Drug Report 2014 (https://www.unodc.org/documents/wdr2014/ World_Drug_Report_2014_web.pdf, accessed 5 March 2016).

See Atlas: substance use in the Eastern Mediterranean Region 2012. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2012.

Atlas: substance use in the Eastern Mediterranean Region 2015

Findings for annual prevalence of opioid use • There are large regional differences in the annual prevalence of opioid use, with an annual prevalence of more than 2% in Afghanistan, Pakistan and Islamic Republic of Iran and less than 0.5% in the other countries in the Region for which data are available; see Fig. 2. • The prevalence of opioid use in Afghanistan, Pakistan and Islamic Republic of Iran is among the highest in the world. • Based on 13 countries, the regional median is 0.16%, which is similar to the regional median estimated in the Atlas 2012. However, as mentioned above, some of the data have not been updated since that previous report.

Findings for annual prevalence of amfetamine-type stimulant (ATS) use • ATS use is reported for five countries with the annual prevalence estimated at 0.2%. Fig. 4 presents the data for these countries.

Findings for annual prevalence of cocaine use • Prevalence data are available for five countries in the Region (see Fig. 3) and show a median of less than 0.1%, which is similar to the regional median estimated in the Atlas 2012.

3.2.3 Illicit drug use among young people Information on drug use among young people is extracted from the global school-based student health survey (GSHS). Data are provided for Iraq, Lebanon, Kuwait, Morocco, West Bank, Gaza and the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) in Gaza, Lebanon, Syrian Arab Republic and West Bank. The year at which the surveys were conducted varies between 2010 and 2012.

Cannabis Among all students aged 13–15 years, the lifetime prevalence of cannabis use ranges from 2.1% to 5%, with a median of 3.5%. The proportion of girls who reported having

7 6 Prevalence (%) 5 4 3 2 1 0 9) 4) 2) 9) 06 06 00 00 5) 2) 01 00 20 20 (2 (2 00 00 (2 (2 s( t( (2 (2 (2 Sa ud iA ra bia 00 6) ) ) an

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Fig. 1. Annual prevalence of use of cannabis among population aged 15–64 years

ite

Substance use and health: situation in the Region

3.5 3 Prevalence (%) 2.5 2 1.5 1 0.5 0 Re (2 pu 01 bli 2) co fI ra n (2 01 0) Eg yp t( 20 06 Le ) ba no n (2 00 3) Ku wa it (2 00 4) So m ali a( 20 04 ) Lib ya (2 00 4) Tu nis ia (2 01 1) M or oc co (2 Sa 01 ud 1) iA Sy ra ria b ia nA (2 ra 00 b 6) R ep Un ub ite lic dA (2 ra 00 b 5) Em ira te s( 20 04 ) Af gh an ist an Pa kis ta n Isl am ic (2 00 9)

Fig. 2. Annual prevalence of use of opioids among population aged 15–64 years

0.6 0.5 Prevalence (%) Prevalence (%) 0.4 0.3 0.2 0.1 0.0

0.6 0.5 0.4 0.3 0.2 0.1 0.0

Fig. 3. Annual prevalence of use of cocaine among population aged 15-64 years

Fig. 4. Annual prevalence of use of ATS (excluding ecstasy) among population aged 15-64 years

used cannabis more than once in their lifetime is six times lower than among boys. Indeed, the median lifetime prevalence for girls is 1% and 6.2% for boys. Fig. 5 shows the lifetime prevalence of cannabis use for all of the countries by sex.

Amfetamines Fig. 6 shows the lifetime prevalence of amfetamine use by sex and by country. Among all students aged 13–15 years, the lifetime prevalence of amfetamine use varied between 2.1% and 5%, with a median of 3.3%. As for cannabis use, the proportion of girls who

Eg yp t( 20 Sa 06 ud ) iA ra bi a( 20 06 ) Ku w ait (2 00 Isl 5) am ic Re Ira pu n blic (2 01 of 0) Pa kis ta n (2 01 2)

Eg yp t( 20 Isl 06 am ) ic Re Ira pu n blic (2 00 of Pa 8) kis ta n (2 01 2)

(2 00 4) M or oc co

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(2 00 5)

Atlas: substance use in the Eastern Mediterranean Region 2015

8 7 6 Prevalence (%) 5 4 3 2 1 0 West Bank 2010 Gaza Strip 2010 Lebanon 2011 Both Male Morocco 2010 Female Kuwait 2011 Iraq 2012

Fig. 5. Proportion of students aged 13–15 years who used cannabis more than once in their lifetime

reported having used amfetamines more than once in lifetime is nearly six times lower than among boys. The median lifetime prevalence for girls is 1% and 5.7% for boys. Fig. 7 shows the proportion of students who first used drugs before 14 years out of the total number of students who ever used drugs. The median for the countries that reported data is 87.25%. Few countries from the Region have conducted the GSHS. Out of the countries that have 12 10 Prevalence (%) 8 6 4 2 0

conducted it, not all of the questions regarding drug use were completed, which decreases the quality of the data. More efforts should be made to use this tool to assess behavioural risk factors among schoolchildren.

3.2.4 Prevalence of alcohol use disorders Table 5 provides the prevalence estimates of alcohol use disorders by sex for the Region and the world. These data are extracted from the Global status report on alcohol and health 201412.

Morocco 2010 (n = 2924)

Lebanon 2011 (n = 2286) Both Male

Kuwait 2011 (n = 2672) Female

Iraq 2012 (n = 2038)

Fig. 6. Proportion of students aged 13–15 years who used amfetamines more than once in lifetime 12

Global status report on alcohol and health 2014. Geneva: World Health Organization, 2014.

Substance use and health: situation in the Region

94 92 90 Prevalence (%)

for alcohol use disorders. However, the sex difference is higher for alcohol consumption than for alcohol use disorders.

88 86 84 82 80 West Bank 2010 Gaza Strip 2010 Morocco 2010

Fig. 7. Proportion of students aged 13–15 years of age who ever used drugs and first used drugs before 14 years of age

3.2.5 Prevalence of drug dependence Table 6 provides the latest estimates for drug dependence in the North Africa and Middle East Region13 and globally. These data are extracted from Degenhardt et al., 2013 and are based on the Global Burden of Disease Study 2010. Estimates are available for cannabis, amfetamine, cocaine and opioid dependence.

Findings • The estimated prevalence for opioid dependence in the North Africa and Middle East Region is 0.29%, which is 1.3 times higher than the global prevalence. • The estimated prevalence for cocaine dependence is 0.14% in this region and 0.1% globally. • Amfetamine dependence is similar to global estimates. • The estimated prevalence for cannabis dependence in this region is 1.4 times lower than the global estimates.

Table 5. Prevalence (%) of alcohol use disorders in population aged 15 years or older by sex, 2010 Eastern Mediterranean Region Female Male Both 0.2 0.6 0.3 World 1.3 7.2 4.1

Findings • The prevalence estimates of alcohol use disorders in the Eastern Mediterranean Region is almost 14 times lower than the global prevalence. • Compared to alcohol consumption estimates, the difference between the regional and global estimates is higher

3.2.6 Mortality estimates Estimates of the number of deaths due to alcohol and drug use disorders are extracted from the WHO Global Health Estimates 2012. Fig. 8 shows the number of deaths per 100 000

Table 6. Estimated number of cases and age-standardized and sex-standardized prevalence of drug dependence in 2010 Prevalence in North Africa and Middle East % (95% UI) Cannabis dependence Amfetamine dependence Cocaine dependence Opioid dependence 0.14 (0.12–0.18) 0.24 (0.20–0.28) 0.14 (0.11–0.17) 0.29 (0.22–0.37) 13

Global prevalence % (95% UI) 0.19 (0.17–0.21) 0.25 (0.22–0.28) 0.10 (0.09–0.11) 0.22 (0.20–0.25)

The North Africa and Middle East Region includes the countries of the WHO Eastern Mediterranean Region with the exceptions of Afghanistan, Djibouti, Pakistan, Somalia and Sudan. Algeria and Turkey are in the North Africa and Middle East Region, but they are not part of the WHO Eastern Mediterranean Region.

Atlas substance use in the Eastern Mediterranean Region 2015

population due to alcohol use disorders and drug use disorders for the Eastern Mediterranean Region and the world. Table 7 provides the number of deaths due to drug use disorders for each country in the Region by sex and age group.

Findings • The number of deaths per 100 000 population in the Eastern Mediterranean Region due to alcohol use disorders is one of the lowest in the world and is 25 times lower than the global estimate. • The number of deaths due to drug use disorders in the Region is 1.82 per 100 000 population, which is 1.4 times higher than the global estimate (i.e. 1.32).

3.2.7 Morbidity estimates Estimates of the number of disability adjusted life years (DALYs) lost due to alcohol and drug use disorders are extracted from the WHO Global Health Estimates 2012. DALYs represent a measure of the disease burden, quantifying the mortality and morbidity due to substance use disorders in a single measure. Fig. 9 provides the number of DALYs due to alcohol use disorders and drug use disorders for the Region and the world. Table 8 provides the number of DALYs per 100 000 population due to drug use disorders for each country in the Eastern Mediterranean Region by sex and age group.

Table 7. Number of deaths per 100 000 population due to drug use disorders by sex and age group, 2012 Age group Female 15–29 Afghanistan Bahrain Djibouti Egypt Islamic Republic of Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Qatar Saudi Arabia Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates Yemen Note: . denotes zero estimated deaths

Male 60–69 2.13 0.57 2.08 5.23 6.22 4.13 0.99 . . 0.33 2.06 . 1.48 . . 2.26 1.57 . 0.34 1.03 4.35 15–29 2.49 0.62 4.37 2.17 8.88 0.84 0.84 1.27 . 0.12 0.94 0.04 1.00 0.02 0.02 7.13 4.13 0.02 0.37 0.51 2.10 30–59 3.92 1.03 4.38 5.42 12.94 3.89 2.08 2.12 0.02 0.50 2.50 0.06 1.75 0.04 0.02 7.37 5.02 0.07 0.85 0.64 4.48 60–69 4.44 2.05 3.95 7.96 13.76 7.55 4.19 4.99 0.07 1.27 3.60 0.13 2.31 0.08 0.06 3.74 3.03 0.15 1.10 2.13 5.59

30–59 2.22 0.10 1.90 1.74 1.66 1.13 0.32 . . 0.09 0.79 . 0.75 . . 2.04 1.56 . 0.11 0.07 1.89

1.66 0.02 1.39 0.29 0.49 0.19 0.07 . . 0.02 0.18 . 0.43 . . 1.41 1.01 . 0.02 0.02 0.57

Substance use and health: situation in the Region

Number of DALYs per 100 000 population Alcohol use disorders Drug use disorders World

Number of deaths per 100 000 population

2.0

500 400 300 200 100 0

1.5

1.0

0.5

0.0

Alcohol use disorders

Drug use disorders World

Eastern Mediterranean Region

Fig. 8. Number of deaths per 100 000 population due to alcohol and drug use disorders, both sexes, all ages, 2012

Fig. 9. Number of DALYs per 100 000 population due to alcohol and drug use disorders, both sexes, all ages, 2012

Table 8. Number of DALYs per 100 000 population due to drug use disorders by sex and age group, 2012 Age group Female 15–29 Afghanistan Bahrain Djibouti Egypt Islamic Republic of Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Qatar Saudi Arabia Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates Yemen 237.34 153.95 203.33 163.18 171.71 145.97 143.68 154.14 130.38 145.91 150.19 148.27 158.36 164.29 143.64 201.60 174.40 137.90 139.82 163.25 169.27 30–59 235.33 152.99 189.41 211.98 208.25 188.60 158.93 164.41 124.00 150.07 165.32 164.56 158.54 173.54 146.84 190.30 171.04 137.94 131.20 197.93 223.48 60–69 70.48 27.01 66.68 155.75 183.11 124.93 37.82 12.03 9.80 19.82 67.89 10.83 51.73 12.42 10.56 71.72 52.30 10.54 20.10 42.35 131.19 15–29 543.51 618.52 637.50 618.51 1120.98 482.02 514.29 628.21 435.75 485.41 527.48 585.32 467.62 662.80 512.20 797.34 596.19 444.49 479.31 667.49 556.47 Male 30–59 457.20 373.57 425.00 538.53 948.97 485.53 409.37 446.30 253.20 330.39 395.82 391.89 343.24 386.70 327.96 580.49 458.91 298.44 300.56 497.12 522.30 60–69 152.18 82.66 128.66 249.25 414.47 236.58 141.36 171.51 24.79 61.23 128.52 30.33 90.58 32.68 29.39 123.24 102.93 28.68 55.32 92.35 180.65

Atlas: substance use in the Eastern Mediterranean Region 2015

Findings • The estimated number of DALYs due to alcohol use disorders is 36 per 100 000 population in the Region, which is almost 13 times lower than the global average of 454. • The estimated number of DALYs per 100 000 population due to drug use disorders is 253, which is almost 1.18 times higher than the global average of 215.

4. Country responses to the Atlas questionnaire 4.1 Leadership and governance 4.1.1 Government unit/official for prevention/treatment

use (63%) or treatment of substance use disorders (75%). • Three countries reported having no unit/ official responsible for prevention of substance use. • Among countries with a unit/official responsible for alcohol and drugs together, the majority reported that this unit/official is also responsible for mental health policies. Two countries (14%) reported that this unit/official is responsible for substance use policies only.

4.1.2 Ministry with primary responsibility for prevention/treatment

Background Respondents were asked to indicate the ministry taking primary responsibility regarding prevention of substance use and/or treatment of substance use disorders (Fig. 12).

Background Respondents were asked about the presence of a government unit/official responsible for a policy regarding prevention of substance use*14 and/ or treatment of substance use disorders*. They were also asked to specify whether alcohol and drug policies were under the same government unit/official (Fig. 10). If there was a government unit/official for prevention of substance use or treatment of substance use disorders, respondents were requested to indicate if this unit was also responsible for other areas, such as mental health, tobacco, noncommunicable diseases, health promotion and criminal justice (Fig. 11).

Findings • The ministry of health was reported as being responsible for prevention and 100 90 Percentage of countries

80 70 60 50 40 30 20 10 0 Treatment (n = 20) Prevention (n = 22)

Findings • Most countries in the Eastern Mediterranean Region have a unit/official responsible for prevention of substance

Unknown None Two separate units/ofﬁcials for alcohol and drugs One unit/ofﬁcial for drugs only One unit/ofﬁcial for alcohol and drugs

 The terms followed by an asterisk are defined in the glossary.

Fig. 10. Government unit/official responsible for prevention/treatment of substance use

Country responses to the Atlas questionnaire

80 70 Percentage of countries

60 50 40 30 20 10 0 Mental health Tobacco Health promotion Noncommunicable diseases Gambling Behavioural addictions Criminal justice None

Prevention (n = 14)

Treatment (n = 15)

Fig. 11. Areas under responsibility of the government unit/official responsible for alcohol and drugs together

treatment by the majority of the countries of the Eastern Mediterranean Region. • The ministries of interior, education and social welfare were also reported as being responsible for prevention of alcohol and drug use, but were less often reported as being responsible for treatment.

Notes and comments • This question asked for the ministry that takes primary responsibility for prevention and/or treatment. It was allowed to select a maximum of two ministries if responsibilities were equally shared. However, some countries selected more than two ministries, particularly for prevention.

100 80 60 40 20 0

Percentage of countries

Ministry of health

Ministry of interior

Ministry of social welfare

Ministry of education

Ministry of justice

Ofﬁce of the prime minister/ president

Other

Prevention – alcohol (n = 19)

Treatment – alcohol (n = 20)

Prevention – drugs (n = 19)

Treatment – drugs (n = 20)

Fig. 12. Ministry with primary responsibility for prevention/treatment

Atlas: substance use in the Eastern Mediterranean Region 2015

• Two countries reported that there is no ministry that is responsible for treatment of alcohol use disorders. • Other ministries, such as the ministry of sports affairs and the ministry of religious affairs were reported as being responsible for treatment of drug use disorders.

Findings • Representatives of nongovernmental organizations were reported to be involved in the development and formulation of policies and strategies regarding prevention and treatment by most of the countries of the Eastern Mediterranean Region. • 40% of the countries reported that representatives of youth organizations were involved in the development and formulation of policies and strategies regarding prevention. • 40% of the countries reported that representatives of drug users, patients and/or family members were involved in the development and formulation of policies and strategies regarding treatment. • Most countries reported that representatives of nongovernmental organizations were involved in the development and implementation of national programmes regarding prevention and treatment.

4.1.3 Stakeholder involvement in policies, strategies and national programmes

Background Nominated focal points were requested to indicate whether representatives of affected and targeted populations were regularly involved in the development and formulation of policies and strategies, as well as in the development and implementation of national programmes. Representatives of affected and targeted populations included representatives of youth organizations, of drug users, of patients and of family members of patients. They were also requested to indicate whether representatives of nongovernmental organizations and representatives of economic operators (including the alcohol, tobacco and pharmaceutical industries) were involved (Fig. 13 and 14). 80 70 Percentage of countries

60 50 40 30 20 10 0 Nongovernmental organizations Youth organizations Prevention (n = 12) Drug users, patients and/ or their family members Treatment (n = 10) Economic operators

Fig. 13. Stakeholders involvement in development and formulation of policies and strategies

Country responses to the Atlas questionnaire

100 80 60 40 20 0 Nongovernmental organizations Drug users, patients and/ or their family members Prevention (n = 12) Youth organizations Economic operators

Percentage of countries

Treatment (n = 9)

Fig. 14. Stakeholders involvement in development and implementation of national programmes

Notes and comments • Between nine and 12 countries provided responses to these questions because such policies, strategies or national programmes do not exist.

Findings • Government resources for prevention of drug use have overall increased (either slightly or significantly) in most countries of the Eastern Mediterranean Region. • One country reported that government resources for prevention and treatment of both alcohol and drug use disorders have significantly decreased due to an ongoing war. • Between 10% and 27% of countries of the Region reported that the changes to the allocation of government resources for prevention or treatment of alcohol and drug use disorders are unknown. • Overall, international cooperation in prevention of drug use and treatment of drug use disorders has increased (either slightly or significantly) in the majority of countries.

4.1.4 Five-year change in resources and international cooperation in prevention/treatment

Background Respondents were asked to indicate the change in government resources (financial or human resources) and international cooperation in prevention of substance use and treatment of substance use disorders over the past five years. It refers to the past five years because two important documents were adopted and published prior to 2010. Indeed, in 2009 Member States of the United Nations adopted the Political Declaration and Plan of Action on International Cooperation towards an Integrated and Balanced Strategy to Counter the World Drug Problem, and in 2010, the World Health Assembly endorsed the Global strategy to reduce the harmful use of alcohol15(Fig. 15 and 16). 15

Notes and comments • Between three and six countries responded “not applicable” for the changes to the allocation of government resources for prevention and treatment of alcohol or drug use disorders. These results are not displayed on the graph. 19

 Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization, 2010.

Atlas: substance use in the Eastern Mediterranean Region 2015

50 40 30 20 10 0

Percentage of countries

Prevention – alcohol (n = 22)

Treatment – alcohol (n = 20) Decreased No change

Prevention – drugs (n = 22) Increased Unknown

Treatment – drugs (n = 20)

Fig. 15. Changes to the allocation of government resources in the last five years

• Between one and five countries responded “not applicable” for the changes in international cooperation in prevention and treatment of alcohol or drug use disorders. These results are not displayed on the graph.

4.1.5 Confidentiality of people in treatment

Background Nominated focal points were asked to indicate if there exists a law or a legal regulation at the national or subnational level which protects the confidentiality of people in treatment for alcohol and drug use disorders (Fig. 17).

80 70 Percentage of countries

60 50 40 30 20 10 0 Prevention – alcohol (n = 21) Treatment – alcohol (n = 19) No change Prevention – drugs (n = 21) Unknown Treatment – drugs (n = 19)

Increased

Fig. 16. Changes in international cooperation in the last 5 years

Country responses to the Atlas questionnaire

100 90 Percentage of countries

80 70 60 50 40 30 20 10 0 For people with alcohol use disorders (n = 22) Unknown No

4.1.6 Voluntary treatment as an alternative/in addition to criminal sanctions

Background Respondents were asked to report on the existence of legislative or administrative provisions (at the national or subnational level) for offering voluntary treatment as an alternative to or in addition to criminal sanctions for people with substance use disorders who come into contact with the criminal justice system (Fig. 18). Countries of the Eastern Mediterranean Region that reported having such legislative or administrative provisions were then asked whether a policy of encouraging voluntary treatment as an alternative to or in addition to criminal sanctions exists at the national or subnational level (Fig. 19).

For people with drug use disorders (n = 21) Yes

Fig. 17. Existence of a law or legal regulation for protecting the confidentiality of people in treatment

Findings • The majority of the countries of the Region reported having a law or legal regulations to protect the confidentiality of people in treatment for alcohol or drug use disorders.

Findings • The existence of legislation for offering voluntary treatment for drug use disorders was reported by most countries of the Region.

100 80 60 40 20 0

Percentage of countries

As an alternative for alcohol use disorders (n = 21)

In addition for alcohol use disorders (n = 18) Yes No

As an alternative for drug use disorders (n = 20) Unknown

In addition for drug use disorders (n = 18)

Fig. 18. Existence of legislative or administrative provision for offering voluntary treatment for substance use disorders as an alternative in addition to criminal sanctions

Atlas: substance use in the Eastern Mediterranean Region 2015

100 80 60 40 20 0

Percentage of countries

As an alternative for alcohol use disorders (n = 12)

In addition for alcohol use disorders (n = 12) Yes No

As an alternative for drug use disorders (n = 13) Unknown

In addition for drug use disorders (n = 12)

Fig. 19. Existence of a policy of encouraging voluntary treatment as an alternative and/or in addition to criminal sanctions

• Half of the countries reported having legislation for offering voluntary treatment for alcohol use disorders. • Among the countries with legislation for offering voluntary treatment, half of them have a policy of encouraging voluntary treatment for drug use disorders as an alternative to criminal sanctions.

• More than one-third of countries reported having a mechanism for compulsory treatment for alcohol use disorders in addition to criminal sanctions.

4.1.8 Drug courts

Background Respondents were asked to report on the existence of a system of drug courts*.

4.1.7 Compulsory treatment as an alternative in addition to criminal sanctions

Findings • The majority of the countries of the Eastern Mediterranean Region (77%) reported having no system of drug courts. • Three countries (13%) reported having a system of drug courts.

Background Respondents were asked to report on the existence of a mechanism for compulsory treatment as an alternative in addition to criminal sanctions for people with substance use disorders who come into contact with the criminal justice system (Fig. 20).

4.2 Financing 4.2.1 Budget line for prevention/ treatment

Findings • The majority of the countries of the Eastern Mediterranean Region reported having a mechanism for compulsory treatment for drug use disorders in addition to criminal sanctions.

Background Respondents were asked to indicate all of the ministries with a specific budget line* for prevention of substance use and/or for treatment of substance use disorders (Fig. 21).

Country responses to the Atlas questionnaire

100 80 60 40 20 0

Percentage of countries

As an alternative for alcohol use disorders (n = 20)

In addition for alcohol use disorders (n = 19) Yes No

As an alternative for drug use disorders (n = 20) Unknown

In addition for drug use disorders (n = 19)

Fig. 20. Existence of a mechanism of compulsory treatment as an alternative and/or in addition to criminal sanctions

80 70 Percentage of countries

60 50 40 30 20 10 0 Ministry of health Ministry of social welfare Ministry of justice Ofﬁce of the prime minister/ president Ministry of education Ministry of interior No speciﬁc budget line

Prevention (n = 21)

Treatment (n = 19)

Fig. 21. Ministries with (a) specific budget line(s) for prevention/treatment of substance use disorders

If the ministry of health was reported as having a specific budget line, respondents were requested to report on the other areas also covered by this budget line (Fig. 22).

Findings • The ministry of health was reported by the majority of the countries of the Eastern Mediterranean Region as having a

budget line for prevention and treatment of substance use disorders. • 19% of the countries reported having no specific budget line for prevention of substance use. • 15% of the countries reported having no specific budget line for treatment of substance use disorders.

Atlas: substance use in the Eastern Mediterranean Region 2015

100 80 60 40 20 0

Percentage of countries

Mental health Prevention – alcohol (n = 12)

Tobacco

Health promotion

Noncommunicable diseases

Stand-alone budget line Treatment – drugs (n = 13)

Treatment – alcohol (n = 12)

Prevention – drugs (n = 12)

Fig. 22. Areas included in the budget line(s) for prevention and treatment of substance use at the Ministry of Health

• Among the countries with a specific budget line at the ministry of health, all of them reported that this budget line also covered mental health. • Among the countries with a specific budget line at the ministry of health, 16% reported having a stand-alone budget line for prevention of drug use and 15% reported having a stand-alone budget line for treatment of drug use disorders.

services for substance use disorders. For each treatment service, it was asked to select one of the following financing methods: government financing*, employer financing*, household financing*, nongovernmental organization and other external financing*, or Global Fund financing (Fig. 23 and 24).

Findings • The majority of the countries of the Eastern Mediterranean Region reported that government financing is the main financing methods for treatment services for alcohol and drug use disorders. • Between 18% and 31% (depending on the treatment services) of countries reported that direct out-of-pocket payment is the main financing method for treatment for alcohol use disorders.

Notes and comments • Two countries reported that the ministry of health has a specific budget line for treatment of drug use disorders. • One country reported that the ministry of health has a specific budget line for prevention of drug use. • Two countries reported that the ministry of the interior has a specific budget line for prevention of drug use.

Notes and comments • The response rate to this question varied between 31% and 81% because some treatment services are not available in some countries, such as opioid agonist maintenance therapy or outpatient detoxification for alcohol use disorders.

4.2.2 Financing methods for treatment services

Background Respondents were requested to indicate the main financing method for different treatment

Country responses to the Atlas questionnaire

100 80 60 40 20 0

Percentage of countries

Outpatient detoxiﬁcation* (n = 13)

Inpatient detoxiﬁcation* (n = 16) Government ﬁnancing Households

Outpatient treatment* (n = 16)

Inpatient treatment* (n = 16) Global Fund ﬁnancing Other

Rehabilitation* (n = 14)

Nongovernmental organization and other external ﬁnancing

Fig. 23. Main financing method for treatment services for alcohol use disorders

100 80 60 40 20 0 Outpatient detoxiﬁcation* (n = 16) Inpatient detoxiﬁcation* (n = 17) Outpatient treatment* (n = 18) Inpatient treatment* (n = 17) Rehabilitation* (n = 15) Opioid agonist maintenance therapy (n = 8)

Percentage of countries

Government ﬁnancing Households Nongovernmental organization and other external ﬁnancing

Global Fund ﬁnancing Other

Fig. 24. Main financing method for treatment services for drug use disorders

• The question asked for the main financing method for each treatment service, and for some respondents, it was not possible to report a single financing method.

Indeed, countries combine several methods to fund treatment for substance use disorders.

Atlas: substance use in the Eastern Mediterranean Region 2015

4.2.3 Hypothecated taxes

Findings • The majority of the countries of the Eastern Mediterranean Region reported that people with substance use disorders are not eligible to receive government benefits of any form. • However, 27% of the countries reported that people with substance use disorders are eligible to receive government benefits in the form of monetary support.

Background Respondents were asked about hypothecated taxes* designated to be spent on treatment and prevention of substance use disorders.

Findings • More than 81% of the countries of the Eastern Mediterranean Region reported having no hypothecated taxes designated specifically to be spent on the treatment and prevention of substance use disorders. • One country reported having hypothecated taxes designated to be spent on the prevention and treatment of substance use disorders.

4.3 Service organization and delivery 4.3.1 Treatment sectors and providers 4.3.1.1 Main sector for treatment services

4.2.4 Social support

Background Respondents were asked to indicate in what sector the majority of the people receive treatment services for substance use disorders. For each treatment service, they were asked to select one of the following sectors: public health sector, private health sector, public social care sector, private social care sector, criminal justice sector and nongovernmental organizations (Fig. 26 and 27).

Background Respondents were asked whether people with substance use disorders were eligible to receive government benefits, either monetary (e.g. disability payment or income support) or nonmonetary (e.g. housing support, access to employment, educational assistance, subsidies for food) (Fig.25). 100 80 60 40 20 0 Monetary support for people with alcohol use disorders (n = 22) Nonmonetary support for people with alcohol use disorders (n = 20) Yes

Percentage of countries

Monetary support for people with drug use disorders (n = 22) No Unknown

Nonmonetary support for people with drug use disorders (n = 21)

Fig. 25. Government benefits for people with substance use disorders

Country responses to the Atlas questionnaire

Findings • The public health sector was reported by the majority of the countries of the Eastern Mediterranean Region to be 100 80 60 40 20 0

the main sector for providing treatment services for alcohol and drug use disorders.

Percentage of countries

Outpatient detoxiﬁcation* (n = 17)

Inpatient detoxiﬁcation* (n = 19)

Outpatient treatment* (n = 19)

Inpatient treatment* (n = 19) Criminal justice sector Nongovernmental organizations Other

Rehabilitation* (n = 17)

Public health sector Private health sector Public social care sector Private social care sector

Fig. 26. Main sector providing treatment services for alcohol use disorders

100 80 60 40 20 0

Percentage of countries

Outpatient detoxiﬁcation* (n = 15)

Inpatient detoxiﬁcation* (n = 18)

Outpatient treatment* (n = 18)

Inpatient treatment* (n = 18)

Rehabilitation* (n = 15)

Opioid agonist maintenance therapy (n = 13)

Public health sector Private health sector Public social care sector Private social care sector

Criminal justice sector Nongovernmental organizations Other

Fig. 27. Main sector providing treatment services for drug use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Notes and comments • The response rate to this question varied between 59% and 86% because some treatment services are not available, such as opioid agonist maintenance therapy and outpatient detoxification. • Moreover, the question asked for the sector in which the majority of the people received treatment services, and for some respondents it was not possible to report a single sector as the main provider. Countries appear to use different sectors for providing treatment services. 4.3.1.2 Main providers of treatment services

Mediterranean Region to be the main provider of treatment services for alcohol use disorders. • Stand-alone treatment facilities were reported as the main provider of treatment services for drug use disorders by more than 44% of the countries of the Region. • Mental health facilities were reported as the second main provider of treatment services for drug use disorders by 39% of the countries of the Region.

Notes and comments • Not all of the countries which responded to the question provided responses to ranks four and five. Thus, the response rate for these ranks is lower than for the first three ranks. 4.3.1.3 Specialized treatment facilities for substance use disorders

Background Respondents were asked to select the five main providers for treatment services for substance use disorders. The most important treatment provider was defined in terms of coverage of the target population (Fig. 28 and 29).

Findings • Mental health facilities were reported by 47% of the countries of the Eastern 50 40 30 20 10 0

Background Respondents were asked if there are privately or publicly funded specialized treatment facilities*16 for substance use disorders in

Percentage of countries

Mental health facilities

Stand-alone Mental health treatment facilities services Ranked ﬁrst Ranked second

General hospitals Ranked third

Other health care facilities

General health services

Community-based self-support groups

Ranked fourth

Ranked ﬁfth

Fig. 28. Ranking of the most important providers for treatment services for alcohol use disorders (n = 17) 16

 Specialized facilities designed and designated for treatment of substance use disorders. This category also includes mental health care facilities that offer specialized treatment for substance use disorders.

Country responses to the Atlas questionnaire

different regions in the country, such as the capital city, other major cities*, or in other areas* (Fig. 30).

Findings • The majority of the countries of the Eastern Mediterranean Region reported having publicly funded specialized treatment facilities for substance use disorders in the capital city.

• 28% of the countries of the Region reported having publicly funded specialized treatment facilities for substance use disorders in areas of the country other than the capital city or other major cities.

Notes and comments • The response rate for private facilities is lower than for public facilities as data may be less available.

50 40 30 20 10 0

Percentage of countries

Stand-alone Mental health treatment facilities facilities Ranked ﬁrst

General hospitals Ranked second

Mental health services Ranked third

Other health care facilities

General health services

Community-based self-support groups

Ranked fourth

Ranked ﬁfth

Fig. 29. Ranking of the most important providers for treatment services for drug use disorders (n = 18)

80 70 Percentage of countries

60 50 40 30 20 10 0 Public (n = 22) Private (n = 16)

In other major cities

In the capital city

In other areas

None

Unknown

Fig. 30. Specialized treatment facilities for substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

4.3.1.3 Standards of treatment and care for specialized treatment services

Findings • Cannabis and opioids are reported by 27% of the countries as the main substances that are reported at treatment entry and by 22% of the countries as the second main substances reported at treatment entry. • Sedatives, anxiolytics and sleeping pills are reported by 45% of the countries as the third main substances reported at treatment entry.

Background Respondents were asked about the existence of national standards of treatment and care for the public specialized treatment services.

Findings • 41% of the countries of the Eastern Mediterranean Region reported having national standards of treatment and care for public specialized treatment facilities. • 54% of the countries of the Region reported having no national standards of treatment and care for public specialized treatment facilities.

Notes and comments • Not all of the countries which responded to the question provided responses to rank four and five. Thus, the response rate for these ranks is lower than for the first three ranks. 4.3.2.2 Number of beds for substance use disorders

4.3.2 Beds, treatment episodes and treatment coverage 4.3.2.1 Main substances reported at treatment entry

Background Respondents were asked to report on the total number of beds available for inpatient treatment of substance use disorders in general health care facilities, mental health care

Background Respondents were asked about the five main substances that are most commonly reported as being the main drug at treatment entry (i.e. primary diagnosis) (Fig. 31). 50 40 30 20 10 0

Percentage of countries

Opioids

Cannabis

Alcohol

Sedatives, anxiolytics and sleeping pills

ATS

Ranked ﬁrst

Ranked second

Ranked third

Ranked fourth

Ranked ﬁfth

Fig. 31. Ranking of the main substances that are most commonly reported at treatment entry (n = 22)

Country responses to the Atlas questionnaire

facilities and specialized health care facilities17, either publicly or privately funded (Table 9).

Findings • Overall, the number of treatment episodes for substance use disorders is 9.17 per 100 000 population.

Findings • Overall, the median number of beds for substance use disorders is 0.73 per 100 000 population.

Notes and comments • Only 10 countries provided data on the number of treatment episodes for substance use disorders. 4.3.2.4 Treatment coverage for substance dependence

Notes and comments • Only 13 countries provided data on the number of beds for treatment of substance use disorders. 4.3.2.3 Number of treatment episodes for substance use disorders

Background Respondents were asked to indicate the treatment coverage, i.e. the proportion of people with alcohol dependence, opioid dependence, cocaine dependence or cannabis dependence (including those who are not seeking treatment) that are in contact with treatment services18 (Fig. 32).

Background Respondents were asked about the total number of treatment episodes in specialized treatment facilities for substance use disorders during the most recent year for which data were available (Table 10).

Table 9. Bed availability for inpatient treatment of substance use disorders Median number of beds (per 100 000 population) for treatment of substance use disorders Public general health care facilities (n = 2) Public mental health care facilities (n = 3) Private mental health care facilities (n = 1) Public specialized health care facilities (n = 10) 4

1.11 0.17 0.92 0.80 0.70 1.33 0.73

Private specialized health care facilities1 (n = 2) Other public health care facilities (n = 2) Total (n = 13)

Table 10.Total number of treatment episodes Number of treatment episodes for substance use disorders Public outpatient specialized health care facilities (n = 7) Public inpatient specialized health care facilities (n = 7) Private inpatient specialized health care facilities (n = 3) Other publicly funded facilities (n = 1) Other privately funded facilities (n = 1) Total (n = 10) 17

31.97 9.22 3.10 9.17 608.25 9.17 18

 For this question, this includes specialized health care facilities for substance use disorders only and does not include specialized mental health care facilities that offer specialized treatment for substance use disorders

 Here defined as currently receiving treatment or in remission or relapse, but still in contact with treatment services.

Atlas: substance use in the Eastern Mediterranean Region 2015

Findings • Between 45 and 52% (depending on the substance dependence) of the countries of the Eastern Mediterranean Region reported that the treatment coverage for substance dependence is unknown. • 27% of the countries of the Region reported that the treatment coverage for alcohol dependence is very limited. 120 100 Percentage of countries

4.3.2.5 Access to treatment for substance dependence

Background Respondents were asked about the proportion of people who seek treatment for substance dependence that receive such treatment19 (Fig. 33).

80 60 40 20 0 Opioid dependence (n = 19) Unknown Cannabis dependence (n = 18) High (more than 40%) Very limited (approx. 1%–10%) Cocaine dependence (n = 18) Substantial (21%–40%) Alcohol dependence (n = 20) Limited (1%–20%)

Close to none (around 0%)

Fig. 32. Treatment coverage for substance dependence

100 Percentage of countries

80 60 40 20 0 Opioid dependence (n = 17) Cannabis dependence (n = 16) Unknown 99%–100% Cocaine dependence (n = 14) 90%–98% 1%–10% Alcohol dependence (n = 18)

50%–90%

21%–50%

11%–20%

Fig. 33. Proportion of people who seek treatment and receive treatment 19

 Here defined as commencing treatment. If the person leaves treatment of their own accord they are not considered as demanding.

Country responses to the Atlas questionnaire

Findings • Between 23% and 40% (depending on the substance dependence) of the countries of the Eastern Mediterranean Region reported that the proportion of people who seek treatment and receive treatment for substance dependence is unknown. • 19% of the countries of the Region reported that the proportion of people who seek treatment and receive treatment for opioids and cannabis dependence is very low, i.e. 1% to 10%.

• Two countries of the Region reported having guidelines on pharmacological treatment only for drug use disorders. 4.3.3.2 Pharmacotherapy

Background Respondents were asked whether opioid agonist pharmacotherapy with methadone, buprenorphine and buprenorphine/naloxone is used for detoxification and maintenance treatments (Fig. 34 and 35).

4.3.3 Pharmacological treatment 4.3.3.1 Guidelines on pharmacological treatment

Findings • The majority of the countries of the Eastern Mediterranean Region reported that opioid agonist pharmacotherapy is not available. 4.3.3.3 Medications

Background Respondents were asked if there are guidelines on the pharmacological treatment of substance use disorders (alcohol and/or drug use disorders).

Background Respondents were asked about the registration of specific medications in their country, their availability for use in publicly funded treatment services and whether outpatient dosing is supervised20 (Fig. 36–38). 100 90 Percentage of countries

Findings • Half of the countries of the Eastern Mediterranean Region reported having guidelines on pharmacological treatment for substance use disorders. 100 90 Percentage of countries

80 70 60 50 40 30 20 10 0 Methadone (n = 22) Buprenorphine (n = 22) No Yes

Buprenorphine/ naloxone (n = 22)

Fig. 35. Availability of pharmacotherapies for maintenance treatment of opioid dependence 20

Fig. 34. Availability of pharmacotherapies for detoxification treatment of opioid dependence

 Refers to whether outpatients are required to have doses supervised daily unless an individual assessment determined that daily supervision of dosing is not necessary. In supervised methadone treatment, for example, patients come each day for their dose at the beginning of treatment until they are assessed as suitable to receive take-home methadone.

Atlas: substance use in the Eastern Mediterranean Region 2015

34 D iaz ep a m fo r alc Percentage of countries

iaz ep Percentage of countries

iaz ep am

D iaz ep am fo r

fo r

fo ra

lco ho

100

nz od ia

ith

be nz od iaz ep ine wi th dr aw al Cl on idi aw al wi th dr

oh ol

100

aw a

th dr

aw a

Fig. 36. Registration of medications (n = 22)

Unknown

Bu No

pr en

or ph Yes

alo xo n

Bu p

ine

re no r

/n alo xo

on id

ine

Yes

ine

(ta

alo xo

ble

ts)

(ﬁ

)

N alt re xo n

M et ha

(li

alt

re x

fo ra

id)

(ta

on e

lco ho

fo r

ble t

io id

nc y

Fig. 37. Availability of medications in publicly funded treatment services (n = 22) ne N alo xo ne Bu pr en or M ph et ine ha do ne (ta N alt ble M re e ts) th xo ad ne o ne fo ra N (li alt qu lco re id) ho xo l de ne pe fo nd ro Bu en pio pr cy en id or d e ph p en ine de /n nc Bu alo y pr x on en e or (ta ph ble ine ts) /n alo xo ne (ﬁ lm ) D isu lﬁr am Ac am pr os at e Lo fex idi ne

pe n

pr en

ph ine

fex

idi

pr os at

isu

lﬁr

Country responses to the Atlas questionnaire

100 80 60 40 20 0 ts) cy l nz od iaz wi epin th dr e aw al wi th dr aw a ine lm id) ts) (li qu de n ble ble ph (ﬁ isu lﬁ D or (ta (ta ne en ra m ) e

Percentage of countries

re n

alo xo

do n

Bu p

alo xo

do n

M et ha

alc oh

M et ha

fo r

ine

fo r

iaz ep

re n

iaz ep

re n

Bu p

Unknown

Yes

Fig. 38. Supervision of dosing for outpatient treatment (n = 22)

Findings • The following substances are available in the majority of the countries of the Eastern Mediterranean Region: diazepam for alcohol or benzodiazepine withdrawal, clonidine for opioid withdrawal, and naloxone for opioid overdose. • Diazepam and naloxone are available in publicly funded treatment services in more than 50% of the countries of the Region.

4.3.4 Special programmes and services 4.3.4.1 HIV and hepatitis C testing and treatment in specialized facilities and services for substance use disorders

Background Respondents were asked to report on the percentage of the total specialized facilities and services for substance use disorders that provide HIV and hepatitis C testing, counselling and treatment (Fig. 39 and 40).

Notes and comments • Not all of the countries that responded to the question provided responses for all of the mentioned medications. Thus, the response rate for some medications is lower than for others.

Findings • 33% of the countries of the Eastern Mediterranean Region reported that most of the specialized treatment facilities for substance use disorders provide HIV and hepatitis C testing and counselling as well as HIV treatment. • 37% of the countries of the Region reported that a few of the specialized treatment facilities for substance use disorders provide hepatitis vaccination. 35

N alt re x

Bu p

fo r

de p

Atlas: substance use in the Eastern Mediterranean Region 2015

100 90 Percentage of countries

80 70 60 50 40 30 20 10 0 HIV testing and counselling (n = 21) Unknown Most (61%–100%) Some or many (11%–60%) HIV (ARV) treatment (n = 18) Few (1%–10%) None

80 70 60 50 40 30 20 10 0 Hepatitis testing and counselling (n = 21) Hepatitis vaccination (n = 16) Hepatitis treatment (n = 16) Few (1%–10%) None

Unknown Most (61%–100%) Some or many (11%–60%)

Fig. 39. Percentage of the total number of specialized facilities and services for substance use disorders that provide HIV testing, counselling and treatment

Fig. 40. Percentage of the total number of specialized facilities and services for substance use disorders that provide hepatitic testing, counselling, vaccination and treatment

Notes and comments • The response for hepatitis vaccination and hepatitis treatment was lower than for the other items. 4.3.4.2 Availability of programmes

• 31% of the countries of the Region reported having condom distribution programmes. 4.3.4.3 Special treatment programmes for women with substance use disorders

Background Nominated focal points were requested to report whether the following programmes are readily21 available: needle/syringe exchange programmes, outreach services for injecting drug users, “drop-in” services, naloxone distribution and condom distribution (Fig. 41).

Background Respondents were asked about the existence of special treatment programmes for women with substance use disorders in different parts of the country (Fig. 42).

Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no special treatment programmes for women with substance use disorders.

Findings • Needle/syringe exchange programmes are reported to be available by 33% of the countries of the Eastern Mediterranean Region.

In this context means for the majority of the (specific) population irrespective of insurance status and place of residence and in a reasonable time period.

Country responses to the Atlas questionnaire

100 80 60 40 20 0

Percentage of countries

Needle/syringe exchange programmes (n = 21)

Outreach services for injecting drug users (n = 20)

“Drop-in” services (n = 20) No Yes

Naloxone distribution programmes (n = 19)

Condom distribution programmes (n = 22)

Unknown

Fig. 41. Availability of harm reduction programmes

80 70 Percentage of countries

60 50 40 30 20 10 0 For women with alcohol use disorders (n = 21) In the capital city In other major cities For women with drug use disorders (n = 21) In other areas None

Fig. 42. Special treatment programmes for women with substance use disorders

4.3.4.4 Special treatment programmes for children and adolescents with substance use disorders

Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no special treatment programmes for children and adolescents with substance use disorders.

Background Respondents were asked about the existence of special treatment programmes for children and adolescents with substance use disorders in different parts of the country (Fig. 43).

Atlas: substance use in the Eastern Mediterranean Region 2015

80 70 Percentage of countries

60 50 40 30 20 10 0 For children and adolescents with alcohol use disorders (n = 19) In the capital city For children and adolescents with drug use disorders (n = 19) In other major cities None

Fig. 43. Special treatment programmes for children and adolescents with substance use disorders

4.3.4.5 Special programmes for gambling disorders

programmes for people with gambling disorders. 4.3.4.6 Special housing services

Background Respondents were asked about the existence of special treatment programmes for people with gambling disorders in different parts of the country.

Background Respondents were asked about the existence of special housing services for people with substance use disorders as part of the treatment and rehabilitation process.They were requested to indicate the location of these services, i.e. in the capital city, in other major cities or in other areas (Fig. 44).

Findings • No country of the Eastern Mediterranean Region reported having special treatment

100 80 60 40 20 0 For people with alcohol use disorders (n = 22) In the capital city In other major cities For people with drug use disorders (n = 22) None

Fig. 44. Special housing services for people with substance use disorders

Percentage of countries

Country responses to the Atlas questionnaire

Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no special housing services for people with substance use disorders. 4.3.4.7 Employment services

on the existence of telephone help-lines, web-based interventions or mobile phonebased interventions for alcohol and drug use (Fig. 46 and 47).

Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no open access interventions for alcohol or drug use. • Telephone help-lines for drug use were reported by 28% of the countries of the Region. • Telephone help-lines for alcohol use were reported by 23% of the countries. 4.3.4.9 Mutual support/self-help groups

Background Respondents were asked about the existence of employment services for people with substance use disorders as part of the treatment and rehabilitation process. They were requested to indicate the location of these services, i.e. in the capital city, in other major cities or in other areas (Fig. 45).

Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no employment services for people with substance use disorders. 4.3.4.8 Open access interventions

Background Respondents were asked about the availability of mutual support/self-help groups* in different parts of the country (Fig. 48).

Findings • The majority of the countries of the Eastern Mediterranean Region reported that Narcotics Anonymous, Cocaine Anonymous, Al-Anon/Alateen and family support groups are not available.

Background Respondents were asked to report on the availability of open access interventions for addressing substance use disorders in their country. They were asked to report 100 80 60 40 20 0 For people with alcohol use disorders (n = 20) In the capital city

Percentage of countries

For people with drug use disorders (n = 21) None

In other major cities

Fig. 45. Employment services for people with substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

100 90 Percentage of countries

80 70 60 50 40 30 20 10 0 Telephone help-lines (n = 21) Web-based interventions (n = 20) No Mobile phonebased interventions (n = 20) Yes

80 70 60 50 40 30 20 10 0 Telephone help-lines (n = 21) Web-based interventions (n = 21) Unknown No Mobile phonebased interventions (n = 21) Yes

Unknown

Fig. 46. Open access interventions for alcohol use

Fig. 47. Open access interventions for drug use

• 35% of the countries of the Region reported that Narcotics Anonymous is available in the capital city or other major cities in the country. • 31% of the countries reported that Alcoholics Anonymous is available in the capital city or other major cities in the country.

4.3.5 Prevention 4.3.5.1 Prevention programmes

Background Respondents were required to indicate the existence of different tools/programmes for prevention of substance use and substance use disorders. They were also requested to indicate the estimated coverage of the target population for each tool/programme (Fig. 49–51).

100 80 60 40 20 0

Percentage of countries

Narcotics Anonymous (n = 20)

Alcoholics Anonymous (n = 22)

Family support groups (n = 18)

Al-Anon/Alateen (n = 16) None

Cocaine Anonymous (n = 17)

In the capital city

In other major cities

In other areas

Unknown

Fig. 48. Availability of mutual support/self-help groups

M Percentage of countries

as sm 100 20 40 60 80 0

M as ed ia (a ud io vis ua l) Percentage of countries

ed ia Ad ve rt ise m en ts in pu bli cp lac es

io vis

as s

m M as sm ed ia (p rin t) ho o l( m an ua l) -b as ed pr og ra m m es pr og W or kp lac

Ad Sc

ve r

tis em

rin

Fig. 49. Availability of prevention programmes for alcohol and drugs

Very high (61%–100%) Co m m un ity -b as ed Drugs (n = 22)

bli

m un

ity -b

lac es

as e

ol (

pr og

High (31%–60%) e

an ua l)-

se d

m m es pr og Pa Se rv ing s

Fig. 50. Coverage of prevention programmes for alcohol use (n = 19) Alcohol (n = 19)

rv ing

pr og r

sta

ff t

ini

m m es re nt pr og ta ff tra

pr og

Some (1%–30%)

Pa re n

m m es ini ng pr og

Country responses to the Atlas questionnaire

None (0%)

ro gr

W or k

m m es

pla ce

pr og r

on e

Atlas: substance use in the Eastern Mediterranean Region 2015

100 80 60 40 20 0 (p rin t) ua l) es es es es pu bli cp lac ud io vis m m m ra m ra m ra m ra m W or kp lac e pr og m es

Percentage of countries

ed ia

en ts in

M as

-b as

ve rt ise m

Very high (61%–100%)

High (31%–60%)

m un ity

an ua l)

M as

Some (1%–30%)

Fig. 51. Coverage of prevention programmes for drug use (n = 22)

Findings • Prevention programmes are available in the majority of the countries of the Eastern Mediterranean Region. • Overall, more countries of the Region reported having prevention programmes for drug use than for alcohol use. • The coverage of prevention programmes varies between the types of programme, but is overall higher for drug use than for alcohol use.

actively involved in prevention of substance use disorders (Fig. 52).

Findings • Various groups and agencies are reported to be involved in prevention of substance use disorders. • Nongovernmental organizations are involved in 89% of the countries of the Region, followed by schools (84%) and religious groups (78%).

Notes and comments • Not all of the countries that provided a response to this question responded on all of the prevention programmes. 4.3.5.2 Groups and agencies involved in prevention

Notes and comments • This question does not differentiate between prevention of alcohol or drug use disorders. 4.3.5.3 Prevention programmes for target population groups

Background Respondents were requested to indicate whether different groups and agencies are 42

Background Respondents were asked about the existence of specific prevention programmes and/or

re nt pr og

ed ia

pr og

None (0%)

Country responses to the Atlas questionnaire

100 80 60 40 20 0 ns ol s ies ns ps s s ps rs s s ke r ke r io n io n Em plo ye r tio gr ou gr ou ho nc tio lw or wo r at at iza Sc iza ge ta niz niz he ale s

Percentage of countries

ity

lig io

m en

Co m m un

fo rc e

alt

tie

tio

go ve r

La w

Fig. 52. Groups and agencies involved in prevention of substance use disorders (n = 19)

interventions to reduce substance use and/or substance use disorders specifically targeting population groups (Fig. 53).

N on

4.3.5.4 Screening and brief interventions in primary health care

Background Respondents were asked whether primary health care services are expected to implement, according to national guidelines and standards of care, screening22 and brief interventions for hazardous and harmful use of tobacco, alcohol, cannabis and prescription drugs. Respondents were also asked about the proportion of primary health care services that have implemented screening and brief interventions for harmful and hazardous alcohol and drug use. They were requested to specify whether this is for routine screening (for the majority of patients) or selective screening (for a minority of patients) (Fig. 54 and 55).

Findings • Prevention programmes for drug use targeting prisoners are reported by 77% of the countries of the Eastern Mediterranean Region. • Prevention programmes for drug use targeting young people are reported by 77% of the countries of the Region. • 11% of the countries of the Region reported having specific prevention programmes for drug use among pregnant women.

Notes and comments • The response rate was lower for prevention programmes for alcohol use compared to those for drug use.

Findings • 42% of the countries of the Eastern Mediterranean Region reported that there 22

 Screening can be done by simply asking all pregnant women about substance use and need not involve a standardized screening questionnaire or testing.

In t

Tr a

dit

io n

cia

Atlas: substance use in the Eastern Mediterranean Region 2015

80 70 Percentage of countries

60 50 40 30 20 10 0 ls ex Pe wo rs on rk er sw s he it alt h h me Ch ild diso nta re rd l n e th at r rs eir isk fam an ilie d s* Pe P op ar en le ts wi t h Ch HI ild V/ re AI n D an S d ad ol es ce nt s Pr iso ne rs Yo un ga du lts en ou sp eo wi ple th tu be rc ulo Pr sis eg na nt wo m en M ino rit yg ro up s Pe op le Re fu ge es m Co m er cia Eld er ly

In dig

Alcohol (n = 14)

Drugs (n = 18)

Fig. 53. Prevention programmes for target populations

is no recommendation for screening and brief interventions for alcohol or cannabis use in primary health care services. • The existence of recommendations for screening and brief interventions for tobacco, alcohol and cannabis use is reported to be unknown by 33% of the countries of the Region. • More than half of the countries of the Region reported that the proportion of primary care services that have implemented screening and brief interventions for alcohol or drug use is zero. • Between 23% and 28% (depending on whether it is for routine screening or selective screening) of the countries of the Region reported that the proportion of primary care services that have implemented screening and brief interventions for alcohol or drug use is unknown.

Notes and comments • Four countries reported that there are recommendations for screening and brief interventions for opioid use in primary health care services. 100 90 Percentage of countries

80 70 60 50 40 30 20 10 0 Cannabis (n = 21) Prescription drugs (n = 21) Unknown Alcohol (n = 21) No Yes Tobacco (n = 21)

Fig. 54. National guidelines and standards of care recommendations for screening and brief interventions in primary health care services

Country responses to the Atlas questionnaire

100 80 60 40 20 0

Percentage of countries

Routine screening for alcohol use (n = 21) Unknown

Selective screening for alcohol use (n = 21) Some or many (11%–60%)

Routine screening for drug use (n = 22) Few (1%–10%)

Selective screening for drug use (n = 21) None

Fig. 55. Proportion of primary care services that have implemented screening and brief interventions for harmful and hazardous substance use

4.3.5.5 Screening and brief interventions in ante-natal services

4.4 Workforce 4.4.1 Professionals providing treatment

Background Respondents were asked whether antenatal services are expected to screen23 all pregnant women about their use of tobacco, alcohol, cannabis and prescription drugs. Respondents were also asked about the proportion of antenatal services that have implemented screening and brief interventions for harmful and hazardous alcohol and drug use (Fig. 56 and 57).

Background Respondents were asked what types of professionals provide treatment and care for management of substance use disorders in their country (Fig. 58).

Findings • A range of professionals provides treatment and care for substance use disorders in the Eastern Mediterranean Region. Psychiatrists are reported by all of the countries of the Region. • 36% of the countries of the Region reported that addiction specialists provide treatment and care for substance use disorders.

Findings • 45% of the countries of the Eastern Mediterranean Region reported having recommendations for screening and brief interventions for prescription drug use in antenatal services. • Half of the countries of the Region reported that there are no screening and brief interventions for alcohol and drug use in antenatal services. 23

4.4.2 Level of educational attainment in prevention/treatment

Background Respondents were asked what level of educational attainment is possible to achieve in the areas of prevention of substance use and/or treatment of substance use disorders (Fig. 59). 45

 Screening can be done by simply asking all pregnant women about substance use and need not involve a standardized screening questionnaire or testing.

Atlas: substance use in the Eastern Mediterranean Region 2015

100 90 Percentage of countries

80 70 60 50 40 30 20 10 0 Cannabis (n = 20) Prescription drugs (n = 20) Unknown Alcohol (n = 19) No Yes Tobacco (n = 20)

80 70 60 50 40 30 20 10 0 Alcohol (n = 20) Unknown Drugs (n = 22) None (0%)

Few (1%–10%)

Fig. 56. National guidelines and standards of care recommendations for screening and brief interventions in antenatal services

Fig. 57. Proportion of antenatal services that have implemented screening and brief intervention for substance use

Findings • Short-cycle tertiary education in prevention is reported by 40% of the countries of the Eastern Mediterranean Region. • Short-cycle tertiary education in treatment is reported by 31% of the countries of the Region. 100 80 60 40 20 0 M ed ica ld oc to rs

• 31% of the countries of the Region do not have any educational programme in prevention or treatment.

Percentage of countries

Ps yc hia tri cn ur se s

Ps yc ho lo gis ts

So cia lw or ke rs

co un se llo rs *

Ps yc hia tri sts

sp ec ial ist s*

Ad dic tio n

Fig. 58. Professionals providing treatment and care for management of substance use disorders (n = 22)

Co m m un ity

he alt h

wo rk er s*

N ur se s

Country responses to the Atlas questionnaire

50 40 30 20 10 0

Percentage of countries

Short-cycle tertiary education*

Bachelor’s or equivalent level

Master’s or equivalent level

Doctoral or equivalent level

None (non-existent in these areas)

Unknown

Prevention (n = 22)

Treatment (n = 22)

Fig. 59. Level of educational attainment that is possible to achieve in prevention and treatment

4.4.3 Postgraduate training programmes in prevention/treatment

4.4.4 Continuing professional development in prevention/treatment

Background Respondents were asked whether certified postgraduate training programmes* in prevention of substance use and/or treatment of substance use disorders are available for specific professionals (Fig. 60).

Background Respondents were requested to report on the availability of continuing professional development/education* for professionals working in the areas of prevention and/or treatment of substance use disorders (Fig. 61).

Findings • Postgraduate training programmes in prevention of substance use are available for psychiatrists in 45% of the countries of the Eastern Mediterranean Region. • Postgraduate training programmes in treatment of substance use disorders are available for psychiatrists in 50% of the countries of the Region. • 36% and 40% of the countries of the Region reported that there is no postgraduate training programme in prevention and treatment respectively.

Findings • Continuing professional education is available for psychiatrists in more than half of the countries of the Eastern Mediterranean Region. • 27% of the countries of the Region reported that there is no continuing professional education for professionals working in the area of treatment of substance use disorders.

Atlas: substance use in the Eastern Mediterranean Region 2015

50 40 30 20 10 0

Percentage of countries

Psychiatrists

Medical doctors

Psychologists

Nurses

Social workers

Counsellors Community health workers* Treatment (n = 22)

None

Unknown

Prevention (n = 22)

Fig. 60. Availability of postgraduate training programmes in prevention and treatment

80 70 Percentage of countries

60 50 40 30 20 10 0 Psychiatrists Medical Psychologists doctors Nurses Social workers Addiction Community Addiction specialists* health counsellors* workers* Treatment (n = 22) None Unknown

Prevention (n = 22)

Fig. 61. Availability of continuing professional development/education for professionals working in prevention and treatment

4.4.6 National standards of care for professionals

Findings • More than half of the countries of the Eastern Mediterranean Region reported having national standards of care for psychiatrists, psychologists and social workers.

Background Respondents were asked whether national standards of care are developed for professionals working with people with substance use disorders (Fig. 62).

Country responses to the Atlas questionnaire

100 80 60 40 20 0 Ps yc ho lo gis ts Ps yc hia tri sts So cia lw or ke rs M ed ica ld oc to Ad rs dic tio n sp ec ial ist s* Ps yc hia tri cn ur se s N ur se s wo rk O er ut s* re ac h/ ﬁe ld wo rk er s co un se llo rs *

Percentage of countries

Ad dic tio n

Fig. 62. National standards of care for professionals working with people with substance use disorders (n = 18)

Notes and comments • The response rate to this question is lower than the other questions regarding the workforce as national standards of care for professionals do not exist in some countries.

Finally, respondents were asked to report on a national system of epidemiological data collection for substance use among children and adolescents, by means of specific schooltargeted surveys, or by means of surveys targeting the general population (Fig. 63–65).

4.5 Information systems 4.5.1 Epidemiological data collection system

Findings • More than half of the countries of the Eastern Mediterranean Region do not have an epidemiological data collection system for substance use. • 27% have an epidemiological data collection system for both alcohol and drug use. • Among the countries of the Region with an epidemiological data collection system, 62% of them collect data on a regular basis. • Among the countries of the Region with an epidemiological data collection system, more than half of them collect data on cannabis use, cocaine use, ATS use, opioid use and prescription drug use.

Background Respondents were asked to report on the existence of a national system of epidemiological data collection* for psychoactive substance use. They were requested to indicate if the system collects data on alcohol use only, on drug use only, on both, or whether there are two separate data collection systems for alcohol and drug use respectively. It was also required to report on the frequency of data collection as well as on data collection on specific kinds of drugs.

Co m m un ity

he alt h

Atlas: substance use in the Eastern Mediterranean Region 2015

• Among the countries of the Region with an epidemiological data collection system, the vast majority do not have a specific data collection system among children and adolescents.

4.5.2 Data collection system from health services delivery

disorders. They were requested to indicate if the system collects data for alcohol use disorders only, for drug use disorders only, for both, or whether there are two separate data collection systems for alcohol and drug use disorders respectively (Fig. 66).

Background Respondents were asked about the existence of a national system of data collection based on health services delivery* that collects data on the number of people with substance use

Findings • 45% of the countries of the Eastern Mediterranean Region do not have a data collection system based on health service delivery for substance use disorders.

9.1 27.3 Unknown None One data collection system for drug use only Two separate data collection systems for alcohol and drugs 4.5 54.5 4.5 One data collection system for both alcohol and drug use

Fig. 63. National system of epidemiological data collection for substance use (n = 22)

100 80 60 40 20 0

Percentage of countries

Cannabis use (n = 7)

Opioid use (n = 7)

Cocaine use (n = 7) Unknown

ATS use (n = 7) No Yes

Prescription drug use (n = 7)

Use of new psychoactive substances (n = 7)

Fig. 64. Data collection for specific drug use

Country responses to the Atlas questionnaire

100 80 60 40 20 0

Percentage of countries

School-targeted surveys for alcohol use (n = 8)

General population survey for alcohol use (n = 8) Unknown

School-targeted surveys for drug use (n = 8) No Yes

General population survey for drug use (n = 8)

Fig. 65. Epidemiological data collection system among children and adolescents

9.1

40.9

Unknown None Two separate data collection systems for alcohol and drug use disorders One data collection system for both alcohol and drug use disorders

45.5 4.5

Fig. 66. National system of data collection based on health services delivery (n = 22)

4.5.3 Data reporting

Findings • 38% of the countries of the Eastern Mediterranean Region reported that epidemiological data on substance use have been reported in the past five years (in a specific substance use report or in a general health statistics report). • 47% of the countries of the Region reported that data from health services delivery have been reported in the past five years (in a specific substance use report or in a general health statistics report).

Background Respondents were asked whether epidemiological data and data from health services delivery have been included in any of the country’s reports* in the past five years. They were asked to specify if the data were compiled in a specific substance use report or in a report compiled for general health statistics (Fig. 67).

Atlas: substance use in the Eastern Mediterranean Region 2015

4.5.4 Monitoring substance use involvement in death in forensic pathology

• Two countries of the Region reported having a system of monitoring opioid overdose mortality.

Background Respondents were asked about the existence of a system of monitoring alcohol and drugs involvement in deaths and related deaths (as a direct cause or underlying cause) in forensic pathology. It was asked to specify the location of such system in the country. Respondents were also asked to report on the existence of a system of monitoring opioid overdose mortality (Fig. 68).

5. Comparison of data between Atlas 2012 and Atlas 2015 A comparison of Atlas 2012 and Atlas 2015 was conducted to track changes in resources for prevention and treatment of substance use disorders over time. Data collection for these exercises occurred in 2011 and 2014, respectively. The analysis was conducted for the countries that provided data in 2011 and 2014 and was restricted to indicators that were addressed in a similar way between the two assessments. Indeed, in order to improve quality of gathered data, several indicators have been modified and specified for alcohol use disorders and drug use disorders in 2014. In addition, there was an attempt to standardize indicators with the ones collected in the atlases on mental health resources and neurological 60 50 Percentage of countries

Findings • 45% of the countries of the Eastern Mediterranean Region have a system of monitoring alcohol and drugs involvement in forensic pathology, either in forensic examinations or in toxicology units.

100 80 60 40 20 0

Percentage of countries

40 30 20 10

Epidemiological data reporting (n = 21) Unknown

Data from health services delivery reporting (n = 21)

0 Alcohol (n = 22) Drugs (n = 22)

Unknown None In toxicology units (poisonings and intoxications) In forensic examinations (deaths)

Compiled in a speciﬁc substance use report Compiled but not in a speciﬁc substance use report Not reported in the past ﬁve years

Fig. 67. Epidemiological and health services delivery data reporting

Fig. 68. System of monitoring alcohol and drugs involvement in forensic pathology

Comparison of data between Atlas 2012 and Atlas 2015

resources that were conducted at the global level in 2014 as well. Overall, differences in the reported level of resources between 2011 and 2014 are small. Increases are observed in many areas, particularly in service organization and delivery. However, these differences may be due to changes in the methodology rather than a real change in the resource base. In addition, these changes may also reflect improvements in collecting the information. Although the comparison is made on the same countries that provided data in both 2011 and 2014, it should be noted that the response rate increased overall between 2011 and 2014. A comparison of specific indicators is made in the sections below.

(i.e. seven) reported having a mechanism for offering compulsory treatment.

5.1.4 Drug courts • The number of countries reported having a system of drug courts has decreased. Indeed, in 2011, four countries reported having a system of drug courts, while no country reported that in 2014.

5.2 Financing (Fig. 70) 5.2.1 Budget line • A higher number of countries reported having a specific budget line for prevention and treatment of substance use disorders in 2014 compared to 2011. • In 2014, 12 countries reported having a budget line for prevention compared to six in 2011. • In 2014, 11 countries reported having a budget line for treatment compared to six in 2011. • However, this question was worded differently. In 2014, focal points were requested to indicate which ministries 12 10 Percentage of countries

5.1 Leadership and governance (Fig. 69) 5.1.1 Government unit/official • The same number of countries (i.e. 11) reported having a government unit/ official responsible for treatment of substance use disorders. • The number of countries reporting having a government unit/official responsible for prevention of substance use has increased from two to 12. 5.1.2 Confidentiality of people in treatment • The number of countries having a law to protect confidentiality of people in treatment for alcohol drug use disorders has increased from seven to nine. 5.1.3 Compulsory treatment • In 2014, this indicator was operationalized in a different way which enabled the collection of more precise information. But overall, the same number of countries

8 6 4 2 0 2011 2014

Existence of a government unit/ ofﬁcial for treatment of substance use disorders Existence of a law for conﬁdentiality of people in treatment Existence of a mechanism for compulsory treatment Existence of a system of drug courts

Fig. 69. Comparison of leadership and governance indicators between 2011 data and 2014 data

Atlas: substance use in the Eastern Mediterranean Region 2015

12 10 Percentage of countries

8 6 4 2 0 2011 2014

Existence of budget line(s) for treatment of substance use disorders Government ﬁnancing as the main ﬁnancing method for treatment services Household ﬁnancing as the main ﬁnancing method for treatment services Monetary support for people with substance use disorders

Fig. 70. Comparison of financing indicators between 2011 data and 2014 data

rehabilitation and opioid agonist maintenance therapy. • The number of countries that reported having government financing as the main financing method for all treatment services for alcohol use disorders has increased from three to six between 2011 and 2014. • Regarding treatment services for drug use disorders, the number of countries that reported government financing as the main financing method increased from two to seven. • In terms of household financing, there has been a decrease from two to one in the number of countries reporting this method as the main financing method for treatment services for alcohol and drug use disorders.

have a specific budget line for treatment of substance use disorders, while in 2011 focal points were asked whether there is a specific budget line in the annual budget of the government for treatment services for substance use disorders. Thus, this increase may reflect a difference in how this indicator was operationalized rather than a real difference in resources.

5.2.3 Social support • Two countries reported having government benefits in the form of monetary support for people with substance use disorders in 2014, while one country reported that in 2011. • For the other countries that responded in 2011 and 2014, no change has been reported.

5.2.2 Financing methods for treatment services • In 2011, respondents were asked to indicate the most common financing method for treatment services for alcohol use disorders and for drug use disorders. This item was worded differently in 2014. Respondents were requested to indicate the main financing method for specific treatment services for alcohol and drug use disorders. These treatment services were the following: outpatient detoxification, inpatient detoxification, inpatient treatment, outpatient treatment, 54

5.3 Service organization and delivery 5.3.1 Number of beds • When comparing the same countries that provided data in both 2011 and 2014, the number of beds per 100 000 population decreased from 0.4 in 2011 to 0.31 in 2014, which corresponds to a 20% decrease (Fig. 71). It is important to note that the population in these countries increased by 10% between 2011 and 2014.

Comparison of data between Atlas 2012 and Atlas 2015

5 4 3 2 1 0 2011 2014

Fig. 71. Comparison of the number of beds for treatment of substance use disorders per 100 000 population between 2011 and 2014

5.3.5 Harm reduction programmes • An increase in the number of countries having harm reduction programmes is observed between 2014 and 2011. Indeed, in 2014 three countries reported having needle/syringe exchange programmes while two reported that in 2011. • The number of countries that reported having outreach services for injecting drug users increased from two to four. • Two countries reported having naloxone distribution programmes in 2014, while none reported such programmes in 2011. 5.3.6 Open access interventions • The number of countries that reported having telephone help-lines for drug use increased from three to four between 2011 and 2014. • One country reported having web-based interventions for drug use while none reported such interventions in 2011. 5.3.7 Mutual support/self-help groups • Overall, a slight increase in the number of countries having Alcoholic Anonymous groups (six in 2011 and eight in 2014) and Cocaine Anonymous groups (zero in 2011 and one in 2014) is observed between 2011 and 2014. • However, the number of countries reporting having Al-Anon/Alateen decreased from four to one between 2011 and 2014. 5.3.8 Screening and brief interventions in primary health care • Three countries reported having implemented screening and brief interventions for alcohol or drug use in primary health care. 5.3.9 Groups and agencies involved in prevention • A slight increase in the number of countries reporting specific groups 55

5.3.2 Main substances reported at treatment entry • Changes have been observed in the ranking of the three main substances reported at treatment entry. • In 2011, alcohol was reported as the main substance at treatment entry, cannabis the second and opioids the third. • In 2014, cannabis was reported as the main substance at treatment entry, followed by opioids and alcohol. 5.3.3 Guidelines on pharmacological treatment • The number of countries reporting having guidelines on pharmacological treatment for substance use disorders has increased from seven to nine between 2011 and 2014. 5.3.4 Availability of opioid agonist pharmacotherapy • Between 2011 and 2014, the number of countries that reported having methadone available for opioid detoxification and/or maintenance treatment has increased from three to six (Fig. 72).

Percentage of countries

Atlas: substance use in the Eastern Mediterranean Region 2015

7 6 Percentage of countries

5 4 3 2 1 0 2011 2014

Availability of methadone for detoxiﬁcation or maintenance treatment Availability of open access interventions for drug use Implementation of screening and brief interventions in primary health care Existence of prevention programmes for children at risk and their families Availability of needle/syringe exchange programmes

Fig. 72. Comparison of service organization and delivery indicators between 2011 data and 2014 data

5.3.11 Prevention programmes for target populations • Overall, more countries reported having specific prevention programmes for target populations. • In 2011, six countries reported having special prevention programmes for drug use among prisoners, and in 2014, 10 countries reported having such programmes. • The number of countries reported having prevention programmes for drug use targeting people with HIV/AIDS, increased from three in 2011 to six in 2014. • Regarding prevention programmes for drug use among children at risk and their families, two countries reported such programmes in 2011, while five countries reported that in 2014.

and agencies involved in prevention is observed between 2011 and 2014. • The number of countries that reported that social workers are involved in prevention increased from five to 11 between 2011 and 2014. • Four additional countries (five in 2011 and nine in 2014) reported that community groups are involved in prevention.

5.4 Workforce 5.4.1 National standards of care for professionals • The number of countries reporting having national standards of care for professionals working with substance use disorders increased from four to 10 between 2011 and 2014 . • However, it should be highlighted that this question was worded differently in 2014. Focal points were requested to indicate the professional categories that have national standards of treatment and care, whereas in 2011 focal points were asked whether there are national standards of care developed for professionals providing treatment for people with substance use disorders. This increase might reflect a difference in how this indicator was operationalized rather than a real difference in resources.

5.3.10 Prevention programmes • In 2014, 13 countries reported having community-based programmes for drug use, compared to eight in 2011. • In 2013, 13 countries reported having work place programmes for drug use compared to six in 2011. • The number of countries reporting having school-based programmes for drug use increased from 11 in 2011 to 13 in 2014.

Comparison of data between Atlas 2012 and Atlas 2015

5.5 Information systems (Fig. 73) 5.5.1 Epidemiological data collection system among children and adolescents • The number of countries reporting having an epidemiological data collection system increased from five in 2011 to seven in 2014. 5.5.2 Data collection system from health services delivery • In 2014, one additional country (six in 2011 and seven in 2014) reported having a data collection system for substance use disorders based on health services delivery compared to 2011. Percentage of countries

8 7 6 5 4 3 2 1 0 2011 2014

Existence of an epidemiological data collection system for substance use Existence of a data collection system from health services delivery

Fig. 73. Comparison of information systems indicators between 2011 data and 2014 data

Atlas: substance use in the Eastern Mediterranean Region 2015

6. Conclusion Information on substance use in the Eastern Mediterranean Region is scarce and not updated. All efforts to collect data on the epidemiology of alcohol and drug use need to be guided in order to assess the needs and plan resources accordingly. Tools such as the global school-based student health survey should be conducted on a regular basis in order to monitor substance use among children and young adolescents. Current estimates show that the burden of drug use disorders in the Region is high compared to global estimates, which highlights the importance of considering substance use and substance use disorders in health policy. Resources for the prevention and treatment of substance use disorders varies across countries,

but remains overall insufficient to provide adequate care and treatment for people with substance use disorders. Social support such as government benefits, housing or employment services are rarely available for people with substance use disorders. Interventions that have proven to be efficient, such as pharmacotherapy or screening and brief interventions, are available in a minority of the countries in the Region. Services should be scaled up to be available in all parts of each country and not limited to the major cities. More important, information systems should be strengthened and data collected in a systematic way in order to provide the information needed for planning services and resources.

Glossary

Glossary • Addiction counsellors: professionals certified to work as counsellors for patients with substance use disorders and behavioural addictions after completion of formal training of varying intensity. Educational requirements for addiction counsellors vary depending on the type of certification, and higher levels of certification may require bachelor’s or equivalent level of education. • Addiction specialists/narcologist: medical doctors with specialization in addiction medicine/narcology. • Budget line: source of money available and allocated for actions directed towards treatment and prevention of substance use disorders. • Community health workers: members of a community who are chosen by community members or organizations to provide basic health and medical care to their community. Other names for this type of health care provider include village health worker, community health aide, community health promoter and lay health adviser. • Continuing professional development/education: any certified training activities that are followed by people after completion of their formal professional training in order to maintain skills and knowledge related to their professional career. • Detoxification: refers to a relatively short-term treatment aimed at withdrawing an individual from the effects of a psychoactive substance and usually involves clinical management of intoxication and/or withdrawal syndrome in a safe and effective manner. • Drug court: specialized court that aims to stop drug abuse and related criminal activity of offenders through court-

•

• •

•

directed treatment and rehabilitation programmes. Drug courts order the treatment of suitable drug-related offenders as an alternative to prosecution or imprisonment and usually monitor compliance with treatment through court appearances and court-mandated regular tests (e.g. urine tests) or examinations. Employer financing: social health insurance scheme in which workers and employers are obliged to contribute to health insurance funds. Facilities: refers to treatment centres, departments, wards, and units designed and designated for treatment of substance use disorders. These facilities can be stand-alone (like, for example, national addiction treatment centres, drug treatment centres/clinics and narcological dispensaries) or integrated with other health care centres, clinics or dispensaries (such as general health care or mental health centres or hospitals, HIV clinics etc.). Government benefits: benefits that are provided by a government from public funds for disabled persons including those with substance use disorders that cause impairment leading to functional limitations. Benefits can be provided in different ways such as disability pensions, free access to services, housing and personal staff care. Government financing: national, regional/subnational or local government financing from tax-based funding or national health insurance. Household financing: direct out-ofpocket payment. Hypothecated taxes: in this context it refers to taxes that are specifically reserved for prevention and treatment of substance use disorders. Inpatient treatment: refers to different treatment modalities beyond

Atlas: substance use in the Eastern Mediterranean Region 2015

•

• •

detoxification that are implemented on an inpatient basis, i.e. with formal hospital admission that usually involves an overnight stay or in residential care when a patient lives in a residential treatment setting rather than in his/her own home or family home. Major cities: refers to cities with relatively large populations and tertiary and higher levels of health care available, including highly specialized facilities such as university hospitals or highly specialized treatment centres such as those for neurosurgery or radiology. Mutual-support groups: more widely known as self-help groups. A group in which participants support each other in recovering or maintaining recovery from alcohol or other drug dependence or problems, or from the effects of another’s dependence, without professional therapy or guidance. Examples of mutual support groups are Alcoholics Anonymous, Narcotics Anonymous and Al-Anon/ Alateen (for family members of people with alcohol use disorders). Nongovernmental organizations and other external financing: financing through funds provided by voluntary organizations, charitable groups, advocacy groups, professional associations or international organizations. Number of treatment episodes: refers to the total number of annual treatment admissions to inpatient and outpatient specialized treatment facilities including the repeated treatment admissions for the same person during the year. Other areas: refers to urban and rural areas outside the capital and major cities. Outpatient treatment: refers to different treatment modalities beyond detoxification that are implemented on outpatient/ambulatory basis.

• Postgraduate training programme: training that is pursued after a first degree (such as a bachelor’s degree) in a specific field or area. • Rehabilitation: refers here to a longerterm process aimed at enabling people with substance use disorders to achieve an optimal state of health, psychological functioning and social well-being through a combination of approaches including psychosocial, medical and recoveryoriented interventions implemented on in patient and/or out patient basis as well as in community-based support groups. • Report: regular report on information covering health or social services use, available resources (services, human resources) programmes and allocation of funds for each year by the government. • Services: refers to the functions of providing prevention and treatment interventions for substance use disorders by health professionals, but not necessary implemented in specialized facilities designed and designated for treatment of substance use disorders. Examples include provision of screening and brief interventions for alcohol and drug use by health professionals in emergency rooms or primary health care centres, or management of substance use disorders, including pharmacotherapy of substance dependence, by medical doctors or other professionals working in different areas of medicine, psychology and social care (family doctors and nurses, psychiatrists, gastroenterologists, oncologists, social workers, community health workers, etc.). • Short-cycle tertiary education: includes advanced vocational, academic or professional education in specialized areas of education but not reaching bachelor’s or equivalent level.

Glossary

• Specialized treatment facilities for substance use disorders: specialized facilities designed and designated for treatment of substance use disorders. These include mental health care facilities that offer specialized treatment for substance use disorders. • Substance use disorders: a group of conditions related to alcohol or other drug use. In ICD-10 section F10–F19 it is referred to as “Mental and behavioural disorders due to psychoactive substance use” and contains a wide variety of disorders of different severity and clinical forms, all having in common the use of one or more psychoactive substances, which may or may not have been medically prescribed. • Substance use: refers to the nonmedical use of alcohol, illicit drugs or

other psychoactive substances, including prescription drugs. • System of data collection based on health service delivery: refers to an organized system of collecting data based on health service delivery which usually incorporates admission and discharge data, number of outpatient contacts and similar. • System of epidemiological data collection: refers to an organized epidemiological surveillance system, which usually incorporates results of regular epidemiological studies/surveys on prevalence of substance use and substance use disorders, patterns of substance use and similar.

Country fact sheets: substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Legend and abbreviations /: –: AUDs: CSWs: DUDs: MH: NCDs: OAMT: SUDs: not applicable missing/not reported alcohol use disorders commercial sex workers drug use disorders mental health noncommunicable diseases opioid agonist maintenance therapy substance use disorders

Country profiles

Afghanistan DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 28 100 24 31 60 Low income Prevention Ministries of health and of counter narcotics Yes, for drugs only This unit is also responsible for policies covering mental health, noncommunicable diseases and health promotion Treatment Ministries of health and of counter narcotics Yes, for drugs only This unit is also responsible for policies covering mental health, noncommunicable diseases and health promotion In addition to criminal sanctions Yes No

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes No None

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Inpatient detoxification Yes Outpatient treatment Yes Inpatient Rehabilitation OAMT treatment Yes Yes

Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First

Yes

Second – Mental health facilities

Third – General health care facilities In other areas Yes

– Stand-alone facilities for substance use disorders In the capital city Yes

Availability of specialized treatment facilities for substance use disorders In other major cities Yes Opioids Cannabis Sedatives Very limited (1%–10%) Very limited (1%–10%) Very limited (1%–10%) Very limited (1%–10%)

Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence

Atlas: substance use in the Eastern Mediterranean Region 2015

Buprenorphine (sublingual tablets) for opioid dependence Buprenorphine/naloxone (tablets) for opioid dependence Buprenorphine/naloxone (films) for opioid dependence Naltrexone (tablets) for opioid dependence Methadone (liquid) for opioid dependence Methadone (tablets) for opioid dependence Clonidine (tablets) for opioid withdrawal Lofexidine (tablets) for opioid withdrawal Naloxone (for injection) for opioid overdose For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Diazepam (tablets) for alcohol withdrawal Disulfiram (tablets) for alcohol dependence Naltrexone (tablets) for alcohol dependence For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal

No No No No No Yes Yes No Yes – Yes No No Yes

No No No No No For detoxification and maintenance treatment Yes – Yes No Yes No No Yes

Country profiles

Special treatment programmes for women, children and adolescents with substance use disorders For women For children and adolescents Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous Yes Cocaine Anonymous No Al-Anon/ Alateen – Family support groups Yes In the capital city No No In the capital city No No Alcohol use No No No In other major cities Yes Yes In other major cities No No Drug use No No Yes In other areas No No In other areas No No

Social services for people with substance use disorders

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women – – Commercial sex workers – – Refugees People with HIV/ AIDS – Yes Children and adolescents – Yes Persons with mental health disorders – Yes In antenatal services – None Young adults – Yes Coverage for alcohol use Coverage for drug use Some (1%–30%) Some (1%–30%) Some (1%–30%)

– – –

Alcohol use Drug use Alcohol use Drug use

– Yes

Screening and brief interventions for substance use In primary health care services Unknown Unknown

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals Unknown For psychiatrists and medical doctors For psychiatrists and medical doctors

INFORMATION SYSTEMS Epidemiological substance use data Substance use indicators as a part of the health information system Monitoring of substance use related deaths Collected No Yes No Reported Unknown Yes /

Atlas: substance use in the Eastern Mediterranean Region 2015

Bahrain DEMOGRAPHIC INFORMATION Total population (000), 2012 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 1 200 100 94 77 High income Prevention Ministries of health, interior and education Yes This unit is also responsible for policies covering mental health As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts – – None Treatment Ministries of health and interior Yes This unit is also responsible for policies covering mental health In addition to criminal sanctions Yes Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizationss and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient treatment Yes Inpatient treatment Yes Rehabilitation Yes OAMT Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Mental health facilities Second General health care facilities General health care facilities In other major cities – Opioids Amfetamine-type stimulant Alcohol More than 40% – Unknown Substantial (21%–40%) Third Community-based selfsupport groups Community-based selfsupport groups In other areas –

Country profiles

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose Buprenorphine (sublingual tablets) for opioid dependence Buprenorphine/naloxone (tablets) for opioid dependence Buprenorphine/naloxone (films) for opioid dependence Naltrexone (tablets) for opioid dependence Methadone (liquid) for opioid dependence Methadone (tablets) for opioid dependence Clonidine (tablets) for opioid withdrawal Lofexidine (tablets) for opioid withdrawal Naloxone (for injection) for opioid overdose For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Diazepam (tablets) for alcohol withdrawal Disulfiram (tablets) for alcohol dependence Naltrexone (tablets) for alcohol dependence For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal No Yes No No No No Yes No No Yes / Yes No / Yes Registration No No No No No Yes No No Yes Availability No No No No No For detoxification treatment No No Yes Daily supervised dosing available for outpatients No No No No No No / / / Yes Unknown Unknown Unknown Unknown

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city No No No No No No No In other major cities No No In other areas No No 61%–100% 61%–100% 61%–100% 61%–100% 61%–100%

Special treatment programmes for women, children and adolescents with substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous Yes Cocaine Anonymous – Al-Anon/ Alateen – Family support groups – In the capital city No No Alcohol use No No No In other major cities No No Drug use No No No In other areas No No

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – Yes Children and adolescents – – Persons with mental health disorders Young adults Coverage for alcohol use Coverage for drug use Some (1%–30%) Some (1%–30%) Some (1%–30%)

– – –

Alcohol use Drug use Alcohol use Drug use

– Yes

– –

– – In antenatal services Unknown Unknown

– Yes

Screening and brief interventions for substance use In primary health care services Unknown Unknown

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, addiction medicine specialists, other medical doctors, psychiatric nurses, psychologists, social workers and addiction counsellors None None

Country profiles

Djibouti DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2009 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 860 84 – 61 Lower middle income Prevention Ministry of health and office of the prime minister/president Yes This unit is also responsible for policies covering tobacco As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Unknown Few jurisdictions Treatment Ministry of health – –

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system In addition to criminal sanctions – –

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First – – In the capital city No Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence – – – Unknown Cannabis Alcohol Opioids Second – – In other major cities No Third – – In other areas No

Availability of specialized treatment facilities for substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence – – – Unknown Yes Registration Availability Daily supervised dosing available for outpatients – – – – – – / / / / – – / –

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Unknown Unknown – – – – – – – Unknown – – – –

Unknown Unknown – – – – – – – – – – – –

– – – – – – – – Yes In other major cities No – In other areas No –

Special treatment programmes for women, children and adolescents with substance use disorders

–

Country profiles

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous – Cocaine Anonymous – Al-Anon/ Alateen – Family support groups – In the capital city No In other major cities No – Alcohol use Drug use – – – In other areas No –

–

Open access interventions for substance use problems

– – –

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – – Persons with mental health disorders – – In antenatal services None Few (1%–10%) Young adults Coverage for alcohol use Coverage for drug use None – –

– – –

Alcohol use Drug use Alcohol use Drug use

– –

Screening and brief interventions for substance use In primary health care services Unknown Unknown

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, addiction medicine specialists and other medical doctors For community health workers None

Atlas: substance use in the Eastern Mediterranean Region 2015

Egypt DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2012 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 84 628 43 70 71 Lower middle income Prevention Ministries of health and social welfare Yes This unit is also responsible for policies covering mental health As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts No – None Treatment Ministry of health Yes This unit is also responsible for policies covering mental health In addition to criminal sanctions No Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Mental health facilities Second Stand-alone facilities for substance use disorders Stand-alone facilities for substance use disorders In other major cities Yes Prescription opioids Opioids Sedatives Limited (11%–20%) Limited (11%–20%) None Very limited (1%–10%) Third General hospitals General hospitals

Availability of specialized treatment facilities for substance use disorders In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence In other areas Yes

Country profiles

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown No Registration Availability Daily supervised dosing available for outpatients – – – Yes – – / / / / Yes – / Yes

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

No No No Yes No No Yes No No No Yes No Yes Yes

No No No Yes No No Yes – – – Yes – Yes Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents Special housing services Employment services In the capital city Yes Yes In the capital city No No Yes Yes Unknown Yes Yes In other major cities Yes Yes In other major cities No No In other areas – – In other areas No No 11%–30% – 11%–30% – –

Special treatment programmes for women, children and adolescents with substance use disorders

Social services for people with substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Unknown Narcotics Anonymous Yes Cocaine Anonymous Unknown Al-Anon/ Alateen Unknown Family support groups Yes Alcohol use Yes No No Drug use Yes No No

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – Yes Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use – – – Coverage for drug use – – –

Alcohol use Drug use Alcohol use Drug use

– –

– Yes

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals – For medical doctors For psychiatrists, psychologists, social workers and nurses

Country profiles

Iran (Islamic Republic of) DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 76 942 72 83 74 Upper middle income Prevention Ministries of health, education, social welfare and drug control headquarters Yes This unit is also responsible for policies covering mental health As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes None Treatment Ministry of health and drug control headquarters Yes This unit is also responsible for policies covering mental health In addition to criminal sanctions Yes Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organization and other external financing Global Fund financing Yes Yes Yes Yes Yes Yes Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health services Stand-alone facilities for substance use disorders In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence More than 40% Unknown Unknown Unknown Opioids ATS Prescription opioids Second General health care services General health care facilities Third General hospitals Mental health services In other areas Yes

Availability of specialized treatment facilities for substance use disorders In other major cities Yes

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 21%–50% Unknown Unknown Unknown Yes Registration Availability Daily supervised dosing available for outpatients Yes Yes Yes No Yes Yes / / / / Yes No / Yes

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Yes Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes

For detoxification and maintenance treatment For detoxification and maintenance treatment For detoxification and maintenance treatment Yes For maintenance treatment For maintenance treatment Yes – Yes No Yes No Yes Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city Yes No Yes Yes Yes No Yes In other major cities Yes No In other areas No No 1%–10% None 1%–10% None None

Special treatment programmes for women, children and adolescents with substance use disorders

Country profiles

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous Yes Cocaine Anonymous Yes Al-Anon/ Alateen Yes Family support groups Yes In the capital city Yes Yes Alcohol use No No No In other major cities Yes Yes Drug use Yes No No In other areas No No

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – Yes Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use None Some (1%–30%) Some (1%–30%) Coverage for drug use Some (1%–30%) Some (1%–30%) Some (1%–30%)

Alcohol use Drug use Alcohol use Drug use

– Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, other medical doctors, psychologists and outreach/field workers For psychiatrists, medical doctors and psychologists For psychiatrists, medical doctors and psychologists

Atlas: substance use in the Eastern Mediterranean Region 2015

Iraq DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 35 095 69 21 70 Upper middle income Prevention Ministries of health, interior, education, justice and social welfare, Yes As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts No No None Treatment Ministry of health Yes In addition to criminal sanctions No No

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Mental health facilities Second General health care facilities General health care facilities In other major cities Yes Other Alcohol Sedatives Unknown Unknown Unknown Unknown Third Mental health services Mental health services

Country profiles

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence – – – 50%–90% No Registration Availability Daily supervised dosing available for outpatients – – – – – – / / / / Yes – / Yes

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Yes No No Yes No No Yes Yes Yes Yes Yes No Yes Yes

– No No No No No No No No No Yes No No Yes

Special treatment programmes for women, children and adolescents with substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholic Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No In the capital city No No Alcohol use No No No In other major cities No No In other areas No No Drug use No No No

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents Yes Yes Persons with mental health disorders Yes Yes In antenatal services Unknown Unknown Young adults Coverage for alcohol use Some (1%–30%) None Some (1%–30%) Coverage for drug use Some (1%–30%) None None

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services Some (11%–30%) Some (11%–30%)

WORKFORCE Availability of postgraduate training programmes Prevention Treatment None For psychiatrists, medical doctors, psychologists, social workers and nurses For psychiatrists, medical doctors, psychologists, social workers and nurses

National standards of care for professionals

Country profiles

Jordan DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 6 530 83 93 74 Upper middle income Prevention Ministries of health and interior No As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes None Treatment Ministries of health and interior No In addition to criminal sanctions Yes Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders First Stand-alone facilities for substance use disorders Stand-alone facilities for substance use disorders Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown Alcohol Opioids Sedatives In the capital city Yes Second Mental health facilities Third Community-based selfsupport groups Community-based selfsupport groups

Drug use disorders

Mental health facilities

Availability of specialized treatment facilities for substance use disorders In other major cities – In other areas –

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 50%–90% 1%–10% Unknown 50%–90% Yes Registration Availability Daily supervised dosing available for outpatients – – – – – – / / / / – – / –

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

– – – – Yes – – – Yes – Yes – – Yes

– – – – For detoxification treatment – – – Yes – Yes – – Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city Yes Yes No No No No No In other major cities – – In other areas – – 61%–100% 61%–100% 61%–100% 61%–100% 61%–100%

Special treatment programmes for women, children and adolescents with substance use disorders

Country profiles

Social services for people with substance use disorders Special housing services Employment services Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No Alcohol use No No No Drug use No No No In the capital city No No In other major cities No No In other areas No No

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Yes Yes Children and adolescents Yes Yes Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use Some (1%–30%) None Some (1%–30%) Coverage for drug use Some (1%–30%) None Some (1%–30%)

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Yes Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services Few (1%–10%) Few (1%–10%)

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, psychiatric nurses, psychologists and social workers Unknown Unknown

Atlas: substance use in the Eastern Mediterranean Region 2015

Kuwait DEMOGRAPHIC INFORMATION Total population (000), 2012 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 3 806 100 95 78 High income Prevention Ministry of health Yes This unit is also responsible for policies covering health promotion Treatment Ministry of health Yes This unit is also responsible for policies covering mental health and criminal justice In addition to criminal sanctions Yes Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes Most jurisdictions

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Mental health facilities Second Therapeutic communities Therapeutic communities In other major cities Yes Opioids ATS Sedatives Unknown Unknown Unknown Unknown Third Community-based self-support groups Community-based self-support groups In other areas Yes

Availability of specialized treatment facilities for substance use disorders Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence In the capital city Yes

Country profiles

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 99%–100% 99%–100% 99%–100% 99%–100% Yes Registration Availability Daily supervised dosing available for outpatients – – – – – – / / / / Yes – / Yes

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

No No Yes No No No Yes No Yes No Yes No No Yes

No No Yes for detoxification only – No No No – Yes – Yes – – Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city Yes No No Yes No No No In other major cities Yes No In other areas Yes No 61%–100% 61%–100% 61%–100% 61%–100% 61%–100%

Special treatment programmes for women, children and adolescents with substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Social services for people with substance use disorders Special housing services Employment services Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous Yes Cocaine Anonymous No Al-Anon/ Alateen Yes Family support groups Yes Alcohol use Yes Yes Yes Drug use Yes Yes Yes In the capital city No No In other major cities No No In other areas No No

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Yes Yes Children and adolescents Yes Yes Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use High (31%–60%) – High (31%–60%) Coverage for drug use High (31%–60%) – High (31%–60%)

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services None None

Country profiles

Lebanon DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2012 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 4 168 85 99 80 Upper middle income Prevention Ministries of health, interior and social welfare No As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts No No None Treatment Ministry of health Yes for drugs only In addition to criminal sanctions No No

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Yes Yes Yes Yes Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Standalone facilities for SUDs In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown Sedatives Cannabis Opioids Second General health care facilities Mental health facilities Third General health care services General health care facilities In other areas No

Availability of specialized treatment facilities for substance use disorders In other major cities No

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown 11%–20% Unknown Unknown Yes Registration Availability Daily supervised dosing available for outpatients Yes

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Buprenorphine (sublingual tablets) for opioid dependence

Yes

For detoxification and maintenance treatment No No No No No No No No No No No No No

Buprenorphine/naloxone (tablets) for opioid dependence Buprenorphine/naloxone (films) for opioid dependence Naltrexone (tablets) for opioid dependence Methadone (liquid) for opioid dependence Methadone (tablets) for opioid dependence Clonidine (tablets) for opioid withdrawal Lofexidine (tablets) for opioid withdrawal Naloxone (for injection) for opioid overdose For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Diazepam (tablets) for alcohol withdrawal Disulfiram (tablets) for alcohol dependence Naltrexone (tablets) for alcohol dependence For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal

No No No Yes Yes No No Yes No Yes No No Yes

No No No No No / / / / Yes No / Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop–in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city No No No No No Yes No In other major cities No No In other areas No No None None 1%–10% 1%–10% 1%–10%

Special treatment programmes for women, children and adolescents with substance use disorders

Country profiles

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self–help groups Alcoholics Anonymous Yes Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No In the capital city No No Alcohol use No No No In other major cities No No In other areas No No Drug use No No No

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – – Persons with mental health disorders – – In antenatal services Few (1%–10%) Few (1%–10%) Young adults Coverage for alcohol use Some (1%–30%) None None Coverage for drug use Some (1%–30%) None None

Alcohol use Drug use Alcohol use Drug use

– –

Yes Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, addiction medicine specialists, psychiatric nurses, psychologists and social workers For psychiatrists and psychologists For psychiatrists

Atlas: substance use in the Eastern Mediterranean Region 2015

Libya DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 6 028 86 90 75 Upper middle income Prevention Ministry of health Yes This unit is also responsible for policies covering mental health As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes None Treatment Ministry of health Yes This unit is also responsible for policies covering mental health In addition to criminal sanctions Yes Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Mental health facilities In the capital city – Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence None None – None Opioids Cannabis Sedatives Second – – In other major cities Yes Third – – In other areas –

Availability of specialized treatment facilities for substance use disorders

Country profiles

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence – – – – No Registration No No No No No No Yes No No No Yes No No Yes Availability No No No No No No Yes No No No Yes No No Yes Daily supervised dosing available for outpatients No No No No No No / / / / No No / No

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/ overdose Buprenorphine (sublingual tablets) for opioid dependence Buprenorphine/naloxone (tablets) for opioid dependence Buprenorphine/naloxone (films) for opioid dependence Naltrexone (tablets) for opioid dependence Methadone (liquid) for opioid dependence Methadone (tablets) for opioid dependence Clonidine (tablets) for opioid withdrawal Lofexidine (tablets) for opioid withdrawal Naloxone (for injection) for opioid overdose For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Diazepam (tablets) for alcohol withdrawal Disulfiram (tablets) for alcohol dependence Naltrexone (tablets) for alcohol dependence For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop–in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city No No No No No No No In other major cities No No In other areas No No 61%–100% 61%–100% 61%–100% – –

Special treatment programmes for women, children and adolescents with substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Social services for people with substance use disorders Special housing services Employment services Telephone help–lines Web–based interventions Mobile phone based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No In the capital city No No Alcohol use No No No In other major cities No No In other areas No No Drug use No No No

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual) based programmes Work place programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – Yes Children and adolescents – – Persons with mental health disorders – – In antenatal services Unknown Unknown Young adults Coverage for alcohol use – – – Coverage for drug use – – –

Alcohol use Drug use Alcohol use Drug use

– –

Screening and brief interventions for substance use In primary health care services – None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals – None None

Country profiles

Morocco DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 32 950 59 67 71 Lower middle income Prevention Ministry of health Yes This unit is also responsible for policies covering mental health, noncommunicable diseases, tobacco and health promotion As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes None Treatment Ministry of health Yes This unit is also responsible for policies covering mental health, noncommunicable diseases, tobacco and health promotion

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system In addition to criminal sanctions Yes Yes

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Yes Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Standalone facilities for substance use disorders Stand-alone facilities for substance use disorders In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Limited (11%–20%) Very limited (1%–10%) Limited (11%–20%) Very limited (1%–10%) Cannabis Sedatives Alcohol Second Mental health facilities Mental health facilities Third Mental health services Mental health services

Availability of specialized treatment facilities for substance use disorders In other major cities Yes In other areas Yes

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 11%–20% 1%–10% 1%–10% 1%–10% Yes Registration No Yes Unknown Yes Yes No Yes Unknown Yes Unknown Yes Unknown Yes Yes Availability No – Unknown Yes For maintenance treatment No Yes Unknown Yes Unknown Yes Unknown Yes Yes Daily supervised dosing available for outpatients Unknown Yes Yes Yes Yes – / / / / No Unknown / No

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city No No Yes Yes Yes – Yes In other major cities No No In other areas No No 1%–10% 61%–100% 1%–10% None 11%–30%

Special treatment programmes for women, children and adolescents with substance use disorders

Country profiles

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No In the capital city No No Alcohol use No No No In other major cities No No In other areas No No Drug use No No No

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual) based programmes Work place programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – Yes Children and adolescents Yes Yes Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use Some (1%–30%) Some (1%–30%) – Coverage for drug use Some (1%–30%) Some (1%–30%) Some (1%–30%)

Alcohol use Drug use Alcohol use Drug use

– Yes

Yes –

– Yes

– –

– Yes

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, addiction medicine specialists and other medical doctors For psychiatrists, medical doctors and nurses For psychiatrists, medical doctors and nurses

Atlas: substance use in the Eastern Mediterranean Region 2015

Oman DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2010 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 3 855 75 88 76 High income Prevention Ministry of health Yes As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes None Treatment Ministry of health Yes In addition to criminal sanctions No Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Mental health facilities In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 99%–100% 99%–100% Unknown 99%–100% – – – More than 40% Cannabis Opioids Sedatives Second Mental health services Mental health services In other major cities – Third – – In other areas –

Availability of specialized treatment facilities for substance use disorders

Country profiles

No No No No No Yes No No No

No No No – No – – – –

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents Special housing services Employment services In the capital city Yes – In the capital city No No Unknown Unknown Unknown Unknown Unknown In other major cities – – In other major cities No No In other areas – – In other areas No No 1%–10% 1%–10% 1%–10% None 1%–10%

Special treatment programmes for women, children and adolescents with substance use disorders

Social services for people with substance use disorders

Atlas: substance use in the Eastern Mediterranean Region 2015

Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous Yes Cocaine Anonymous – Al-Anon/ Alateen – Family support groups – Alcohol use Yes No No Drug use Yes No No

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Yes Yes Children and adolescents – Yes Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use None None None Coverage for drug use High (31%–60%) Some (1%–30%) High (31%–60%)

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, addiction medicine specialists, other medical doctors, nurses, psychologists and social workers Unknown Unknown

100

Country profiles

Pakistan DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 184 350 38 58 65 Lower middle income Prevention Ministries of health and of narcotics control board Yes As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes None Treatment Ministries of health and of narcotics control board Yes In addition to criminal sanctions Yes Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Yes Yes Yes Yes Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First General hospitals General hospitals Second Other general health care services Other general health care services In other major cities Yes Cannabis Opioids Sedatives Very limited (1%–10%) Very limited (1%–10%) Very limited (1%–10%) Very limited (1%–10%) Third Community-based self-support groups Community-based self-support groups In other areas –

101

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 1%–10% 1%–10% 1%–10% 11%–20% No Registration Availability Daily supervised dosing available for outpatients – – – No No No / / / / No No / No

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Yes No No No No No Yes Unknown No Unknown Yes Unknown No Yes

– No No No No No No No No No Yes No No Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents Special housing services Employment services In the capital city No No In the capital city No No Yes No No No No In other major cities No No In other major cities No No In other areas No No In other areas No No 1%–10% 1%–10% 11%–30% 1%–10% 1%–10%

Special treatment programmes for women, children and adolescents with substance use disorders

Social services for people with substance use disorders

102

Country profiles

Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous Yes Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No Alcohol use No No No Drug use Yes Yes Yes

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – – Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use None None None Coverage for drug use None None None

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Yes Yes

– –

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists None None

103

Atlas: substance use in the Eastern Mediterranean Region 2015

Qatar DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 2 003 100 98 79 High income Prevention Ministries of health, education, interior and social welfare Yes This unit is also responsible for policies covering mental health, tobacco, noncommunicable disease and health promotion Treatment Ministries of health and social welfare Yes This unit is also responsible for policies covering mental health, tobacco, noncommunicable disease and health promotion In addition to criminal sanctions Unknown Unknown

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Unknown Unknown Unknown

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation treatment treatment Yes Yes Yes OAMT Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Stand-alone facilities for substance use disorders Stand-alone facilities for substance use disorders In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown Alcohol Cannabis Opioids Second Mental health facilities Mental health facilities Third General health care facilities –

Availability of specialized treatment facilities for substance use disorders In other major cities – In other areas –

104

Country profiles

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 90%–98% 99%–100% Unknown 90%–98% Yes Registration Availability Daily supervised dosing available for outpatients – – – Unknown – – / / / / – Unknown / –

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Yes Yes Yes Unknown Yes Yes Yes Yes Yes Yes Yes Unknown Unknown Yes

For detoxification and maintenance treatment For detoxification and maintenance treatment For detoxification and maintenance treatment Unknown For detoxification and maintenance treatment For detoxification and maintenance treatment – Yes Yes Yes Yes – No Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city No Yes No No Unknown No No In other major cities No – In other areas No – Unknown Unknown Unknown Unknown Unknown

Special treatment programmes for women, children and adolescents with substance use disorders

105

Atlas: substance use in the Eastern Mediterranean Region 2015

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Unknown Narcotics Anonymous Unknown Cocaine Anonymous Unknown Al-Anon/ Alateen Unknown Family support groups Unknown In the capital city No No Alcohol use No Unknown Unknown In other major cities No No Drug use – Unknown Unknown In other areas No No

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Yes Yes Children and adolescents Yes Yes Persons with mental health disorders Yes Yes Young adults Coverage for alcohol use Some (1%–30%) Some (1%–30%) Some (1%–30%) Coverage for drug use Some (1%–30%) Some (1%–30%) Some (1%–30%)

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services Unknown Unknown In antenatal services Unknown Unknown

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists None None

106

Country profiles

Saudi Arabia DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2012 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 29 994 83 99 76 High income Prevention Ministries of health and interior Yes This unit is also responsible for policies covering mental health and health promotion Treatment Ministries of health and interior Yes This unit is also responsible for policies covering mental health and health promotion In addition to criminal sanctions Yes Yes

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes None

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Stand-alone facilities for substance use disorders Stand-alone facilities for substance use disorders In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Substantial (21%–40%) Substantial (21%–40%) Substantial (21%–40%) Substantial (21%–40%) Cannabis ATS Alcohol Second Mental health facilities Mental health facilities Third – –

Availability of specialized treatment facilities for substance use disorders In other major cities Yes In other areas Yes

107

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown Yes Registration Availability Daily supervised dosing available for outpatients Yes Yes Yes No – – / / / / Yes – / –

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Yes Yes Yes Yes No No Yes No Yes – Yes Yes Yes –

For detoxification and maintenance treatment For detoxification and maintenance treatment For detoxification and maintenance treatment Yes No No – – Yes – Yes – Yes –

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city Yes Yes No No Yes No No In other major cities Yes Yes In other areas – – Unknown Unknown Unknown Unknown Unknown

Special treatment programmes for women, children and adolescents with substance use disorders

108

Country profiles

Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous – Cocaine Anonymous – Al-Anon/ Alateen – Family support groups Yes In the capital city Yes Yes Alcohol use Yes Yes Yes In other major cities Yes Yes Drug use Yes Yes Yes In other areas – –

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – – Persons with mental health disorders Yes Yes In antenatal services Unknown Unknown Young adults Coverage for alcohol use High (31%–60%) High (31%–60%) High (31%–60%) Coverage for drug use – High (31%–60%) High (31%–60%)

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Screening and brief interventions for substance use In primary health care services None None

109

Atlas: substance use in the Eastern Mediterranean Region 2015

Somalia DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2009 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 10 195 37 – 53 Low income Prevention – No As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts No No None Treatment Ministries of health, interior and justice – In addition to criminal sanctions – –

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First – – In the capital city No Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence – – – – – – – – Alcohol Opioids Cocaine Second – – In other major cities No Third – – In other areas No

Availability of specialized treatment facilities for substance use disorders

110

Country profiles

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients No No No No No No / / / / No No / No No

No No No No No No No No No No No No No No

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents Special housing services Employment services In the capital city No No In the capital city No No No No No No No In other major cities No No In other major cities No No In other areas No No In other areas No No 1%–10% 1%–10% 1%–10% 1%–10% –

Special treatment programmes for women, children and adolescents with substance use disorders

Social services for people with substance use disorders

111

Atlas: substance use in the Eastern Mediterranean Region 2015

Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No Alcohol use No No No Drug use No No No

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Coverage for alcohol use None None None Refugees People with HIV/ AIDS – – Children and adolescents – – Coverage for drug use None None None Persons with mental health disorders – – Young adults

Alcohol use Drug use

– –

Screening and brief interventions for substance use Alcohol use Drug use In primary health care services None None In antenatal services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals – None None

112

Country profiles

Sudan DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2012 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 36 163 30 50 63 Lower middle income Prevention Ministry of interior Yes, for drugs only This unit is also responsible for policies covering health promotion, noncommunicable diseases, tobacco and mental health As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts No No None Treatment Ministry of interior Yes This unit is also responsible for policies covering mental health

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system In addition to criminal sanctions No No

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employers financing Households Nongovernmental and other external financing Global Fund financing Yes Yes Yes Yes Yes Yes Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First General hospitals General hospitals In the capital city No Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown Alcohol Cannabis Opioids Second – – In other major cities No Third – – In other areas No

Availability of specialized treatment facilities for substance use disorders

113

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 1%–10% 21%–50% 1%–10% 50%–90% No Registration Availability Daily supervised dosing available for outpatients Unknown Unknown Unknown – – – / / / / Yes – / Yes

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Unknown Unknown Unknown No No No No No No Unknown Yes No No Yes

Unknown Unknown Unknown No No No No No No Unknown – No No –

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents Social services for people with substance use disorders Special housing services Employment services In the capital city No No In other major cities No No In other areas No No In the capital city No No No No No No No In other major cities No No In other areas No No None None None None None

Special treatment programmes for women, children and adolescents with substance use disorders

114

Country profiles

Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No Alcohol use No No No Drug use No No No

Prevention activities Prevention programmes School (manual)-based programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – – Persons with mental health disorders – – In antenatal services None None Young adults Coverage for alcohol use None None None Coverage for drug use None None None

Alcohol use Drug use Alcohol use Drug use

– –

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, psychologists and social workers None None

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Atlas: substance use in the Eastern Mediterranean Region 2015

Syrian Arab Republic DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2012 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 21 639 54 86 68 Lower middle income Prevention Ministry of health Yes This unit is also responsible for policies covering mental health As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes No None Treatment Ministry of health Yes This unit is also responsible for policies covering mental health In addition to criminal sanctions Yes No

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employers financing Households Nongovernmental and other external financing Global Fund financing Yes Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health facilities Mental health facilities In the capital city Yes Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown Opioids Prescription opioids Alcohol Second General health care facilities General health care facilities In other major cities – Third Mental health services Mental health services In other areas –

Availability of specialized treatment facilities for substance use disorders

116

Country profiles

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 21%–50% 21%–50% 21%–50% 21%–50% No Registration Availability Daily supervised dosing available for outpatients – – – – – – / / / / No – / No

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

No No No No No No Yes No Yes No Yes No No Yes

No No No No No No No No Yes No – No No Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents Social services for people with substance use disorders Special housing services Employment services In the capital city No No In other major cities No No In other areas No No In the capital city No No No No No No No In other major cities No No In other areas No No 31%–60% – 31%–60% – –

Special treatment programmes for women, children and adolescents with substance use disorders

117

Atlas: substance use in the Eastern Mediterranean Region 2015

Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No Alcohol use No No No Drug use No No No

Prevention activities Prevention programmes School (manual) based-programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Yes Yes Children and adolescents – – Persons with mental health disorders – – In antenatal services Few (1%–10%) Few (1%–10%) Young adults Coverage for alcohol use – – – Coverage for drug use – – –

Alcohol use Drug use Alcohol use Drug use

– –

Screening and brief interventions for substance use In primary health care services Few (1%–10%) Few (1%–10%)

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals – None None

118

Country profiles

Tunisia DEMOGRAPHIC INFORMATION Total population (000), 2012 Population in urban areas (%), 2012 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 10 886 66 97 74 Upper middle income Prevention Ministry of health Yes This unit is also responsible for policies covering mental health and tobacco As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes No None Treatment Ministry of health Yes This unit is also responsible for policies covering mental health and tobacco In addition to criminal sanctions Yes No

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Mental health services Mental health services Second General health care services General health care services Third – Nongovernmental organizations In other areas Yes

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Atlas: substance use in the Eastern Mediterranean Region 2015

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

No No No No No No Yes No Yes No Yes No No Yes

No No No – No No No – Yes – No – – No

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city No No Yes No No No Yes In other major cities No No In other areas No No 61%–100% None 61%–100% None None

Special treatment programmes for women, children and adolescents with substance use disorders

120

Country profiles

Social services for people with substance use disorders Special housing services Employment services Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No Alcohol use No No No Drug use No No No In the capital city No No In other major cities No No In other areas No No

Prevention activities Prevention programmes School (manual) based-programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – Yes Children and adolescents – Yes Persons with mental health disorders – – In antenatal services Unknown Unknown Young adults Coverage for alcohol use None None None Coverage for drug use High (31%–60%) Some (1%–30%) Some (1%–30%)

Alcohol use Drug use Alcohol use Drug use

– Yes

– –

– Yes

– –

– Yes

Screening and brief interventions for substance use In primary health care services None Few (1%–10%)

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, addiction medicine specialists and psychologists For psychiatrists, medical doctors and psychologists For psychiatrists, medical doctors and psychologists

121

Atlas: substance use in the Eastern Mediterranean Region 2015

United Arab Emirates DEMOGRAPHIC INFORMATION Total population (000), 2012 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 9 206 – 94 76 High income Prevention Ministries of health, education, interior and the national rehabilitation centre Yes This unit is also responsible for policies covering mental health, tobacco, noncommunicable diseases, health promotion and criminal justice Treatment Ministries of health, interior, justice and the national rehabilitation centre Yes This unit is also responsible for policies covering mental health, tobacco, noncommunicable diseases, health promotion and criminal justice In addition to criminal sanctions – Unknown

LEADERSHIP AND GOVERNANCE Principal ministry(ies)

Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Yes Yes Some jurisdictions

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Yes Inpatient detoxification Yes Outpatient Inpatient Rehabilitation OAMT treatment treatment Yes Yes Yes

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First Stand-alone facilities for substance use disorders Stand-alone facilities for substance use disorders In the capital city Yes Main substance reported at treatment entry First Second Third Prescription opioids Alcohol Sedatives Second Mental health facilities Mental health facilities Third General health care facilities General health care facilities In other areas Yes

Availability of specialized treatment facilities for substance use disorders In other major cities Yes

122

Country profiles

Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence 1%–10% 1%–10% – 11%–20% No Registration Availability Daily supervised dosing available for outpatients – – – – – – / / / / Yes – / Yes Substantial (21%–40%) – None Very limited (1%–10%)

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

No No No No – Yes Yes – No No Yes – No Yes

No No No – – For detoxification treatment Yes – – No Yes – – Yes

123

Atlas: substance use in the Eastern Mediterranean Region 2015

Special treatment programmes for women, children and adolescents with substance use disorders For women For children and adolescents Social services for people with substance use disorders Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone based interventions Mutual support/self-help groups Alcoholics Anonymous Yes Narcotics Anonymous Yes Cocaine Anonymous – Al-Anon/ Alateen – Family support groups – In the capital city Yes Yes Alcohol use Yes – – In other major cities Yes Yes Drug use Yes Unknown Unknown In other areas No – In the capital city – – In other major cities – – In other areas – –

Open access interventions for substance use problems

Prevention activities Prevention programmes School (manual) based-programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Yes Yes Children and adolescents Yes Yes Persons with mental health disorders Yes – In antenatal services – None Young adults Coverage for alcohol use Some (1%–30%) – None Coverage for drug use Some (1%–30%) – Some (1%–30%)

Alcohol use Drug use Alcohol use Drug use

Yes Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services None None

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists None None

124

Country profiles

West Bank and Gaza Strip DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 4 485 73 96 72.9 Lower middle income Prevention Ministries of health and interior Yes, for drugs only As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts No No None Treatment Ministry of health Yes, for drugs only In addition to criminal sanctions No No

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First – – In the capital city No Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence – – – – – – – Second – – In other major cities No Third – – In other areas No

Availability of specialized treatment facilities for substance use disorders

125

Atlas: substance use in the Eastern Mediterranean Region 2015

Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence – – – – No Registration Availability Daily supervised dosing available for outpatients – – – – – – / / / / – – / –

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose

Yes – – Yes Yes No Yes Unknown Yes – Yes Yes Yes Yes

– – – – For maintenance treatment No – Yes Yes – Yes – – Yes

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents In the capital city No No Yes – – – Yes In other major cities No No In other areas No No – Unknown Unknown – Unknown

Special treatment programmes for women, children and adolescents with substance use disorders

126

Country profiles

Social services for people with substance use disorders Special housing services Employment services Open access interventions for substance use problems Telephone help-lines Web-based interventions Mobile phone–based interventions Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No Alcohol use No No No Drug use No No No In the capital city No No In other major cities No No In other areas No No

Prevention activities Prevention programmes School (manual) based-programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – – Persons with mental health disorders – – In antenatal services Unknown Unknown Young adults Coverage for alcohol use None None None Coverage for drug use None None None

Alcohol use Drug use Alcohol use Drug use

– Yes

– –

Yes Yes

Screening and brief interventions for substance use In primary health care services Unknown Unknown

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists, nurses, psychologists and social workers For psychiatrists, psychologists, social workers and nurses For psychiatrists, psychologists, social workers and nurses

127

Atlas: substance use in the Eastern Mediterranean Region 2015

Yemen DEMOGRAPHIC INFORMATION Total population (000), 2013 Population in urban areas (%), 2013 Adult literacy rate (15–24 years) % Life expectancy at birth (years), 2012 Income group (World Bank) 25 235 29 34 64 Lower middle income Prevention Ministry of health Unknown As an alternative to criminal sanctions Voluntary treatment Compulsory treatment Drug courts Unknown Unknown Unknown Treatment Ministry of health Unknown In addition to criminal sanctions Unknown Unknown

LEADERSHIP AND GOVERNANCE Principal ministry(ies) Unit/entity responsible for policies

Diversion schemes from criminal justice to health care system

FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing Inpatient detoxification Outpatient Inpatient Rehabilitation OAMT treatment treatment

SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services Alcohol use disorders Drug use disorders First – – In the capital city No Main substance reported at treatment entry First Second Third Treatment coverage for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Access to treatment for substance dependence Opioid dependence Cannabis dependence Cocaine dependence Alcohol dependence Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown – – – Second – – In other major cities No Third – – In other areas No

Availability of specialized treatment facilities for substance use disorders

128

Country profiles

Pharmacological treatment Guidelines on pharmacological treatment Registration and availability of medications For opioid dependence/withdrawal/overdose Buprenorphine (sublingual tablets) for opioid dependence Buprenorphine/naloxone (tablets) for opioid dependence Buprenorphine/naloxone (films) for opioid dependence Naltrexone (tablets) for opioid dependence Methadone (liquid) for opioid dependence Methadone (tablets) for opioid dependence Clonidine (tablets) for opioid withdrawal Lofexidine (tablets) for opioid withdrawal Naloxone (for injection) for opioid overdose For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Diazepam (tablets) for alcohol withdrawal Disulfiram (tablets) for alcohol dependence Naltrexone (tablets) for alcohol dependence For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal No No – – No No – – – – / No No / No Registration No No No – – – No – – Availability No No No – – – – – – Daily supervised dosing available for outpatients No No No No No No / / / No

Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling HIV (ARV) treatment Hepatitis testing and counselling Hepatitis vaccination Hepatitis treatment Harm reduction programmes Needle/syringe exchange programmes Outreach services for injecting drug users Drop-in services Naloxone distribution programmes Condom distribution programmes For women For children and adolescents Special housing services Employment services Telephone help-lines Web-based interventions Mobile phone based interventions In the capital city No No In the capital city No No Alcohol use No No No Unknown Unknown Unknown Unknown Unknown In other major cities No No In other major cities No No In other areas No No In other areas No No Drug use No No No Unknown Unknown Unknown – –

Special treatment programmes for women, children and adolescents with substance use disorders

Social services for people with substance use disorders

Open access interventions for substance use problems

129

Atlas: substance use in the Eastern Mediterranean Region 2015

Mutual support/self-help groups Alcoholics Anonymous No Narcotics Anonymous No Cocaine Anonymous No Al-Anon/ Alateen No Family support groups No

Prevention activities Prevention programmes School (manual) based-programmes Workplace programmes Parenting programmes Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS – – Children and adolescents – – Persons with mental health disorders – – In antenatal services Unknown Unknown Young adults Coverage for alcohol use None None None Coverage for drug use None None None

Alcohol use Drug use Alcohol use Drug use

– –

Screening and brief interventions for substance use In primary health care services Unknown Unknown

WORKFORCE Availability of postgraduate training programmes Prevention Treatment National standards of care for professionals For psychiatrists For psychiatrists, medical doctors, psychologists, social workers, nurses, counsellors and community health workers For psychiatrists, medical doctors, psychologists, social workers, nurses, counsellors and community health workers

130

Mental disorders have a profound effect on individuals, their families and society, and are responsible for 11% of disease burden in the Eastern Mediterranean Region yet. WHO’s Project Atlas 2014 has collected and compiled information about mental health resources in countries around the world. This regional review incorporates region-specific data, presenting comparisons with other regions, analysing countries with similar health system characteristics within the Region, and providing concise summary sheets for each country that provided data for the Atlas 2014 Project. It is hoped that this will assist stakeholders in the countries of the Region to identify gaps in current provision and inform decisions around increasing resources to scale up services for mental health.

45EMRO Technical Publications Series Atlas: substance use in the Eastern Mediterranean Region 2015 45EMRO Technical Publications Series Atlas: substance use in the Eastern Mediterranean Region 2015 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited. In any use of this work, there should be no suggestion that WHO endorses then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation . Licence: CC BY- NC-SA 3.0 IGO. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean Atlas: substance use in the Eastern Mediterranean Region 2015 / World Health Organization. Regional Office for the Eastern Mediterranean p. .- (EMRO Technical Publications Series; 45) ISBN: 978-92-9274-547-9 ISBN: 978-92-9274-548-6 (online) ISSN: 1020-0428 1. Substance-Related Disorders - prevention & control 2. Substance-Related Disorders – therapy 3. Substance-Related Disorders - epidemiology - Eastern Mediterranean Region 4. Alcohol-Related Disorders 5. Health Services 6. Atlases I. Title II. Regional Office for the Eastern Mediterranean III. Series (NLM Classification: WM 270) This publication was originally published under ISBN: 978-92-9022-144-9, 978-92-9022-145-6 Contents Executive summary ...................................................................................... 5 Information systems ..................................................................................... 6 1. Introduction ............................................................................................... 7 2. Methodology .............................................................................................. 7 2.1 Data collection ...................................................................................................................................... 7 2.2 Limitations ............................................................................................................................................. 8 3. Substance use and health: situation in the Region ................................. 8 3.1 Sociodemographic characteristics of the Region .......................................................................... 8 3.2 Epidemiology ........................................................................................................................................ 8 4. Country responses to the Atlas questionnaire ..................................... 16 4.1 Leadership and governance .............................................................................................................. 16 4.2 Financing ............................................................................................................................................... 22 4.3 Service organization and delivery ................................................................................................... 26 4.4 Workforce ............................................................................................................................................ 45 4.5 Information systems .......................................................................................................................... 48 5. Comparison of data between Atlas 2012 and Atlas 2015 .................... 52 5.1 Leadership and governance .............................................................................................................. 53 5.2 Financing ............................................................................................................................................... 53 5.3 Service organization and delivery ................................................................................................. 54 5.4 Workforce ............................................................................................................................................ 56 5.5 Information systems .......................................................................................................................... 57 6. Conclusion ................................................................................................ 58 Glossary ........................................................................................................ 59 Country fact sheets: substance use disorders .............................................................................. 63 Afghanistan ................................................................................................................................................. 65 Bahrain ......................................................................................................................................................... 68 Djibouti........................................................................................................................................................ 71 Egypt ............................................................................................................................................................ 74 Iran (Islamic Republic of) ......................................................................................................................... 77 Iraq ............................................................................................................................................................... 80 Jordan ........................................................................................................................................................... 83 Kuwait .......................................................................................................................................................... 86 Lebanon ....................................................................................................................................................... 89 Libya ............................................................................................................................................................. 92 Morocco ...................................................................................................................................................... 95 4Atlas: substance use in the Eastern Mediterranean Region 2015 Oman ........................................................................................................................................................... 98 Pakistan ...................................................................................................................................................... 101 Qatar ........................................................................................................................................................ 104 Saudi Arabia .............................................................................................................................................. 107 Somalia....................................................................................................................................................... 110 Sudan .......................................................................................................................................................... 113 Syrian Arab Republic ..............................................................................................................................116 Tunisia ........................................................................................................................................................ 119 United Arab Emirates ............................................................................................................................122 West Bank and Gaza Strip ....................................................................................................................125 Yemen ........................................................................................................................................................ 128 5Executive summary Executive summary The atlas project on substance use is a project conducted by the World Health Organization (WHO) that aims to collect, compile and disseminate information on the availability of resources for the prevention and treatment of substance use disorders. A first assessment of available resources was carried out at the global level1 and at the regional level2. This report presents the latest information on the available resources and services at country level for the prevention and treatment of substance use disorders in the Eastern Mediterranean Region. The information presented in this report is based on an atlas questionnaire that was updated from the previous version and sent to all countries. All of the 22 countries of the Region submitted replies to the atlas questionnaire. Key findings of the report are presented below. Substance use and health: situation in the Region • The estimate of the total alcohol per capita consumption in the Region for 2010 is 0.7 litres of pure alcohol, which is almost nine times lower than the global estimate3. • The prevalence of opioid use varies greatly within the Region but is among the highest in the world in some countries. • Lifetime prevalence of cannabis and amfetamine use among students aged 13– 15 years is 3.5% and 3.3% respectively, with large differences between males and females. 1 Atlas on substance use 2010. Resources for the prevention and treatment of substance use disorders. Geneva: World Health Organization; 2010. 2 Atlas: substance use in the Eastern Mediterranean Region 2012. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2012. 3 Global status report on alcohol and health 2014. Geneva: World Health Organization; 2014. • The regional estimated number of deaths due to drug use disorders in 2012 is 1.8 per 100 000 population, which is almost three times the estimated number of deaths due to alcohol use disorders. • The regional estimated number of disability-adjusted life years (DALYs) due to drug use disorders in 2012 is 253 per 100 000 population. Leadership and governance • More than half of the countries have a government unit/official responsible for the prevention and treatment of substance use disorders. • More than 60% of the countries have a legislative provision for offering voluntary treatment for drug use disorders as an alternative or in addition to criminal sanctions. Financing • Specific budget lines for the prevention and treatment of substance use disorders are available at the ministry of health in the majority of the countries. • Government financing is the most common financing method for treatment services for substance use disorders. • In the vast majority of the countries, people with substance use disorders are not eligible to receive government benefits. Service organization and delivery • 60% of the countries have specialized treatment facilities for substance use disorders in the capital city, but only 28% have such facilities in areas other than the capital city or other major cities. • Mental health facilities are the most important providers of treatment services for alcohol use disorders. 6Atlas: substance use in the Eastern Mediterranean Region 2015 • Specialized stand-alone facilities are the most important providers of treatment services for drug use disorders. • The regional median number of beds reserved for the treatment of substance use disorders is 0.7 per 100 000 population. • Information on treatment coverage or access to treatment is not known in the vast majority of countries. • Cannabis and opioids are the main substances reported as the primary drugs being used at treatment entry. Pharmacological treatment • 50% of the countries have guidelines on the pharmacological treatment of substance use disorders. • Pharmacotherapies for opioid dependence are available in less than 25% of the countries. Special programmes and services • Needle/syringe exchange programmes are available in one-third of the countries of the Region. • Less than 25% of the countries have special treatment programmes for women, children or adolescents with substance use disorders. Prevention • Community-based prevention programmes for drug use are available in almost 75% of the countries. • Nongovernmental organizations, schools and religous groups are involved in prevention of substance use in more than 75% of the countries. • Most countries have not implemented screening and brief interventions for substance use in primary health care. Workforce • Psychiatrists, medical doctors, psychologists, social workers and nurses provide treatment for substance use disorders in more than half of the countries. • Postgraduate training programmes for professionals providing treatment are not available in 40% of the countries. Information systems • More than half of the countries do not have an epidemiological data collection system for substance use. • 45% of the countries do not have a system of data collection based on health services delivery for substance use disorders. 7Introduction 1. Introduction The use of alcohol and other psychoactive substances alters brain functions, such as mood, perception and consciousness. It can lead to physical and psychological dependence, coercing a person to continue taking the drug despite adverse consequences. People with substance use disorders may suffer from psychological and psychosocial problems, loss of employment or legal problems. Substance use disorders are chronic mental disorders characterized by remissions and relapses and frequently accompanied by other mental conditions, such as depression or anxiety disorder, or by physical conditions such as HIV/AIDS, hepatitis B and C, and tuberculosis. Given the complexity of their health and social consequences, management of substance use disorders involves a range of prevention, treatment and rehabilitation approaches. Delivery of adequate care and treatment to people with substance use disorders requires a well functioning prevention and treatment system. Pharmacological, psychological and social interventions have been shown to be effective. The WHO atlas project on resources for the prevention and treatment of substance use disorders aims to collect, compile and disseminate information on resources for the prevention and treatment of substance use disorders. A first assessment was conducted in 2011 in order to map resources available in the Eastern Mediterrean Region. The aim of this report is to update that information by providing the regional response to the atlas questionnaire conducted in 2014. The data presented in this report are needed at the country level to assess the current situation and to assist in developing policies, plans and programmes. This report provides the latest information available regarding substance use and health in the Region; the results of the atlas questionnaire are presented in the following sections: leadership and governance, financing, service organization and delivery, workforce, and information systems. A last section aims to monitor progress between the first assessment in 2011 and the latest information presented in this report. Though changes to the instruments make it challenging to compare certain items directly, some information can be tracked. Finally, country fact sheets providing detailed information for each country are presented at the end. 2. Methodology 2.1 Data collection The atlas project on resources for the prevention and treatment of substance use disorders was launched in 2010 by WHO in an attempt to map resources available worldwide for the prevention and treatment of substance use disorders. The 2015 version of the atlas represents the latest information on resources available. The questionnaire has been updated and contains the following sections: • policy, legislation and financing • human resources and training • services and interventions • health information systems. The questionnaire was sent to nominated focal points at ministries of health. The focal point was encouraged to consult with experts and gather relevant information to answering questions. Once a completed questionnaire was received, it was screened for incomplete and inconsistent answers. To ensure high quality data, respondents were contacted again and were asked to respond to the requests for clarification and to correct their responses. 8Atlas: substance use in the Eastern Mediterranean Region 2015 All of the countries in the Region replied to the atlas questionnaire on substance use. 2.2 Limitations Most of the data presented in this report are based on expert opinion; the designated focal points in ministries of health in consultation with related experts having provided the data for development of the atlas. Scarcity of information was a major challenge in compiling the report. For some items, particularly regarding service organization and delivery, information was not provided. A few components that are essential for a comprehensive treatment package for substance use disorders, namely structured psychosocial interventions, were not surveyed in development of the atlas and therefore the relevant data are missing in the current report. 3. Substance use and health: situation in the Region 3.1 Sociodemographic characteristics of the Region Table 1 provides a brief overview of sociodemographic statistics of the WHO Eastern Mediterranean Region. These indicators are extracted from Framework for health information systems and core indicators for monitoring health situation and health system performance 2014 for the Eastern Mediterranean Region4, except for the “Population proportion under 15” indicator which is extracted from the WHO Global Health Observatory5. Findings • The Eastern Mediterranean Region is the least populous among the six WHO regions. • In terms of proportion of population 15 years and under, the Region ranks second. • With almost 50% of the total population in the Region living in urban areas, the Eastern Mediterranean Region ranks fourth among the six WHO regions. • In terms of life expectancy at birth and adult literacy rate the Region ranks fourth. 3.2 Epidemiology 3.2.1 Per capita alcohol consumption Table 2 provides information on recorded and unrecorded per capita alcohol consumption in the Region and in the world for 2010. These data are extracted from the Global status report on alcohol and health 20149. Table 3 provides data on total per capita alcohol consumption by sex. Findings • The Region has the lowest alcohol consumption level among all WHO regions. • The regional estimate is almost nine times lower than the global estimate. • More than half of the alcohol consumed is unrecorded, which refers to alcohol that is not accounted for in official statistics on alcohol taxation or sales. • Alcohol consumption among women in the Region is 11 times lower than consumption among men, while at the global level, women drink nearly four times less than men. 4 Framework for health information systems and core indicators for monitoring health situation and health system performance 2014. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2014. (http://applications.emro.who.int/dsaf/EMROPUB_2014_ EN_1792.pdf?ua=1, accessed 5 March 2016). 5 See http://apps.who.int/gho/data/view.main. POP2020?lang=en, accessed 5 March 2016. 6 Data from five countries are available for 2012. 7 Data from five countries are available for 2012, data from one country are available for 2011 and data for one country are available for 2009. 8 Data are available from 2006 to 2013 depending on the country. 9 Global status report on alcohol and health 2014. Geneva: World Health Organization; 2014. 9Substance use and health: situation in the Region 3.2.2 Prevalence of illicit drug use The data presented in Table 4 are extracted from the latest UNODC annual prevalence of use estimates for population aged 15 to 6410. These data are based on the UNODC annual report questionnaire, UNODC estimates and in some cases governments’ national reports. It should be highlighted that recent information is not available for the majority of the countries of the Region. Findings for annual prevalence of cannabis use • In most countries of the Region, cannabis is the most common drug used by population aged 15 to 64. • According to UNODC estimates that are available for nine countries in the Region, the regional median annual prevalence is 3.6%. Fig. 1 presents the annual prevalence for these countries. • Compared to the last estimated regional median11, this represents an increase of more than 10%. Table 1. Demographic and socioeconomic indicators of the Region Total population (000s), 20136 618 210 Urban population (%), 20137 49.5 Population proportion under 15 (%), 2013 33 Adult literacy rate (15–24 years) (%)8 63.5 Life expectancy at birth (years), 2012 68.5 Table 2. Total recorded and unrecorded per capita alcohol (15+ years) consumption in litres of pure alcohol, 2010 Eastern Mediterranean Region World Recorded per capita alcohol consumption 0.3 4.7 Unrecorded per capita alcohol consumption 0.4 1.5 Total 0.7 6.2 Table 3. Total per capita alcohol (15+ years) consumption in litres of pure alcohol by sex, 2010 Eastern Mediterranean Region World Female 0.1 2.5 Male 1.2 9.9 Both 0.7 6.2 10 United Nations Office on Drugs and Crime. World Drug Report 2014 (https://www.unodc.org/documents/wdr2014/ World_Drug_Report_2014_web.pdf, accessed 5 March 2016). Table 4. Estimates of annual prevalence of illicit drug use for population aged 15–64 (%) Opioids Cocaine Cannabis ATS Afghanistan (2009) 2.92 0 4.28 0 Egypt (2006) 0.44 0.02 6.24 0.48 Islamic Republic of Iran (2010) 2.27 0.01 (2008) 0.13 Kuwait (2004) 0.17 0.04 (2005) 3.1 (2005) 0.27 (2005) Lebanon (2003) 0.2 2 (2009) Libya (2004) 0.14 Morocco (2011) 0.08 0.05 (2004) 4.22 (2004) Pakistan (2012) 2.4 0.01 3.6 0.08 Saudi Arabia (2006) 0.06 0.3 0.4 Somalia (2004) 0.16 2.5 (2002) Syrian Arab Republic (2005) 0.02 0 Tunisia (2011) 0.12 United Arab Emirates (2004) 0.02 5.35 (2006) 11 See Atlas: substance use in the Eastern Mediterranean Region 2012. Cairo: World Health Organization, Regional Office for the Eastern Mediterranean; 2012. 10 Atlas: substance use in the Eastern Mediterranean Region 2015 Findings for annual prevalence of opioid use • There are large regional differences in the annual prevalence of opioid use, with an annual prevalence of more than 2% in Afghanistan, Pakistan and Islamic Republic of Iran and less than 0.5% in the other countries in the Region for which data are available; see Fig. 2. • The prevalence of opioid use in Afghanistan, Pakistan and Islamic Republic of Iran is among the highest in the world. • Based on 13 countries, the regional median is 0.16%, which is similar to the regional median estimated in the Atlas 2012. However, as mentioned above, some of the data have not been updated since that previous report. Findings for annual prevalence of cocaine use • Prevalence data are available for five countries in the Region (see Fig. 3) and show a median of less than 0.1%, which is similar to the regional median estimated in the Atlas 2012. Findings for annual prevalence of amfetamine-type stimulant (ATS) use • ATS use is reported for five countries with the annual prevalence estimated at 0.2%. Fig. 4 presents the data for these countries. 3.2.3 Illicit drug use among young people Information on drug use among young people is extracted from the global school-based student health survey (GSHS). Data are provided for Iraq, Lebanon, Kuwait, Morocco, West Bank, Gaza and the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) in Gaza, Lebanon, Syrian Arab Republic and West Bank. The year at which the surveys were conducted varies between 2010 and 2012. Cannabis Among all students aged 13–15 years, the lifetime prevalence of cannabis use ranges from 2.1% to 5%, with a median of 3.5%. The proportion of girls who reported having Fig. 1. Annual prevalence of use of cannabis among population aged 15–64 years Pr ev al en ce ( % ) 7 6 5 4 3 2 1 0 Eg yp t ( 20 06 ) Un ite d A ra b E mi ra tes (2 00 6) Af gh an ist an (2 00 9) Mo ro cc o (2 00 4) Pa kis tan (2 01 2) Ku wa it (2 00 5) So ma lia (2 00 2) Le ba no n ( 20 09 ) Sa ud i A ra bia (2 00 6) 11 used cannabis more than once in their lifetime is six times lower than among boys. Indeed, the median lifetime prevalence for girls is 1% and 6.2% for boys. Fig. 5 shows the lifetime prevalence of cannabis use for all of the countries by sex. Amfetamines Fig. 6 shows the lifetime prevalence of amfetamine use by sex and by country. Among all students aged 13–15 years, the lifetime prevalence of amfetamine use varied between 2.1% and 5%, with a median of 3.3%. As for cannabis use, the proportion of girls who Pr ev al en ce ( % ) 3.5 3 2.5 2 1.5 1 0.5 0 Af gh an ist an (2 00 9) Pa kis tan (2 01 2) Isl am ic Re pu bli c o f Ir an (2 01 0) Eg yp t ( 20 06 ) Le ba no n ( 20 03 ) Ku wa it (2 00 4) So ma lia (2 00 4) Lib ya (2 00 4) Tu nis ia (2 01 1) Mo ro cc o (2 01 1) Sa ud i A ra bia (2 00 6) Sy ria n A ra b R ep ub lic (2 00 5) Un ite d A ra b E mi ra tes (2 00 4) Fig. 2. Annual prevalence of use of opioids among population aged 15–64 years Fig. 3. Annual prevalence of use of cocaine among population aged 15-64 years Substance use and health: situation in the Region Pr ev al en ce ( % ) 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Mo ro cc o ( 20 04 ) Ku wa it ( 20 05 ) Eg yp t ( 20 06 ) Isl am ic Re pu bli c o f Ira n ( 20 08 ) Pa kis tan (2 01 2) Fig. 4. Annual prevalence of use of ATS (excluding ecstasy) among population aged 15-64 years Sa ud i A rab ia (20 06 ) Pr ev al en ce ( % ) 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Ku wa it ( 20 05 ) Eg yp t ( 20 06 ) Isl am ic Re pu bli c o f Ira n ( 20 10 ) Pa kis tan (2 01 2) 12 Atlas: substance use in the Eastern Mediterranean Region 2015 reported having used amfetamines more than once in lifetime is nearly six times lower than among boys. The median lifetime prevalence for girls is 1% and 5.7% for boys. Fig. 7 shows the proportion of students who first used drugs before 14 years out of the total number of students who ever used drugs. The median for the countries that reported data is 87.25%. Few countries from the Region have conducted the GSHS. Out of the countries that have conducted it, not all of the questions regarding drug use were completed, which decreases the quality of the data. More efforts should be made to use this tool to assess behavioural risk factors among schoolchildren. 3.2.4 Prevalence of alcohol use disorders Table 5 provides the prevalence estimates of alcohol use disorders by sex for the Region and the world. These data are extracted from the Global status report on alcohol and health 201412. 12 Global status report on alcohol and health 2014. Geneva: World Health Organization, 2014. Pr ev al en ce ( % ) 8 7 6 5 4 3 2 1 0 West Bank 2010 Gaza Strip 2010 Lebanon 2011 Morocco 2010 Kuwait 2011 Iraq 2012 Both Male Female Fig. 5. Proportion of students aged 13–15 years who used cannabis more than once in their lifetime Fig. 6. Proportion of students aged 13–15 years who used amfetamines more than once in lifetime Pr ev al en ce ( % ) 12 10 8 6 4 2 0 Morocco 2010 (n = 2924) Lebanon 2011 (n = 2286) Kuwait 2011 (n = 2672) Iraq 2012 (n = 2038) Both Male Female 13 Findings • The prevalence estimates of alcohol use disorders in the Eastern Mediterranean Region is almost 14 times lower than the global prevalence. • Compared to alcohol consumption estimates, the difference between the regional and global estimates is higher for alcohol use disorders. However, the sex difference is higher for alcohol consumption than for alcohol use disorders. 3.2.5 Prevalence of drug dependence Table 6 provides the latest estimates for drug dependence in the North Africa and Middle East Region13 and globally. These data are extracted from Degenhardt et al., 2013 and are based on the Global Burden of Disease Study 2010. Estimates are available for cannabis, amfetamine, cocaine and opioid dependence. Findings • The estimated prevalence for opioid dependence in the North Africa and Middle East Region is 0.29%, which is 1.3 times higher than the global prevalence. • The estimated prevalence for cocaine dependence is 0.14% in this region and 0.1% globally. • Amfetamine dependence is similar to global estimates. • The estimated prevalence for cannabis dependence in this region is 1.4 times lower than the global estimates. 3.2.6 Mortality estimates Estimates of the number of deaths due to alcohol and drug use disorders are extracted from the WHO Global Health Estimates 2012. Fig. 8 shows the number of deaths per 100 000 Fig. 7. Proportion of students aged 13–15 years of age who ever used drugs and first used drugs before 14 years of age Pr ev al en ce ( % ) 94 92 90 88 86 84 82 80 Morocco 2010Gaza Strip 2010West Bank 2010 Substance use and health: situation in the Region Table 5. Prevalence (%) of alcohol use disorders in population aged 15 years or older by sex, 2010 Eastern Mediterranean Region World Female 0.2 1.3 Male 0.6 7.2 Both 0.3 4.1 13 The North Africa and Middle East Region includes the countries of the WHO Eastern Mediterranean Region with the exceptions of Afghanistan, Djibouti, Pakistan, Somalia and Sudan. Algeria and Turkey are in the North Africa and Middle East Region, but they are not part of the WHO Eastern Mediterranean Region. Table 6. Estimated number of cases and age-standardized and sex-standardized prevalence of drug dependence in 2010 Prevalence in North Africa and Middle East % (95% UI) Global prevalence % (95% UI) Cannabis dependence 0.14 (0.12–0.18) 0.19 (0.17–0.21) Amfetamine dependence 0.24 (0.20–0.28) 0.25 (0.22–0.28) Cocaine dependence 0.14 (0.11–0.17) 0.10 (0.09–0.11) Opioid dependence 0.29 (0.22–0.37) 0.22 (0.20–0.25) 14 Atlas substance use in the Eastern Mediterranean Region 2015 population due to alcohol use disorders and drug use disorders for the Eastern Mediterranean Region and the world. Table 7 provides the number of deaths due to drug use disorders for each country in the Region by sex and age group. Findings • The number of deaths per 100 000 population in the Eastern Mediterranean Region due to alcohol use disorders is one of the lowest in the world and is 25 times lower than the global estimate. • The number of deaths due to drug use disorders in the Region is 1.82 per 100 000 population, which is 1.4 times higher than the global estimate (i.e. 1.32). 3.2.7 Morbidity estimates Estimates of the number of disability adjusted life years (DALYs) lost due to alcohol and drug use disorders are extracted from the WHO Global Health Estimates 2012. DALYs represent a measure of the disease burden, quantifying the mortality and morbidity due to substance use disorders in a single measure. Fig. 9 provides the number of DALYs due to alcohol use disorders and drug use disorders for the Region and the world. Table 8 provides the number of DALYs per 100 000 population due to drug use disorders for each country in the Eastern Mediterranean Region by sex and age group. Table 7. Number of deaths per 100 000 population due to drug use disorders by sex and age group, 2012 Age group Female Male 15–29 30–59 60–69 15–29 30–59 60–69 Afghanistan 1.66 2.22 2.13 2.49 3.92 4.44 Bahrain 0.02 0.10 0.57 0.62 1.03 2.05 Djibouti 1.39 1.90 2.08 4.37 4.38 3.95 Egypt 0.29 1.74 5.23 2.17 5.42 7.96 Islamic Republic of Iran 0.49 1.66 6.22 8.88 12.94 13.76 Iraq 0.19 1.13 4.13 0.84 3.89 7.55 Jordan 0.07 0.32 0.99 0.84 2.08 4.19 Kuwait . . . 1.27 2.12 4.99 Lebanon . . . . 0.02 0.07 Libya 0.02 0.09 0.33 0.12 0.50 1.27 Morocco 0.18 0.79 2.06 0.94 2.50 3.60 Oman . . . 0.04 0.06 0.13 Pakistan 0.43 0.75 1.48 1.00 1.75 2.31 Qatar . . . 0.02 0.04 0.08 Saudi Arabia . . . 0.02 0.02 0.06 Somalia 1.41 2.04 2.26 7.13 7.37 3.74 Sudan 1.01 1.56 1.57 4.13 5.02 3.03 Syrian Arab Republic . . . 0.02 0.07 0.15 Tunisia 0.02 0.11 0.34 0.37 0.85 1.10 United Arab Emirates 0.02 0.07 1.03 0.51 0.64 2.13 Yemen 0.57 1.89 4.35 2.10 4.48 5.59 Note: . denotes zero estimated deaths 15 N um be r of d ea th s pe r 10 0 00 0 po pu la tio n 2.0 1.5 1.0 0.5 0.0 World Drug use disordersAlcohol use disorders Eastern Mediterranean Region Fig. 8. Number of deaths per 100 000 population due to alcohol and drug use disorders, both sexes, all ages, 2012 Substance use and health: situation in the Region Fig. 9. Number of DALYs per 100 000 population due to alcohol and drug use disorders, both sexes, all ages, 2012 N um be r of D A LY s pe r 10 0 00 0 po pu la tio n 500 400 300 200 100 0 Drug use disordersAlcohol use disorders WorldEastern Mediterranean Region Table 8. Number of DALYs per 100 000 population due to drug use disorders by sex and age group, 2012 Age group Female Male 15–29 30–59 60–69 15–29 30–59 60–69 Afghanistan 237.34 235.33 70.48 543.51 457.20 152.18 Bahrain 153.95 152.99 27.01 618.52 373.57 82.66 Djibouti 203.33 189.41 66.68 637.50 425.00 128.66 Egypt 163.18 211.98 155.75 618.51 538.53 249.25 Islamic Republic of Iran 171.71 208.25 183.11 1120.98 948.97 414.47 Iraq 145.97 188.60 124.93 482.02 485.53 236.58 Jordan 143.68 158.93 37.82 514.29 409.37 141.36 Kuwait 154.14 164.41 12.03 628.21 446.30 171.51 Lebanon 130.38 124.00 9.80 435.75 253.20 24.79 Libya 145.91 150.07 19.82 485.41 330.39 61.23 Morocco 150.19 165.32 67.89 527.48 395.82 128.52 Oman 148.27 164.56 10.83 585.32 391.89 30.33 Pakistan 158.36 158.54 51.73 467.62 343.24 90.58 Qatar 164.29 173.54 12.42 662.80 386.70 32.68 Saudi Arabia 143.64 146.84 10.56 512.20 327.96 29.39 Somalia 201.60 190.30 71.72 797.34 580.49 123.24 Sudan 174.40 171.04 52.30 596.19 458.91 102.93 Syrian Arab Republic 137.90 137.94 10.54 444.49 298.44 28.68 Tunisia 139.82 131.20 20.10 479.31 300.56 55.32 United Arab Emirates 163.25 197.93 42.35 667.49 497.12 92.35 Yemen 169.27 223.48 131.19 556.47 522.30 180.65 16 Atlas: substance use in the Eastern Mediterranean Region 2015 Findings • The estimated number of DALYs due to alcohol use disorders is 36 per 100 000 population in the Region, which is almost 13 times lower than the global average of 454. • The estimated number of DALYs per 100 000 population due to drug use disorders is 253, which is almost 1.18 times higher than the global average of 215. 4. Country responses to the Atlas questionnaire 4.1 Leadership and governance 4.1.1 Government unit/official for prevention/treatment Background Respondents were asked about the presence of a government unit/official responsible for a policy regarding prevention of substance use*14 and/ or treatment of substance use disorders*. They were also asked to specify whether alcohol and drug policies were under the same government unit/official (Fig. 10). If there was a government unit/official for prevention of substance use or treatment of substance use disorders, respondents were requested to indicate if this unit was also responsible for other areas, such as mental health, tobacco, noncommunicable diseases, health promotion and criminal justice (Fig. 11). Findings • Most countries in the Eastern Mediterranean Region have a unit/official responsible for prevention of substance Fig. 10. Government unit/official responsible for prevention/treatment of substance use14 The terms followed by an asterisk are defined in the glossary. 100 90 80 70 60 50 40 30 20 10 0 Treatment (n = 20) Prevention (n = 22) Unknown None Two separate units/officials for alcohol and drugs One unit/official for drugs only One unit/official for alcohol and drugs Pe rc en ta ge o f c ou nt ri es use (63%) or treatment of substance use disorders (75%). • Three countries reported having no unit/ official responsible for prevention of substance use. • Among countries with a unit/official responsible for alcohol and drugs together, the majority reported that this unit/official is also responsible for mental health policies. Two countries (14%) reported that this unit/official is responsible for substance use policies only. 4.1.2 Ministry with primary responsibility for prevention/treatment Background Respondents were asked to indicate the ministry taking primary responsibility regarding prevention of substance use and/or treatment of substance use disorders (Fig. 12). Findings • The ministry of health was reported as being responsible for prevention and 17 treatment by the majority of the countries of the Eastern Mediterranean Region. • The ministries of interior, education and social welfare were also reported as being responsible for prevention of alcohol and drug use, but were less often reported as being responsible for treatment. Notes and comments • This question asked for the ministry that takes primary responsibility for prevention and/or treatment. It was allowed to select a maximum of two ministries if responsibilities were equally shared. However, some countries selected more than two ministries, particularly for prevention. Fig. 11. Areas under responsibility of the government unit/official responsible for alcohol and drugs together Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 Treatment (n = 15)Prevention (n = 14) None Criminal justice Behavioural addictions Gambling Health promotion TobaccoMental health Noncommunicable diseases Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Treatment – drugs (n = 20)Prevention – drugs (n = 19)Treatment – alcohol (n = 20)Prevention – alcohol (n = 19) OtherOffice of the prime minister/ president Ministry of justice Ministry of education Ministry of social welfare Ministry of interior Ministry of health Fig. 12. Ministry with primary responsibility for prevention/treatment 18 Atlas: substance use in the Eastern Mediterranean Region 2015 • Two countries reported that there is no ministry that is responsible for treatment of alcohol use disorders. • Other ministries, such as the ministry of sports affairs and the ministry of religious affairs were reported as being responsible for treatment of drug use disorders. 4.1.3 Stakeholder involvement in policies, strategies and national programmes Background Nominated focal points were requested to indicate whether representatives of affected and targeted populations were regularly involved in the development and formulation of policies and strategies, as well as in the development and implementation of national programmes. Representatives of affected and targeted populations included representatives of youth organizations, of drug users, of patients and of family members of patients. They were also requested to indicate whether representatives of nongovernmental organizations and representatives of economic operators (including the alcohol, tobacco and pharmaceutical industries) were involved (Fig. 13 and 14). Findings • Representatives of nongovernmental organizations were reported to be involved in the development and formulation of policies and strategies regarding prevention and treatment by most of the countries of the Eastern Mediterranean Region. • 40% of the countries reported that representatives of youth organizations were involved in the development and formulation of policies and strategies regarding prevention. • 40% of the countries reported that representatives of drug users, patients and/or family members were involved in the development and formulation of policies and strategies regarding treatment. • Most countries reported that representatives of nongovernmental organizations were involved in the development and implementation of national programmes regarding prevention and treatment. Fig. 13. Stakeholders involvement in development and formulation of policies and strategies Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 Treatment (n = 10)Prevention (n = 12) Economic operatorsDrug users, patients and/ or their family members Youth organizationsNongovernmental organizations 19 Notes and comments • Between nine and 12 countries provided responses to these questions because such policies, strategies or national programmes do not exist. 4.1.4 Five-year change in resources and international cooperation in prevention/treatment Background Respondents were asked to indicate the change in government resources (financial or human resources) and international cooperation in prevention of substance use and treatment of substance use disorders over the past five years. It refers to the past five years because two important documents were adopted and published prior to 2010. Indeed, in 2009 Member States of the United Nations adopted the Political Declaration and Plan of Action on International Cooperation towards an Integrated and Balanced Strategy to Counter the World Drug Problem, and in 2010, the World Health Assembly endorsed the Global strategy to reduce the harmful use of alcohol15(Fig. 15 and 16). Findings • Government resources for prevention of drug use have overall increased (either slightly or significantly) in most countries of the Eastern Mediterranean Region. • One country reported that government resources for prevention and treatment of both alcohol and drug use disorders have significantly decreased due to an ongoing war. • Between 10% and 27% of countries of the Region reported that the changes to the allocation of government resources for prevention or treatment of alcohol and drug use disorders are unknown. • Overall, international cooperation in prevention of drug use and treatment of drug use disorders has increased (either slightly or significantly) in the majority of countries. Notes and comments • Between three and six countries responded “not applicable” for the changes to the allocation of government resources for prevention and treatment of alcohol or drug use disorders. These results are not displayed on the graph. Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Treatment (n = 9)Prevention (n = 12) Economic operatorsDrug users, patients and/ or their family members Youth organizationsNongovernmental organizations Fig. 14. Stakeholders involvement in development and implementation of national programmes Country responses to the Atlas questionnaire 15 Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization, 2010. 20 Atlas: substance use in the Eastern Mediterranean Region 2015 • Between one and five countries responded “not applicable” for the changes in international cooperation in prevention and treatment of alcohol or drug use disorders. These results are not displayed on the graph. 4.1.5 Confidentiality of people in treatment Background Nominated focal points were asked to indicate if there exists a law or a legal regulation at the national or subnational level which protects the confidentiality of people in treatment for alcohol and drug use disorders (Fig. 17). Pe rc en ta ge o f c ou nt ri es 50 40 30 20 10 0 UnknownIncreasedNo changeDecreased Treatment – drugs (n = 20)Prevention – drugs (n = 22)Treatment – alcohol (n = 20)Prevention – alcohol (n = 22) Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 UnknownIncreasedNo change Treatment – drugs (n = 19)Prevention – drugs (n = 21)Treatment – alcohol (n = 19)Prevention – alcohol (n = 21) Fig. 15. Changes to the allocation of government resources in the last five years Fig. 16. Changes in international cooperation in the last 5 years 21 Findings • The majority of the countries of the Region reported having a law or legal regulations to protect the confidentiality of people in treatment for alcohol or drug use disorders. 4.1.6 Voluntary treatment as an alternative/in addition to criminal sanctions Background Respondents were asked to report on the existence of legislative or administrative provisions (at the national or subnational level) for offering voluntary treatment as an alternative to or in addition to criminal sanctions for people with substance use disorders who come into contact with the criminal justice system (Fig. 18). Countries of the Eastern Mediterranean Region that reported having such legislative or administrative provisions were then asked whether a policy of encouraging voluntary treatment as an alternative to or in addition to criminal sanctions exists at the national or subnational level (Fig. 19). Findings • The existence of legislation for offering voluntary treatment for drug use disorders was reported by most countries of the Region. Fig. 17. Existence of a law or legal regulation for protecting the confidentiality of people in treatment 100 90 80 70 60 50 40 30 20 10 0 Unknown No Yes For people with drug use disorders (n = 21) For people with alcohol use disorders (n = 22) Pe rc en ta ge o f c ou nt ri es Country responses to the Atlas questionnaire Fig. 18. Existence of legislative or administrative provision for offering voluntary treatment for substance use disorders as an alternative in addition to criminal sanctions Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 UnknownNoYes In addition for drug use disorders (n = 18) As an alternative for drug use disorders (n = 20) In addition for alcohol use disorders (n = 18) As an alternative for alcohol use disorders (n = 21) 22 Atlas: substance use in the Eastern Mediterranean Region 2015 • Half of the countries reported having legislation for offering voluntary treatment for alcohol use disorders. • Among the countries with legislation for offering voluntary treatment, half of them have a policy of encouraging voluntary treatment for drug use disorders as an alternative to criminal sanctions. 4.1.7 Compulsory treatment as an alternative in addition to criminal sanctions Background Respondents were asked to report on the existence of a mechanism for compulsory treatment as an alternative in addition to criminal sanctions for people with substance use disorders who come into contact with the criminal justice system (Fig. 20). Findings • The majority of the countries of the Eastern Mediterranean Region reported having a mechanism for compulsory treatment for drug use disorders in addition to criminal sanctions. • More than one-third of countries reported having a mechanism for compulsory treatment for alcohol use disorders in addition to criminal sanctions. 4.1.8 Drug courts Background Respondents were asked to report on the existence of a system of drug courts*. Findings • The majority of the countries of the Eastern Mediterranean Region (77%) reported having no system of drug courts. • Three countries (13%) reported having a system of drug courts. 4.2 Financing 4.2.1 Budget line for prevention/ treatment Background Respondents were asked to indicate all of the ministries with a specific budget line* for prevention of substance use and/or for treatment of substance use disorders (Fig. 21). Fig. 19. Existence of a policy of encouraging voluntary treatment as an alternative and/or in addition to criminal sanctions Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 In addition for drug use disorders (n = 12) As an alternative for drug use disorders (n = 13) In addition for alcohol use disorders (n = 12) As an alternative for alcohol use disorders (n = 12) UnknownNoYes 23 If the ministry of health was reported as having a specific budget line, respondents were requested to report on the other areas also covered by this budget line (Fig. 22). Findings • The ministry of health was reported by the majority of the countries of the Eastern Mediterranean Region as having a budget line for prevention and treatment of substance use disorders. • 19% of the countries reported having no specific budget line for prevention of substance use. • 15% of the countries reported having no specific budget line for treatment of substance use disorders. Fig. 20. Existence of a mechanism of compulsory treatment as an alternative and/or in addition to criminal sanctions Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 In addition for drug use disorders (n = 19) As an alternative for drug use disorders (n = 20) In addition for alcohol use disorders (n = 19) As an alternative for alcohol use disorders (n = 20) UnknownNoYes Country responses to the Atlas questionnaire Fig. 21. Ministries with (a) specific budget line(s) for prevention/treatment of substance use disorders Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 Treatment (n = 19)Prevention (n = 21) No specific budget line Ministry of interior Ministry of education Office of the prime minister/ president Ministry of justice Ministry of social welfare Ministry of health 24 Atlas: substance use in the Eastern Mediterranean Region 2015 • Among the countries with a specific budget line at the ministry of health, all of them reported that this budget line also covered mental health. • Among the countries with a specific budget line at the ministry of health, 16% reported having a stand-alone budget line for prevention of drug use and 15% reported having a stand-alone budget line for treatment of drug use disorders. Notes and comments • Two countries reported that the ministry of health has a specific budget line for treatment of drug use disorders. • One country reported that the ministry of health has a specific budget line for prevention of drug use. • Two countries reported that the ministry of the interior has a specific budget line for prevention of drug use. 4.2.2 Financing methods for treatment services Background Respondents were requested to indicate the main financing method for different treatment services for substance use disorders. For each treatment service, it was asked to select one of the following financing methods: government financing*, employer financing*, household financing*, nongovernmental organization and other external financing*, or Global Fund financing (Fig. 23 and 24). Findings • The majority of the countries of the Eastern Mediterranean Region reported that government financing is the main financing methods for treatment services for alcohol and drug use disorders. • Between 18% and 31% (depending on the treatment services) of countries reported that direct out-of-pocket payment is the main financing method for treatment for alcohol use disorders. Notes and comments • The response rate to this question varied between 31% and 81% because some treatment services are not available in some countries, such as opioid agonist maintenance therapy or outpatient detoxification for alcohol use disorders. Fig. 22. Areas included in the budget line(s) for prevention and treatment of substance use at the Ministry of Health Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Treatment – drugs (n = 13)Prevention – drugs (n = 12)Treatment – alcohol (n = 12)Prevention – alcohol (n = 12) Stand-alone budget line Noncommunicable diseases Health promotionTobaccoMental health 25 • The question asked for the main financing method for each treatment service, and for some respondents, it was not possible to report a single financing method. Indeed, countries combine several methods to fund treatment for substance use disorders. Fig. 23. Main financing method for treatment services for alcohol use disorders Pe rc en ta ge o f c ou nt ri es Rehabilitation* (n = 14) Inpatient treatment* (n = 16) Outpatient treatment* (n = 16) Inpatient detoxification* (n = 16) Outpatient detoxification* (n = 13) Other Global Fund financing Nongovernmental organization and other external financing Households Government financing 0 20 40 60 80 100 Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Opioid agonist maintenance therapy (n = 8) Rehabilitation* (n = 15) Inpatient treatment* (n = 17) Outpatient treatment* (n = 18) Inpatient detoxification* (n = 17) Outpatient detoxification* (n = 16) Other Global Fund financing Nongovernmental organization and other external financing Households Government financing Fig. 24. Main financing method for treatment services for drug use disorders 26 Atlas: substance use in the Eastern Mediterranean Region 2015 4.2.3 Hypothecated taxes Background Respondents were asked about hypothecated taxes* designated to be spent on treatment and prevention of substance use disorders. Findings • More than 81% of the countries of the Eastern Mediterranean Region reported having no hypothecated taxes designated specifically to be spent on the treatment and prevention of substance use disorders. • One country reported having hypothecated taxes designated to be spent on the prevention and treatment of substance use disorders. 4.2.4 Social support Background Respondents were asked whether people with substance use disorders were eligible to receive government benefits, either monetary (e.g. disability payment or income support) or nonmonetary (e.g. housing support, access to employment, educational assistance, subsidies for food) (Fig.25). Findings • The majority of the countries of the Eastern Mediterranean Region reported that people with substance use disorders are not eligible to receive government benefits of any form. • However, 27% of the countries reported that people with substance use disorders are eligible to receive government benefits in the form of monetary support. 4.3 Service organization and delivery 4.3.1 Treatment sectors and providers 4.3.1.1 Main sector for treatment services Background Respondents were asked to indicate in what sector the majority of the people receive treatment services for substance use disorders. For each treatment service, they were asked to select one of the following sectors: public health sector, private health sector, public social care sector, private social care sector, criminal justice sector and nongovernmental organizations (Fig. 26 and 27). Fig. 25. Government benefits for people with substance use disorders Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 UnknownNoYes Nonmonetary support for people with drug use disorders (n = 21) Monetary support for people with drug use disorders (n = 22) Nonmonetary support for people with alcohol use disorders (n = 20) Monetary support for people with alcohol use disorders (n = 22) 27 Findings • The public health sector was reported by the majority of the countries of the Eastern Mediterranean Region to be the main sector for providing treatment services for alcohol and drug use disorders. Fig. 26. Main sector providing treatment services for alcohol use disorders Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Other Criminal justice sector Private social care sector Public social care sector Private health sector Public health sector Rehabilitation* (n = 17) Inpatient treatment* (n = 19) Outpatient treatment* (n = 19) Inpatient detoxification* (n = 19) Outpatient detoxification* (n = 17) Nongovernmental organizations Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Rehabilitation* (n = 15) Inpatient treatment* (n = 18) Outpatient treatment* (n = 18) Inpatient detoxification* (n = 18) Outpatient detoxification* (n = 15) Opioid agonist maintenance therapy (n = 13) Other Criminal justice sector Private social care sector Public social care sector Private health sector Public health sector Nongovernmental organizations Fig. 27. Main sector providing treatment services for drug use disorders 28 Atlas: substance use in the Eastern Mediterranean Region 2015 Notes and comments • The response rate to this question varied between 59% and 86% because some treatment services are not available, such as opioid agonist maintenance therapy and outpatient detoxification. • Moreover, the question asked for the sector in which the majority of the people received treatment services, and for some respondents it was not possible to report a single sector as the main provider. Countries appear to use different sectors for providing treatment services. 4.3.1.2 Main providers of treatment services Background Respondents were asked to select the five main providers for treatment services for substance use disorders. The most important treatment provider was defined in terms of coverage of the target population (Fig. 28 and 29). Findings • Mental health facilities were reported by 47% of the countries of the Eastern Mediterranean Region to be the main provider of treatment services for alcohol use disorders. • Stand-alone treatment facilities were reported as the main provider of treatment services for drug use disorders by more than 44% of the countries of the Region. • Mental health facilities were reported as the second main provider of treatment services for drug use disorders by 39% of the countries of the Region. Notes and comments • Not all of the countries which responded to the question provided responses to ranks four and five. Thus, the response rate for these ranks is lower than for the first three ranks. 4.3.1.3 Specialized treatment facilities for substance use disorders Background Respondents were asked if there are privately or publicly funded specialized treatment facilities*16 for substance use disorders in Fig. 28. Ranking of the most important providers for treatment services for alcohol use disorders (n = 17) Pe rc en ta ge o f c ou nt ri es 50 40 30 20 10 0 Community-based self-support groups General health services Other health care facilities General hospitals Mental health services Stand-alone treatment facilities Mental health facilities Ranked fifthRanked fourthRanked thirdRanked secondRanked first 16 Specialized facilities designed and designated for treatment of substance use disorders. This category also includes mental health care facilities that offer specialized treatment for substance use disorders. 29 different regions in the country, such as the capital city, other major cities*, or in other areas* (Fig. 30). Findings • The majority of the countries of the Eastern Mediterranean Region reported having publicly funded specialized treatment facilities for substance use disorders in the capital city. • 28% of the countries of the Region reported having publicly funded specialized treatment facilities for substance use disorders in areas of the country other than the capital city or other major cities. Notes and comments • The response rate for private facilities is lower than for public facilities as data may be less available. Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 50 40 30 20 10 0 Ranked fifthRanked fourthRanked thirdRanked secondRanked first Community-based self-support groups General health services Other health care facilities General hospitals Mental health services Stand-alone treatment facilities Mental health facilities Fig. 29. Ranking of the most important providers for treatment services for drug use disorders (n = 18) Fig. 30. Specialized treatment facilities for substance use disorders Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 UnknownNoneIn other areasIn other major cities In the capital city Private (n = 16)Public (n = 22) 30 Atlas: substance use in the Eastern Mediterranean Region 2015 4.3.1.3 Standards of treatment and care for specialized treatment services Background Respondents were asked about the existence of national standards of treatment and care for the public specialized treatment services. Findings • 41% of the countries of the Eastern Mediterranean Region reported having national standards of treatment and care for public specialized treatment facilities. • 54% of the countries of the Region reported having no national standards of treatment and care for public specialized treatment facilities. 4.3.2 Beds, treatment episodes and treatment coverage 4.3.2.1 Main substances reported at treatment entry Background Respondents were asked about the five main substances that are most commonly reported as being the main drug at treatment entry (i.e. primary diagnosis) (Fig. 31). Findings • Cannabis and opioids are reported by 27% of the countries as the main substances that are reported at treatment entry and by 22% of the countries as the second main substances reported at treatment entry. • Sedatives, anxiolytics and sleeping pills are reported by 45% of the countries as the third main substances reported at treatment entry. Notes and comments • Not all of the countries which responded to the question provided responses to rank four and five. Thus, the response rate for these ranks is lower than for the first three ranks. 4.3.2.2 Number of beds for substance use disorders Background Respondents were asked to report on the total number of beds available for inpatient treatment of substance use disorders in general health care facilities, mental health care Fig. 31. Ranking of the main substances that are most commonly reported at treatment entry (n = 22) Pe rc en ta ge o f c ou nt ri es 50 40 30 20 10 0 ATSSedatives, anxiolytics and sleeping pills AlcoholCannabisOpioids Ranked fifthRanked fourthRanked thirdRanked secondRanked first 31 facilities and specialized health care facilities17, either publicly or privately funded (Table 9). Findings • Overall, the median number of beds for substance use disorders is 0.73 per 100 000 population. Notes and comments • Only 13 countries provided data on the number of beds for treatment of substance use disorders. 4.3.2.3 Number of treatment episodes for substance use disorders Background Respondents were asked about the total number of treatment episodes in specialized treatment facilities for substance use disorders during the most recent year for which data were available (Table 10). Findings • Overall, the number of treatment episodes for substance use disorders is 9.17 per 100 000 population. Notes and comments • Only 10 countries provided data on the number of treatment episodes for substance use disorders. 4.3.2.4 Treatment coverage for substance dependence Background Respondents were asked to indicate the treatment coverage, i.e. the proportion of people with alcohol dependence, opioid dependence, cocaine dependence or cannabis dependence (including those who are not seeking treatment) that are in contact with treatment services18 (Fig. 32). Country responses to the Atlas questionnaire Table 9. Bed availability for inpatient treatment of substance use disorders Median number of beds (per 100 000 population) for treatment of substance use disorders Public general health care facilities (n = 2) 1.11 Public mental health care facilities (n = 3) 0.17 Private mental health care facilities (n = 1) 0.92 Public specialized health care facilities4 (n = 10) 0.80 Private specialized health care facilities1 (n = 2) 0.70 Other public health care facilities (n = 2) 1.33 Total (n = 13) 0.73 17 For this question, this includes specialized health care facilities for substance use disorders only and does not include specialized mental health care facilities that offer specialized treatment for substance use disorders Table 10. Total number of treatment episodes Number of treatment episodes for substance use disorders Public outpatient specialized health care facilities (n = 7) 31.97 Public inpatient specialized health care facilities (n = 7) 9.22 Private inpatient specialized health care facilities (n = 3) 3.10 Other publicly funded facilities (n = 1) 9.17 Other privately funded facilities (n = 1) 608.25 Total (n = 10) 9.17 18 Here defined as currently receiving treatment or in remission or relapse, but still in contact with treatment services. 32 Atlas: substance use in the Eastern Mediterranean Region 2015 Findings • Between 45 and 52% (depending on the substance dependence) of the countries of the Eastern Mediterranean Region reported that the treatment coverage for substance dependence is unknown. • 27% of the countries of the Region reported that the treatment coverage for alcohol dependence is very limited. 4.3.2.5 Access to treatment for substance dependence Background Respondents were asked about the proportion of people who seek treatment for substance dependence that receive such treatment19 (Fig. 33). Pe rc en ta ge o f c ou nt ri es 120 100 80 60 40 20 0 Alcohol dependence (n = 20)Cocaine dependence (n = 18)Cannabis dependence (n = 18)Opioid dependence (n = 19) Unknown High (more than 40%) Substantial (21%–40%) Limited (1%–20%) Very limited (approx. 1%–10%) Close to none (around 0%) Fig. 32. Treatment coverage for substance dependence Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Unknown 99%–100% 90%–98% 21%–50% 11%–20% 1%–10% 50%–90% Alcohol dependence (n = 18)Cocaine dependence (n = 14)Cannabis dependence (n = 16)Opioid dependence (n = 17) Fig. 33. Proportion of people who seek treatment and receive treatment 19 Here defined as commencing treatment. If the person leaves treatment of their own accord they are not considered as demanding. 33 Findings • Between 23% and 40% (depending on the substance dependence) of the countries of the Eastern Mediterranean Region reported that the proportion of people who seek treatment and receive treatment for substance dependence is unknown. • 19% of the countries of the Region reported that the proportion of people who seek treatment and receive treatment for opioids and cannabis dependence is very low, i.e. 1% to 10%. 4.3.3 Pharmacological treatment 4.3.3.1 Guidelines on pharmacological treatment Background Respondents were asked if there are guidelines on the pharmacological treatment of substance use disorders (alcohol and/or drug use disorders). Findings • Half of the countries of the Eastern Mediterranean Region reported having guidelines on pharmacological treatment for substance use disorders. • Two countries of the Region reported having guidelines on pharmacological treatment only for drug use disorders. 4.3.3.2 Pharmacotherapy Background Respondents were asked whether opioid agonist pharmacotherapy with methadone, buprenorphine and buprenorphine/naloxone is used for detoxification and maintenance treatments (Fig. 34 and 35). Findings • The majority of the countries of the Eastern Mediterranean Region reported that opioid agonist pharmacotherapy is not available. 4.3.3.3 Medications Background Respondents were asked about the registration of specific medications in their country, their availability for use in publicly funded treatment services and whether outpatient dosing is supervised20 (Fig. 36–38). Country responses to the Atlas questionnaire 20 Refers to whether outpatients are required to have doses supervised daily unless an individual assessment determined that daily supervision of dosing is not necessary. In supervised methadone treatment, for example, patients come each day for their dose at the beginning of treatment until they are assessed as suitable to receive take-home methadone. Fig. 34. Availability of pharmacotherapies for detoxification treatment of opioid dependence Fig. 35. Availability of pharmacotherapies for maintenance treatment of opioid dependence 100 90 80 70 60 50 40 30 20 10 0 No Yes Pe rc en ta ge o f c ou nt ri es Buprenorphine/ naloxone (n = 22) Buprenorphine (n = 22) Methadone (n = 22) 100 90 80 70 60 50 40 30 20 10 0 No Yes Pe rc en ta ge o f c ou nt ri es Buprenorphine/ naloxone (n = 22) Buprenorphine (n = 22) Methadone (n = 22) 34 Atlas: substance use in the Eastern Mediterranean Region 2015 Fig. 36. Registration of medications (n = 22) Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Di az ep am fo r a lco ho l w ith dr aw al Di az ep am fo r b en zo dia ze pin e w ith dr aw al Cl on idi ne Na lox on e Bu pr en or ph ine Me th ad on e ( tab let s) Me th ad on e ( liq uid ) Na ltr ex on e f or al co ho l d ep en de nc y Na ltr ex on e f or o pio id de pe nd en cy Bu pr en or ph ine /na lox on e ( tab let s) Bu pr en or ph ine /n alo xo ne (fi lm ) Di su lfir am Ac am pr os ate Lo fex idi ne Unknown No Yes Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Unknown No Yes Di az ep am fo r a lco ho l w ith dr aw al Di az ep am fo r b en zo dia ze pin e w ith dr aw al Na lox on e Cl on idi ne Bu pr en or ph ine /na lox on e ( tab let s) Bu pr en or ph ine /n alo xo ne (fi lm ) Me th ad on e ( liq uid ) Me th ad on e ( tab let s) Na ltr ex on e f or al co ho l d ep en de nc y Na ltr ex on e f or o pio id de pe nd en cy Bu pr en or ph ine Lo fex idi ne Ac am pr os ate Di su lfir am Fig. 37. Availability of medications in publicly funded treatment services (n = 22) 35 Findings • The following substances are available in the majority of the countries of the Eastern Mediterranean Region: diazepam for alcohol or benzodiazepine withdrawal, clonidine for opioid withdrawal, and naloxone for opioid overdose. • Diazepam and naloxone are available in publicly funded treatment services in more than 50% of the countries of the Region. Notes and comments • Not all of the countries that responded to the question provided responses for all of the mentioned medications. Thus, the response rate for some medications is lower than for others. 4.3.4 Special programmes and services 4.3.4.1 HIV and hepatitis C testing and treatment in specialized facilities and services for substance use disorders Background Respondents were asked to report on the percentage of the total specialized facilities and services for substance use disorders that provide HIV and hepatitis C testing, counselling and treatment (Fig. 39 and 40). Findings • 33% of the countries of the Eastern Mediterranean Region reported that most of the specialized treatment facilities for substance use disorders provide HIV and hepatitis C testing and counselling as well as HIV treatment. • 37% of the countries of the Region reported that a few of the specialized treatment facilities for substance use disorders provide hepatitis vaccination. Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Di az ep am fo r a lco ho l w ith dr aw al Di az ep am fo r b en zo dia ze pin e wi th dr aw al Bu pr en or ph ine Bu pr en or ph ine /na lox on e ( tab let s) Bu pr en or ph ine /n alo xo ne (fi lm ) Me th ad on e ( liq uid ) Me th ad on e ( tab let s) Na ltr ex on e f or o pio id de pe nd en cy Di su lfir am Unknown No Yes Fig. 38. Supervision of dosing for outpatient treatment (n = 22) 36 Atlas: substance use in the Eastern Mediterranean Region 2015 Fig. 39. Percentage of the total number of specialized facilities and services for substance use disorders that provide HIV testing, counselling and treatment Fig. 40. Percentage of the total number of specialized facilities and services for substance use disorders that provide hepatitic testing, counselling, vaccination and treatment 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Unknown Most (61%–100%) Some or many (11%–60%) Few (1%–10%) None HIV (ARV) treatment (n = 18) HIV testing and counselling (n = 21) 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Hepatitis treatment (n = 16) Hepatitis vaccination (n = 16) Hepatitis testing and counselling (n = 21) Unknown Most (61%–100%) Some or many (11%–60%) Few (1%–10%) None Notes and comments • The response for hepatitis vaccination and hepatitis treatment was lower than for the other items. 4.3.4.2 Availability of programmes Background Nominated focal points were requested to report whether the following programmes are readily21 available: needle/syringe exchange programmes, outreach services for injecting drug users, “drop-in” services, naloxone distribution and condom distribution (Fig. 41). Findings • Needle/syringe exchange programmes are reported to be available by 33% of the countries of the Eastern Mediterranean Region. • 31% of the countries of the Region reported having condom distribution programmes. 4.3.4.3 Special treatment programmes for women with substance use disorders Background Respondents were asked about the existence of special treatment programmes for women with substance use disorders in different parts of the country (Fig. 42). Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no special treatment programmes for women with substance use disorders. 21 In this context means for the majority of the (specific) population irrespective of insurance status and place of residence and in a reasonable time period. 37 4.3.4.4 Special treatment programmes for children and adolescents with substance use disorders Background Respondents were asked about the existence of special treatment programmes for children and adolescents with substance use disorders in different parts of the country (Fig. 43). Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no special treatment programmes for children and adolescents with substance use disorders. Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Condom distribution programmes (n = 22) Naloxone distribution programmes (n = 19) “Drop-in” services (n = 20) Outreach services for injecting drug users (n = 20) Needle/syringe exchange programmes (n = 21) Unknown No Yes Fig. 41. Availability of harm reduction programmes Fig. 42. Special treatment programmes for women with substance use disorders Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 NoneIn other areasIn other major citiesIn the capital city For women with drug use disorders (n = 21)For women with alcohol use disorders (n = 21) 38 Atlas: substance use in the Eastern Mediterranean Region 2015 4.3.4.5 Special programmes for gambling disorders Background Respondents were asked about the existence of special treatment programmes for people with gambling disorders in different parts of the country. Findings • No country of the Eastern Mediterranean Region reported having special treatment programmes for people with gambling disorders. 4.3.4.6 Special housing services Background Respondents were asked about the existence of special housing services for people with substance use disorders as part of the treatment and rehabilitation process. They were requested to indicate the location of these services, i.e. in the capital city, in other major cities or in other areas (Fig. 44). Fig. 43. Special treatment programmes for children and adolescents with substance use disorders Fig. 44. Special housing services for people with substance use disorders Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 NoneIn other major citiesIn the capital city For children and adolescents with drug use disorders (n = 19) For children and adolescents with alcohol use disorders (n = 19) Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 NoneIn other major citiesIn the capital city For people with drug use disorders (n = 22)For people with alcohol use disorders (n = 22) 39 Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no special housing services for people with substance use disorders. 4.3.4.7 Employment services Background Respondents were asked about the existence of employment services for people with substance use disorders as part of the treatment and rehabilitation process. They were requested to indicate the location of these services, i.e. in the capital city, in other major cities or in other areas (Fig. 45). Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no employment services for people with substance use disorders. 4.3.4.8 Open access interventions Background Respondents were asked to report on the availability of open access interventions for addressing substance use disorders in their country. They were asked to report on the existence of telephone help-lines, web-based interventions or mobile phone- based interventions for alcohol and drug use (Fig. 46 and 47). Findings • The majority of the countries of the Eastern Mediterranean Region reported that there are no open access interventions for alcohol or drug use. • Telephone help-lines for drug use were reported by 28% of the countries of the Region. • Telephone help-lines for alcohol use were reported by 23% of the countries. 4.3.4.9 Mutual support/self-help groups Background Respondents were asked about the availability of mutual support/self-help groups* in different parts of the country (Fig. 48). Findings • The majority of the countries of the Eastern Mediterranean Region reported that Narcotics Anonymous, Cocaine Anonymous, Al-Anon/Alateen and family support groups are not available. Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 For people with drug use disorders (n = 21)For people with alcohol use disorders (n = 20) NoneIn other major citiesIn the capital city Fig. 45. Employment services for people with substance use disorders 40 Atlas: substance use in the Eastern Mediterranean Region 2015 • 35% of the countries of the Region reported that Narcotics Anonymous is available in the capital city or other major cities in the country. • 31% of the countries reported that Alcoholics Anonymous is available in the capital city or other major cities in the country. 4.3.5 Prevention 4.3.5.1 Prevention programmes Background Respondents were required to indicate the existence of different tools/programmes for prevention of substance use and substance use disorders. They were also requested to indicate the estimated coverage of the target population for each tool/programme (Fig. 49–51). Fig. 48. Availability of mutual support/self-help groups Fig. 46. Open access interventions for alcohol use Fig. 47. Open access interventions for drug use 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Unknown No Yes Mobile phone- based interventions (n = 20) Web-based interventions (n = 20) Telephone help-lines (n = 21) 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Unknown No Yes Mobile phone- based interventions (n = 21) Web-based interventions (n = 21) Telephone help-lines (n = 21) Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 UnknownNoneIn other areasIn other major citiesIn the capital city Cocaine Anonymous (n = 17) Al-Anon/Alateen (n = 16) Family support groups (n = 18) Alcoholics Anonymous (n = 22) Narcotics Anonymous (n = 20) 41 Country responses to the Atlas questionnaire Fig. 49. Availability of prevention programmes for alcohol and drugs Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Ma ss me dia (a ud iov isu al) Ad ve rti se me nt s i n p ub lic pl ac es Ma ss me dia (p rin t) Sc ho ol (m an ua l)- ba se d p ro gr am me s Co mm un ity -b ase d p ro gr am me s W or kp lac e p ro gr am me s Pa re nt pr og ra mm es Se rv ing st aff tr ain ing pr og ra mm es No ne Drugs (n = 22) Alcohol (n = 19) Fig. 50. Coverage of prevention programmes for alcohol use (n = 19) Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 Ma ss me dia (a ud iov isu al) Ma ss me dia (p rin t) Ad ve rti se me nt s i n p ub lic pl ac es Co mm un ity -b ase d p ro gr am me s Sc ho ol (m an ua l)- ba se d p ro gr am me s Se rv ing st aff tr ain ing pr og ra mm es Pa re nt pr og ra mm es W or kp lac e p ro gr am me s Very high (61%–100%) High (31%–60%) Some (1%–30%) None (0%) 42 Atlas: substance use in the Eastern Mediterranean Region 2015 Findings • Prevention programmes are available in the majority of the countries of the Eastern Mediterranean Region. • Overall, more countries of the Region reported having prevention programmes for drug use than for alcohol use. • The coverage of prevention programmes varies between the types of programme, but is overall higher for drug use than for alcohol use. Notes and comments • Not all of the countries that provided a response to this question responded on all of the prevention programmes. 4.3.5.2 Groups and agencies involved in prevention Background Respondents were requested to indicate whether different groups and agencies are actively involved in prevention of substance use disorders (Fig. 52). Findings • Various groups and agencies are reported to be involved in prevention of substance use disorders. • Nongovernmental organizations are involved in 89% of the countries of the Region, followed by schools (84%) and religious groups (78%). Notes and comments • This question does not differentiate between prevention of alcohol or drug use disorders. 4.3.5.3 Prevention programmes for target population groups Background Respondents were asked about the existence of specific prevention programmes and/or Fig. 51. Coverage of prevention programmes for drug use (n = 22) Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Ad ve rti se me nt s i n p ub lic pl ac es Ma ss me dia (p rin t) Ma ss me dia (a ud iov isu al) Sc ho ol (m an ua l)- ba se d p ro gr am me s Co mm un ity -b as ed pr og ra mm es Pa re nt pr og ra mm es W or kp lac e p ro gr am me s Very high (61%–100%) High (31%–60%) Some (1%–30%) None (0%) 43 interventions to reduce substance use and/or substance use disorders specifically targeting population groups (Fig. 53). Findings • Prevention programmes for drug use targeting prisoners are reported by 77% of the countries of the Eastern Mediterranean Region. • Prevention programmes for drug use targeting young people are reported by 77% of the countries of the Region. • 11% of the countries of the Region reported having specific prevention programmes for drug use among pregnant women. Notes and comments • The response rate was lower for prevention programmes for alcohol use compared to those for drug use. 4.3.5.4 Screening and brief interventions in primary health care Background Respondents were asked whether primary health care services are expected to implement, according to national guidelines and standards of care, screening22 and brief interventions for hazardous and harmful use of tobacco, alcohol, cannabis and prescription drugs. Respondents were also asked about the proportion of primary health care services that have implemented screening and brief interventions for harmful and hazardous alcohol and drug use. They were requested to specify whether this is for routine screening (for the majority of patients) or selective screening (for a minority of patients) (Fig. 54 and 55). Findings • 42% of the countries of the Eastern Mediterranean Region reported that there Country responses to the Atlas questionnaire Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 No ng ov er nm en tal o rg an iza tio ns Sc ho ols Re lig iou s g ro up s So cia l w or ke rs He alt h c are w or ke rs Co mm un ity gr ou ps La w en for ce me nt ag en cie s Int er na tio na l o rg an iza tio ns Pa tie nt o rg an iza tio ns La bo ur o rg an iza tio ns Tr ad itio na l h ea ler s Em plo ye rs Fig. 52. Groups and agencies involved in prevention of substance use disorders (n = 19) 22 Screening can be done by simply asking all pregnant women about substance use and need not involve a standardized screening questionnaire or testing. 44 Atlas: substance use in the Eastern Mediterranean Region 2015 is no recommendation for screening and brief interventions for alcohol or cannabis use in primary health care services. • The existence of recommendations for screening and brief interventions for tobacco, alcohol and cannabis use is reported to be unknown by 33% of the countries of the Region. • More than half of the countries of the Region reported that the proportion of primary care services that have implemented screening and brief interventions for alcohol or drug use is zero. • Between 23% and 28% (depending on whether it is for routine screening or selective screening) of the countries of the Region reported that the proportion of primary care services that have implemented screening and brief interventions for alcohol or drug use is unknown. Notes and comments • Four countries reported that there are recommendations for screening and brief interventions for opioid use in primary health care services. Fig. 53. Prevention programmes for target populations Fig. 54. National guidelines and standards of care recommendations for screening and brief interventions in primary health care services Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 Eld er ly Ind ige no us pe op le Pe op le wi th tu be rcu los is Pr eg na nt w om en Mi no rit y g ro up s Re fug ee s Co mm er cia l s ex w or ke rs Pe rso ns w ith m en tal he alt h d iso rd er s Ch ild re n a t r isk an d th eir fa mi lie s* Pa re nt s Pe op le wi th H IV /A ID S Ch ild re n a nd ad ole sc en ts Pr iso ne rs Yo un g a du lts Drugs (n = 18)Alcohol (n = 14) 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Unknown No Yes Tobacco (n = 21) Alcohol (n = 21) Prescription drugs (n = 21) Cannabis (n = 21) 45 4.3.5.5 Screening and brief interventions in ante-natal services Background Respondents were asked whether antenatal services are expected to screen23 all pregnant women about their use of tobacco, alcohol, cannabis and prescription drugs. Respondents were also asked about the proportion of antenatal services that have implemented screening and brief interventions for harmful and hazardous alcohol and drug use (Fig. 56 and 57). Findings • 45% of the countries of the Eastern Mediterranean Region reported having recommendations for screening and brief interventions for prescription drug use in antenatal services. • Half of the countries of the Region reported that there are no screening and brief interventions for alcohol and drug use in antenatal services. 4.4 Workforce 4.4.1 Professionals providing treatment Background Respondents were asked what types of professionals provide treatment and care for management of substance use disorders in their country (Fig. 58). Findings • A range of professionals provides treatment and care for substance use disorders in the Eastern Mediterranean Region. Psychiatrists are reported by all of the countries of the Region. • 36% of the countries of the Region reported that addiction specialists provide treatment and care for substance use disorders. 4.4.2 Level of educational attainment in prevention/treatment Background Respondents were asked what level of educational attainment is possible to achieve in the areas of prevention of substance use and/or treatment of substance use disorders (Fig. 59). Fig. 55. Proportion of primary care services that have implemented screening and brief interventions for harmful and hazardous substance use Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Unknown Some or many (11%–60%) Few (1%–10%) None Selective screening for drug use (n = 21) Routine screening for drug use (n = 22) Selective screening for alcohol use (n = 21) Routine screening for alcohol use (n = 21) Country responses to the Atlas questionnaire 23 Screening can be done by simply asking all pregnant women about substance use and need not involve a standardized screening questionnaire or testing. 46 Atlas: substance use in the Eastern Mediterranean Region 2015 Findings • Short-cycle tertiary education in prevention is reported by 40% of the countries of the Eastern Mediterranean Region. • Short-cycle tertiary education in treatment is reported by 31% of the countries of the Region. • 31% of the countries of the Region do not have any educational programme in prevention or treatment. Fig. 57. Proportion of antenatal services that have implemented screening and brief intervention for substance use Fig. 56. National guidelines and standards of care recommendations for screening and brief interventions in antenatal services 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Unknown No Yes Tobacco (n = 20) Alcohol (n = 19) Prescription drugs (n = 20) Cannabis (n = 20) 100 90 80 70 60 50 40 30 20 10 0 Pe rc en ta ge o f c ou nt ri es Unknown Few (1%–10%) None (0%) Drugs (n = 22)Alcohol (n = 20) Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Ps yc hia tri sts Ps yc ho log ist s So cia l w or ke rs Me dic al do cto rs Ps yc hia tri c n ur se s Nu rse s Ad dic tio n s pe cia list s* Ad dic tio n c ou ns ell or s* Co mm un ity he alt h w or ke rs* Fig. 58. Professionals providing treatment and care for management of substance use disorders (n = 22) 47 4.4.3 Postgraduate training programmes in prevention/treatment Background Respondents were asked whether certified postgraduate training programmes* in prevention of substance use and/or treatment of substance use disorders are available for specific professionals (Fig. 60). Findings • Postgraduate training programmes in prevention of substance use are available for psychiatrists in 45% of the countries of the Eastern Mediterranean Region. • Postgraduate training programmes in treatment of substance use disorders are available for psychiatrists in 50% of the countries of the Region. • 36% and 40% of the countries of the Region reported that there is no postgraduate training programme in prevention and treatment respectively. 4.4.4 Continuing professional development in prevention/treatment Background Respondents were requested to report on the availability of continuing professional development/education* for professionals working in the areas of prevention and/or treatment of substance use disorders (Fig. 61). Findings • Continuing professional education is available for psychiatrists in more than half of the countries of the Eastern Mediterranean Region. • 27% of the countries of the Region reported that there is no continuing professional education for professionals working in the area of treatment of substance use disorders. Country responses to the Atlas questionnaire Fig. 59. Level of educational attainment that is possible to achieve in prevention and treatment Pe rc en ta ge o f c ou nt ri es 50 40 30 20 10 0 Treatment (n = 22)Prevention (n = 22) UnknownNone (non-existent in these areas) Doctoral or equivalent level Master’s or equivalent level Bachelor’s or equivalent level Short-cycle tertiary education* 48 Atlas: substance use in the Eastern Mediterranean Region 2015 4.4.6 National standards of care for professionals Background Respondents were asked whether national standards of care are developed for professionals working with people with substance use disorders (Fig. 62). Findings • More than half of the countries of the Eastern Mediterranean Region reported having national standards of care for psychiatrists, psychologists and social workers. Pe rc en ta ge o f c ou nt ri es 50 40 30 20 10 0 Treatment (n = 22)Prevention (n = 22) UnknownNoneCommunity health workers* CounsellorsSocial workers NursesPsychologistsMedical doctors Psychiatrists Fig. 60. Availability of postgraduate training programmes in prevention and treatment Fig. 61. Availability of continuing professional development/education for professionals working in prevention and treatment Pe rc en ta ge o f c ou nt ri es 80 70 60 50 40 30 20 10 0 Treatment (n = 22)Prevention (n = 22) UnknownNoneCommunity health workers* Addiction counsellors* Social workers NursesPsychologistsMedical doctors Psychiatrists Addiction specialists* 49 Notes and comments • The response rate to this question is lower than the other questions regarding the workforce as national standards of care for professionals do not exist in some countries. 4.5 Information systems 4.5.1 Epidemiological data collection system Background Respondents were asked to report on the existence of a national system of epidemiological data collection* for psychoactive substance use. They were requested to indicate if the system collects data on alcohol use only, on drug use only, on both, or whether there are two separate data collection systems for alcohol and drug use respectively. It was also required to report on the frequency of data collection as well as on data collection on specific kinds of drugs. Finally, respondents were asked to report on a national system of epidemiological data collection for substance use among children and adolescents, by means of specific school- targeted surveys, or by means of surveys targeting the general population (Fig. 63–65). Findings • More than half of the countries of the Eastern Mediterranean Region do not have an epidemiological data collection system for substance use. • 27% have an epidemiological data collection system for both alcohol and drug use. • Among the countries of the Region with an epidemiological data collection system, 62% of them collect data on a regular basis. • Among the countries of the Region with an epidemiological data collection system, more than half of them collect data on cannabis use, cocaine use, ATS use, opioid use and prescription drug use. Fig. 62. National standards of care for professionals working with people with substance use disorders (n = 18) Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Ps yc hia tri sts Ps yc ho log ist s So cia l w or ke rs Me dic al do cto rs Ad dic tio n s pe cia list s* Ps yc hia tri c n ur se s Nu rse s Ad dic tio n c ou ns ell or s* Co mm un ity he alt h w or ke rs* O ut re ac h/ fie ld wo rk er s Country responses to the Atlas questionnaire 50 Atlas: substance use in the Eastern Mediterranean Region 2015 • Among the countries of the Region with an epidemiological data collection system, the vast majority do not have a specific data collection system among children and adolescents. 4.5.2 Data collection system from health services delivery Background Respondents were asked about the existence of a national system of data collection based on health services delivery* that collects data on the number of people with substance use disorders. They were requested to indicate if the system collects data for alcohol use disorders only, for drug use disorders only, for both, or whether there are two separate data collection systems for alcohol and drug use disorders respectively (Fig. 66). Findings • 45% of the countries of the Eastern Mediterranean Region do not have a data collection system based on health service delivery for substance use disorders. 9.1 54.5 4.5 4.5 27.3 Unknown None One data collection system for drug use only Two separate data collection systems for alcohol and drugs One data collection system for both alcohol and drug use Fig. 63. National system of epidemiological data collection for substance use (n = 22) Fig. 64. Data collection for specific drug use Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Unknown No Yes Use of new psychoactive substances (n = 7) Prescription drug use (n = 7) ATS use (n = 7) Cocaine use (n = 7) Opioid use (n = 7) Cannabis use (n = 7) 51 Fig. 65. Epidemiological data collection system among children and adolescents Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Unknown No Yes General population survey for drug use (n = 8) School-targeted surveys for drug use (n = 8) General population survey for alcohol use (n = 8) School-targeted surveys for alcohol use (n = 8) Country responses to the Atlas questionnaire 45.5 9.1 4.5 40.9 Unknown None Two separate data collection systems for alcohol and drug use disorders One data collection system for both alcohol and drug use disorders Fig. 66. National system of data collection based on health services delivery (n = 22) 4.5.3 Data reporting Background Respondents were asked whether epidemiological data and data from health services delivery have been included in any of the country’s reports* in the past five years. They were asked to specify if the data were compiled in a specific substance use report or in a report compiled for general health statistics (Fig. 67). Findings • 38% of the countries of the Eastern Mediterranean Region reported that epidemiological data on substance use have been reported in the past five years (in a specific substance use report or in a general health statistics report). • 47% of the countries of the Region reported that data from health services delivery have been reported in the past five years (in a specific substance use report or in a general health statistics report). 52 Atlas: substance use in the Eastern Mediterranean Region 2015 4.5.4 Monitoring substance use involvement in death in forensic pathology Background Respondents were asked about the existence of a system of monitoring alcohol and drugs involvement in deaths and related deaths (as a direct cause or underlying cause) in forensic pathology. It was asked to specify the location of such system in the country. Respondents were also asked to report on the existence of a system of monitoring opioid overdose mortality (Fig. 68). Findings • 45% of the countries of the Eastern Mediterranean Region have a system of monitoring alcohol and drugs involvement in forensic pathology, either in forensic examinations or in toxicology units. • Two countries of the Region reported having a system of monitoring opioid overdose mortality. 5. Comparison of data between Atlas 2012 and Atlas 2015 A comparison of Atlas 2012 and Atlas 2015 was conducted to track changes in resources for prevention and treatment of substance use disorders over time. Data collection for these exercises occurred in 2011 and 2014, respectively. The analysis was conducted for the countries that provided data in 2011 and 2014 and was restricted to indicators that were addressed in a similar way between the two assessments. Indeed, in order to improve quality of gathered data, several indicators have been modified and specified for alcohol use disorders and drug use disorders in 2014. In addition, there was an attempt to standardize indicators with the ones collected in the atlases on mental health resources and neurological Fig. 67. Epidemiological and health services delivery data reporting Fig. 68. System of monitoring alcohol and drugs involvement in forensic pathology Pe rc en ta ge o f c ou nt ri es 100 80 60 40 20 0 Unknown Compiled in a specific substance use report Compiled but not in a specific substance use report Not reported in the past five years Data from health services delivery reporting (n = 21) Epidemiological data reporting (n = 21) Pe rc en ta ge o f c ou nt ri es 60 50 40 30 20 10 0 Unknown None In toxicology units (poisonings and intoxications) In forensic examinations (deaths) Drugs (n = 22)Alcohol (n = 22) 53 resources that were conducted at the global level in 2014 as well. Overall, differences in the reported level of resources between 2011 and 2014 are small. Increases are observed in many areas, particularly in service organization and delivery. However, these differences may be due to changes in the methodology rather than a real change in the resource base. In addition, these changes may also reflect improvements in collecting the information. Although the comparison is made on the same countries that provided data in both 2011 and 2014, it should be noted that the response rate increased overall between 2011 and 2014. A comparison of specific indicators is made in the sections below. 5.1 Leadership and governance (Fig. 69) 5.1.1 Government unit/official • The same number of countries (i.e. 11) reported having a government unit/ official responsible for treatment of substance use disorders. • The number of countries reporting having a government unit/official responsible for prevention of substance use has increased from two to 12. 5.1.2 Confidentiality of people in treatment • The number of countries having a law to protect confidentiality of people in treatment for alcohol drug use disorders has increased from seven to nine. 5.1.3 Compulsory treatment • In 2014, this indicator was operationalized in a different way which enabled the collection of more precise information. But overall, the same number of countries (i.e. seven) reported having a mechanism for offering compulsory treatment. 5.1.4 Drug courts • The number of countries reported having a system of drug courts has decreased. Indeed, in 2011, four countries reported having a system of drug courts, while no country reported that in 2014. 5.2 Financing (Fig. 70) 5.2.1 Budget line • A higher number of countries reported having a specific budget line for prevention and treatment of substance use disorders in 2014 compared to 2011. • In 2014, 12 countries reported having a budget line for prevention compared to six in 2011. • In 2014, 11 countries reported having a budget line for treatment compared to six in 2011. • However, this question was worded differently. In 2014, focal points were requested to indicate which ministries Comparison of data between Atlas 2012 and Atlas 2015 Fig. 69. Comparison of leadership and governance indicators between 2011 data and 2014 data Pe rc en ta ge o f c ou nt ri es 12 10 8 6 4 2 0 20142011 Existence of a government unit/ official for treatment of substance use disorders Existence of a law for confidentiality of people in treatment Existence of a mechanism for compulsory treatment Existence of a system of drug courts 54 Atlas: substance use in the Eastern Mediterranean Region 2015 have a specific budget line for treatment of substance use disorders, while in 2011 focal points were asked whether there is a specific budget line in the annual budget of the government for treatment services for substance use disorders. Thus, this increase may reflect a difference in how this indicator was operationalized rather than a real difference in resources. 5.2.2 Financing methods for treatment services • In 2011, respondents were asked to indicate the most common financing method for treatment services for alcohol use disorders and for drug use disorders. This item was worded differently in 2014. Respondents were requested to indicate the main financing method for specific treatment services for alcohol and drug use disorders. These treatment services were the following: outpatient detoxification, inpatient detoxification, inpatient treatment, outpatient treatment, rehabilitation and opioid agonist maintenance therapy. • The number of countries that reported having government financing as the main financing method for all treatment services for alcohol use disorders has increased from three to six between 2011 and 2014. • Regarding treatment services for drug use disorders, the number of countries that reported government financing as the main financing method increased from two to seven. • In terms of household financing, there has been a decrease from two to one in the number of countries reporting this method as the main financing method for treatment services for alcohol and drug use disorders. 5.2.3 Social support • Two countries reported having government benefits in the form of monetary support for people with substance use disorders in 2014, while one country reported that in 2011. • For the other countries that responded in 2011 and 2014, no change has been reported. 5.3 Service organization and delivery 5.3.1 Number of beds • When comparing the same countries that provided data in both 2011 and 2014, the number of beds per 100 000 population decreased from 0.4 in 2011 to 0.31 in 2014, which corresponds to a 20% decrease (Fig. 71). It is important to note that the population in these countries increased by 10% between 2011 and 2014. Pe rc en ta ge o f c ou nt ri es 12 10 8 6 4 2 0 20142011 Existence of budget line(s) for treatment of substance use disorders Government financing as the main financing method for treatment services Household financing as the main financing method for treatment services Monetary support for people with substance use disorders Fig. 70. Comparison of financing indicators between 2011 data and 2014 data 55 5.3.2 Main substances reported at treatment entry • Changes have been observed in the ranking of the three main substances reported at treatment entry. • In 2011, alcohol was reported as the main substance at treatment entry, cannabis the second and opioids the third. • In 2014, cannabis was reported as the main substance at treatment entry, followed by opioids and alcohol. 5.3.3 Guidelines on pharmacological treatment • The number of countries reporting having guidelines on pharmacological treatment for substance use disorders has increased from seven to nine between 2011 and 2014. 5.3.4 Availability of opioid agonist pharmacotherapy • Between 2011 and 2014, the number of countries that reported having methadone available for opioid detoxification and/or maintenance treatment has increased from three to six (Fig. 72). 5.3.5 Harm reduction programmes • An increase in the number of countries having harm reduction programmes is observed between 2014 and 2011. Indeed, in 2014 three countries reported having needle/syringe exchange programmes while two reported that in 2011. • The number of countries that reported having outreach services for injecting drug users increased from two to four. • Two countries reported having naloxone distribution programmes in 2014, while none reported such programmes in 2011. 5.3.6 Open access interventions • The number of countries that reported having telephone help-lines for drug use increased from three to four between 2011 and 2014. • One country reported having web-based interventions for drug use while none reported such interventions in 2011. 5.3.7 Mutual support/self-help groups • Overall, a slight increase in the number of countries having Alcoholic Anonymous groups (six in 2011 and eight in 2014) and Cocaine Anonymous groups (zero in 2011 and one in 2014) is observed between 2011 and 2014. • However, the number of countries reporting having Al-Anon/Alateen decreased from four to one between 2011 and 2014. 5.3.8 Screening and brief interventions in primary health care • Three countries reported having implemented screening and brief interventions for alcohol or drug use in primary health care. 5.3.9 Groups and agencies involved in prevention • A slight increase in the number of countries reporting specific groups Pe rc en ta ge o f c ou nt ri es 5 4 3 2 1 0 20142011 Fig. 71. Comparison of the number of beds for treatment of substance use disorders per 100 000 population between 2011 and 2014 Comparison of data between Atlas 2012 and Atlas 2015 56 Atlas: substance use in the Eastern Mediterranean Region 2015 and agencies involved in prevention is observed between 2011 and 2014. • The number of countries that reported that social workers are involved in prevention increased from five to 11 between 2011 and 2014. • Four additional countries (five in 2011 and nine in 2014) reported that community groups are involved in prevention. 5.3.10 Prevention programmes • In 2014, 13 countries reported having community-based programmes for drug use, compared to eight in 2011. • In 2013, 13 countries reported having work place programmes for drug use compared to six in 2011. • The number of countries reporting having school-based programmes for drug use increased from 11 in 2011 to 13 in 2014. 5.3.11 Prevention programmes for target populations • Overall, more countries reported having specific prevention programmes for target populations. • In 2011, six countries reported having special prevention programmes for drug use among prisoners, and in 2014, 10 countries reported having such programmes. • The number of countries reported having prevention programmes for drug use targeting people with HIV/AIDS, increased from three in 2011 to six in 2014. • Regarding prevention programmes for drug use among children at risk and their families, two countries reported such programmes in 2011, while five countries reported that in 2014. 5.4 Workforce 5.4.1 National standards of care for professionals • The number of countries reporting having national standards of care for professionals working with substance use disorders increased from four to 10 between 2011 and 2014 . • However, it should be highlighted that this question was worded differently in 2014. Focal points were requested to indicate the professional categories that have national standards of treatment and care, whereas in 2011 focal points were asked whether there are national standards of care developed for professionals providing treatment for people with substance use disorders. This increase might reflect a difference in how this indicator was operationalized rather than a real difference in resources. Pe rc en ta ge o f c ou nt ri es 7 6 5 4 3 2 1 0 20142011 Availability of methadone for detoxification or maintenance treatment Availability of open access interventions for drug use Implementation of screening and brief interventions in primary health care Existence of prevention programmes for children at risk and their families Availability of needle/syringe exchange programmes Fig. 72. Comparison of service organization and delivery indicators between 2011 data and 2014 data 57 5.5 Information systems (Fig. 73) 5.5.1 Epidemiological data collection system among children and adolescents • The number of countries reporting having an epidemiological data collection system increased from five in 2011 to seven in 2014. 5.5.2 Data collection system from health services delivery • In 2014, one additional country (six in 2011 and seven in 2014) reported having a data collection system for substance use disorders based on health services delivery compared to 2011. Comparison of data between Atlas 2012 and Atlas 2015 Pe rc en ta ge o f c ou nt ri es 8 7 6 5 4 3 2 1 0 20142011 Existence of an epidemiological data collection system for substance use Existence of a data collection system from health services delivery Fig. 73. Comparison of information systems indicators between 2011 data and 2014 data 58 Atlas: substance use in the Eastern Mediterranean Region 2015 6. Conclusion Information on substance use in the Eastern Mediterranean Region is scarce and not updated. All efforts to collect data on the epidemiology of alcohol and drug use need to be guided in order to assess the needs and plan resources accordingly. Tools such as the global school-based student health survey should be conducted on a regular basis in order to monitor substance use among children and young adolescents. Current estimates show that the burden of drug use disorders in the Region is high compared to global estimates, which highlights the importance of considering substance use and substance use disorders in health policy. Resources for the prevention and treatment of substance use disorders varies across countries, but remains overall insufficient to provide adequate care and treatment for people with substance use disorders. Social support such as government benefits, housing or employment services are rarely available for people with substance use disorders. Interventions that have proven to be efficient, such as pharmacotherapy or screening and brief interventions, are available in a minority of the countries in the Region. Services should be scaled up to be available in all parts of each country and not limited to the major cities. More important, information systems should be strengthened and data collected in a systematic way in order to provide the information needed for planning services and resources. 59 Glossary • Addiction counsellors: professionals certified to work as counsellors for patients with substance use disorders and behavioural addictions after completion of formal training of varying intensity. Educational requirements for addiction counsellors vary depending on the type of certification, and higher levels of certification may require bachelor’s or equivalent level of education. • Addiction specialists/narcologist: medical doctors with specialization in addiction medicine/narcology. • Budget line: source of money available and allocated for actions directed towards treatment and prevention of substance use disorders. • Community health workers: members of a community who are chosen by community members or organizations to provide basic health and medical care to their community. Other names for this type of health care provider include village health worker, community health aide, community health promoter and lay health adviser. • Continuing professional development/education: any certified training activities that are followed by people after completion of their formal professional training in order to maintain skills and knowledge related to their professional career. • Detoxification: refers to a relatively short-term treatment aimed at withdrawing an individual from the effects of a psychoactive substance and usually involves clinical management of intoxication and/or withdrawal syndrome in a safe and effective manner. • Drug court: specialized court that aims to stop drug abuse and related criminal activity of offenders through court- directed treatment and rehabilitation programmes. Drug courts order the treatment of suitable drug-related offenders as an alternative to prosecution or imprisonment and usually monitor compliance with treatment through court appearances and court-mandated regular tests (e.g. urine tests) or examinations. • Employer financing: social health insurance scheme in which workers and employers are obliged to contribute to health insurance funds. • Facilities: refers to treatment centres, departments, wards, and units designed and designated for treatment of substance use disorders. These facilities can be stand-alone (like, for example, national addiction treatment centres, drug treatment centres/clinics and narcological dispensaries) or integrated with other health care centres, clinics or dispensaries (such as general health care or mental health centres or hospitals, HIV clinics etc.). • Government benefits: benefits that are provided by a government from public funds for disabled persons including those with substance use disorders that cause impairment leading to functional limitations. Benefits can be provided in different ways such as disability pensions, free access to services, housing and personal staff care. • Government financing: national, regional/subnational or local government financing from tax-based funding or national health insurance. • Household financing: direct out-of- pocket payment. • Hypothecated taxes: in this context it refers to taxes that are specifically reserved for prevention and treatment of substance use disorders. • Inpatient treatment: refers to different treatment modalities beyond Glossary 60 Atlas: substance use in the Eastern Mediterranean Region 2015 detoxification that are implemented on an inpatient basis, i.e. with formal hospital admission that usually involves an overnight stay or in residential care when a patient lives in a residential treatment setting rather than in his/her own home or family home. • Major cities: refers to cities with relatively large populations and tertiary and higher levels of health care available, including highly specialized facilities such as university hospitals or highly specialized treatment centres such as those for neurosurgery or radiology. • Mutual-support groups: more widely known as self-help groups. A group in which participants support each other in recovering or maintaining recovery from alcohol or other drug dependence or problems, or from the effects of another’s dependence, without professional therapy or guidance. Examples of mutual support groups are Alcoholics Anonymous, Narcotics Anonymous and Al-Anon/ Alateen (for family members of people with alcohol use disorders). • Nongovernmental organizations and other external financing: financing through funds provided by voluntary organizations, charitable groups, advocacy groups, professional associations or international organizations. • Number of treatment episodes: refers to the total number of annual treatment admissions to inpatient and outpatient specialized treatment facilities including the repeated treatment admissions for the same person during the year. • Other areas: refers to urban and rural areas outside the capital and major cities. • Outpatient treatment: refers to different treatment modalities beyond detoxification that are implemented on outpatient/ambulatory basis. • Postgraduate training programme: training that is pursued after a first degree (such as a bachelor’s degree) in a specific field or area. • Rehabilitation: refers here to a longer- term process aimed at enabling people with substance use disorders to achieve an optimal state of health, psychological functioning and social well-being through a combination of approaches including psychosocial, medical and recovery- oriented interventions implemented on in patient and/or out patient basis as well as in community-based support groups. • Report: regular report on information covering health or social services use, available resources (services, human resources) programmes and allocation of funds for each year by the government. • Services: refers to the functions of providing prevention and treatment interventions for substance use disorders by health professionals, but not necessary implemented in specialized facilities designed and designated for treatment of substance use disorders. Examples include provision of screening and brief interventions for alcohol and drug use by health professionals in emergency rooms or primary health care centres, or management of substance use disorders, including pharmacotherapy of substance dependence, by medical doctors or other professionals working in different areas of medicine, psychology and social care (family doctors and nurses, psychiatrists, gastroenterologists, oncologists, social workers, community health workers, etc.). • Short-cycle tertiary education: includes advanced vocational, academic or professional education in specialized areas of education but not reaching bachelor’s or equivalent level. 61 Glossary • Specialized treatment facilities for substance use disorders: specialized facilities designed and designated for treatment of substance use disorders. These include mental health care facilities that offer specialized treatment for substance use disorders. • Substance use disorders: a group of conditions related to alcohol or other drug use. In ICD-10 section F10–F19 it is referred to as “Mental and behavioural disorders due to psychoactive substance use” and contains a wide variety of disorders of different severity and clinical forms, all having in common the use of one or more psychoactive substances, which may or may not have been medically prescribed. • Substance use: refers to the non- medical use of alcohol, illicit drugs or other psychoactive substances, including prescription drugs. • System of data collection based on health service delivery: refers to an organized system of collecting data based on health service delivery which usually incorporates admission and discharge data, number of outpatient contacts and similar. • System of epidemiological data collection: refers to an organized epidemiological surveillance system, which usually incorporates results of regular epidemiological studies/surveys on prevalence of substance use and substance use disorders, patterns of substance use and similar.

Country fact sheets: substance use disorders 64 Atlas: substance use in the Eastern Mediterranean Region 2015 Legend and abbreviations / : not applicable – : missing/not reported AUDs: alcohol use disorders CSWs: commercial sex workers DUDs: drug use disorders MH: mental health NCDs: noncommunicable diseases OAMT: opioid agonist maintenance therapy SUDs: substance use disorders 65 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 28 100 Population in urban areas (%), 2013 24 Adult literacy rate (15–24 years) % 31 Life expectancy at birth (years), 2012 60 Income group (World Bank) Low income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health and of counter narcotics Ministries of health and of counter narcotics Unit/entity responsible for policies Yes, for drugs only Yes, for drugs only This unit is also responsible for policies covering mental health, noncommunicable diseases and health promotion This unit is also responsible for policies covering mental health, noncommunicable diseases and health promotion Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment No No Drug courts None FINANCING Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Yes Global Fund financing Yes SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders – – – Drug use disorders Stand-alone facilities for substance use disorders Mental health facilities General health care facilities Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Opioids Second Cannabis Third Sedatives Treatment coverage for substance dependence Opioid dependence Very limited (1%–10%) Cannabis dependence Very limited (1%–10%) Cocaine dependence Very limited (1%–10%) Alcohol dependence Very limited (1%–10%) Afghanistan 66 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence 1%–10% Cannabis dependence – Cocaine dependence – Alcohol dependence – Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No No Buprenorphine/naloxone (tablets) for opioid dependence No No No Buprenorphine/naloxone (films) for opioid dependence No No No Naltrexone (tablets) for opioid dependence No No No Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence Yes For detoxification and maintenance treatment No Clonidine (tablets) for opioid withdrawal Yes Yes / Lofexidine (tablets) for opioid withdrawal No – / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence – No / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence No No No Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 1%–10% HIV (ARV) treatment Unknown Hepatitis testing and counselling 1%–10% Hepatitis vaccination 1%–10% Hepatitis treatment Unknown Harm reduction programmes Needle/syringe exchange programmes Yes Outreach services for injecting drug users Yes Drop-in services Unknown Naloxone distribution programmes Unknown Condom distribution programmes Yes 67 Country profiles Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No Yes No For children and adolescents No Yes No Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No Yes Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No Yes No – Yes Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes – Some (1%–30%) Workplace programmes – Some (1%–30%) Parenting programmes – Some (1%–30%) Prevention programmes for specific populations Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Unknown – Drug use Unknown None WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists and medical doctors Treatment For psychiatrists and medical doctors National standards of care for professionals Unknown INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Unknown Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths No / Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use Yes – – Yes Yes Yes Yes Yes 68 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2012 1 200 Population in urban areas (%), 2013 100 Adult literacy rate (15–24 years) % 94 Life expectancy at birth (years), 2012 77 Income group (World Bank) High income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health, interior and education Ministries of health and interior Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health This unit is also responsible for policies covering mental health Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment – Yes Compulsory treatment – Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities General health care facilities Community-based self- support groups Drug use disorders Mental health facilities General health care facilities Community-based self- support groups Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes – – Main substance reported at treatment entry First Opioids Second Amfetamine-type stimulant Third Alcohol Treatment coverage for substance dependence Opioid dependence More than 40% Cannabis dependence – Cocaine dependence Unknown Alcohol dependence Substantial (21%–40%) Bahrain Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizationss and other external financing Global Fund financing 69 Country profiles Access to treatment for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No No Buprenorphine/naloxone (tablets) for opioid dependence No No No Buprenorphine/naloxone (films) for opioid dependence No No No Naltrexone (tablets) for opioid dependence No No No Methadone (liquid) for opioid dependence No No No Methadone (tablets) for opioid dependence Yes For detoxification treatment No Clonidine (tablets) for opioid withdrawal No No / Lofexidine (tablets) for opioid withdrawal No No / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence No No No Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal No Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 61%–100% HIV (ARV) treatment 61%–100% Hepatitis testing and counselling 61%–100% Hepatitis vaccination 61%–100% Hepatitis treatment 61%–100% Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No 70 Atlas: substance use in the Eastern Mediterranean Region 2015 Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes Yes – – – Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes – Some (1%–30%) Workplace programmes – Some (1%–30%) Parenting programmes – Some (1%–30%) Prevention programmes for specific populations Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Unknown Unknown Drug use Unknown Unknown WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals For psychiatrists, addiction medicine specialists, other medical doctors, psychiatric nurses, psychologists, social workers and addiction counsellors INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Unknown Substance use indicators as a part of the health information system No Unknown Monitoring of substance use related deaths Unknown / Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use Yes – – – Yes – – Yes 71 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 860 Population in urban areas (%), 2009 84 Adult literacy rate (15–24 years) % – Life expectancy at birth (years), 2012 61 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health and office of the prime minister/president Ministry of health Unit/entity responsible for policies Yes – This unit is also responsible for policies covering tobacco – Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes – Compulsory treatment Unknown – Drug courts Few jurisdictions FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders – – – Drug use disorders – – – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas No No No Main substance reported at treatment entry First Cannabis Second Alcohol Third Opioids Treatment coverage for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence Unknown Djibouti Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 72 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence Unknown Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Unknown Unknown – Buprenorphine/naloxone (tablets) for opioid dependence Unknown Unknown – Buprenorphine/naloxone (films) for opioid dependence – – – Naltrexone (tablets) for opioid dependence – – – Methadone (liquid) for opioid dependence – – – Methadone (tablets) for opioid dependence – – – Clonidine (tablets) for opioid withdrawal – – / Lofexidine (tablets) for opioid withdrawal – – / Naloxone (for injection) for opioid overdose – – / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Unknown – / Diazepam (tablets) for alcohol withdrawal – – – Disulfiram (tablets) for alcohol dependence – – – Naltrexone (tablets) for alcohol dependence – – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal – – – Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling Unknown HIV (ARV) treatment – Hepatitis testing and counselling – Hepatitis vaccination – Hepatitis treatment – Harm reduction programmes Needle/syringe exchange programmes – Outreach services for injecting drug users – Drop-in services – Naloxone distribution programmes – Condom distribution programmes Yes Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents – – – 73 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services – – – Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines – – Web-based interventions – – Mobile phone–based interventions – – Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No – – – – Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes – None Workplace programmes – – Parenting programmes – – Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Unknown None Drug use Unknown Few (1%–10%) WORKFORCE Availability of postgraduate training programmes Prevention For community health workers Treatment None National standards of care for professionals For psychiatrists, addiction medicine specialists and other medical doctors INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Unknown Substance use indicators as a part of the health information system Yes Unknown Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use – – – – – – – – 74 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 84 628 Population in urban areas (%), 2012 43 Adult literacy rate (15–24 years) % 70 Life expectancy at birth (years), 2012 71 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health and social welfare Ministry of health Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health This unit is also responsible for policies covering mental health Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment No No Compulsory treatment – Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities Stand-alone facilities for substance use disorders General hospitals Drug use disorders Mental health facilities Stand-alone facilities for substance use disorders General hospitals Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Prescription opioids Second Opioids Third Sedatives Treatment coverage for substance dependence Opioid dependence Limited (11%–20%) Cannabis dependence Limited (11%–20%) Cocaine dependence None Alcohol dependence Very limited (1%–10%) Egypt Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 75 Country profiles Access to treatment for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No – Buprenorphine/naloxone (tablets) for opioid dependence No No – Buprenorphine/naloxone (films) for opioid dependence No No – Naltrexone (tablets) for opioid dependence Yes Yes Yes Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes Yes / Lofexidine (tablets) for opioid withdrawal No – / Naloxone (for injection) for opioid overdose No – / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No – / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence No – – Naltrexone (tablets) for alcohol dependence Yes Yes / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 11%–30% HIV (ARV) treatment – Hepatitis testing and counselling 11%–30% Hepatitis vaccination – Hepatitis treatment – Harm reduction programmes Needle/syringe exchange programmes Yes Outreach services for injecting drug users Yes Drop-in services Unknown Naloxone distribution programmes Yes Condom distribution programmes Yes Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women Yes Yes – For children and adolescents Yes Yes – Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No 76 Atlas: substance use in the Eastern Mediterranean Region 2015 Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines Yes Yes Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Unknown Yes Unknown Unknown Yes Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes – – Workplace programmes – – Parenting programmes – – Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention For medical doctors Treatment For psychiatrists, psychologists, social workers and nurses National standards of care for professionals – INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes Yes Substance use indicators as a part of the health information system No Yes Monitoring of substance use related deaths Unknown / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use – – – – – Yes – Yes 77 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 76 942 Population in urban areas (%), 2013 72 Adult literacy rate (15–24 years) % 83 Life expectancy at birth (years), 2012 74 Income group (World Bank) Upper middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health, education, social welfare and drug control headquarters Ministry of health and drug control headquarters Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health This unit is also responsible for policies covering mental health Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment Yes Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health services General health care services General hospitals Drug use disorders Stand-alone facilities for substance use disorders General health care facilities Mental health services Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Opioids Second ATS Third Prescription opioids Treatment coverage for substance dependence Opioid dependence More than 40% Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Iran (Islamic Republic of) Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Employer financing Households Yes Yes Yes Yes Yes Yes Nongovernmental organization and other external financing Global Fund financing 78 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence 21%–50% Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Yes For detoxification and maintenance treatment Yes Buprenorphine/naloxone (tablets) for opioid dependence Yes For detoxification and maintenance treatment Yes Buprenorphine/naloxone (films) for opioid dependence Yes For detoxification and maintenance treatment Yes Naltrexone (tablets) for opioid dependence Yes Yes No Methadone (liquid) for opioid dependence Yes For maintenance treatment Yes Methadone (tablets) for opioid dependence Yes For maintenance treatment Yes Clonidine (tablets) for opioid withdrawal Yes Yes / Lofexidine (tablets) for opioid withdrawal No – / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence Yes No No Naltrexone (tablets) for alcohol dependence Yes Yes / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 1%–10% HIV (ARV) treatment None Hepatitis testing and counselling 1%–10% Hepatitis vaccination None Hepatitis treatment None Harm reduction programmes Needle/syringe exchange programmes Yes Outreach services for injecting drug users Yes Drop-in services Yes Naloxone distribution programmes No Condom distribution programmes Yes Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women Yes Yes No For children and adolescents No No No 79 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services Yes Yes No Employment services Yes Yes No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No Yes Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes Yes Yes Yes Yes Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes None Some (1%–30%) Workplace programmes Some (1%–30%) Some (1%–30%) Parenting programmes Some (1%–30%) Some (1%–30%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists, medical doctors and psychologists Treatment For psychiatrists, medical doctors and psychologists National standards of care for professionals For psychiatrists, other medical doctors, psychologists and outreach/field workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes Yes Substance use indicators as a part of the health information system No No Monitoring of substance use related deaths Yes / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – Yes Drug use Yes – – – – Yes – Yes 80 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 35 095 Population in urban areas (%), 2013 69 Adult literacy rate (15–24 years) % 21 Life expectancy at birth (years), 2012 70 Income group (World Bank) Upper middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health, interior, education, justice and social welfare, Ministry of health Unit/entity responsible for policies Yes Yes Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment No No Compulsory treatment No No Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities General health care facilities Mental health services Drug use disorders Mental health facilities General health care facilities Mental health services Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes – Main substance reported at treatment entry First Other Second Alcohol Third Sedatives Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Iraq Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 81 Country profiles Access to treatment for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence 50%–90% Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Yes – – Buprenorphine/naloxone (tablets) for opioid dependence No No – Buprenorphine/naloxone (films) for opioid dependence No No – Naltrexone (tablets) for opioid dependence Yes No – Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes No / Lofexidine (tablets) for opioid withdrawal Yes No / Naloxone (for injection) for opioid overdose Yes No / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Yes No / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence No No – Naltrexone (tablets) for alcohol dependence Yes No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 61%–100% HIV (ARV) treatment 61%–100% Hepatitis testing and counselling 61%–100% Hepatitis vaccination 61%–100% Hepatitis treatment 61%–100% Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No 82 Atlas: substance use in the Eastern Mediterranean Region 2015 Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholic Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes Some (1%–30%) Some (1%–30%) Workplace programmes None None Parenting programmes Some (1%–30%) None Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Some (11%–30%) Unknown Drug use Some (11%–30%) Unknown WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists, medical doctors, psychologists, social workers and nurses Treatment For psychiatrists, medical doctors, psychologists, social workers and nurses National standards of care for professionals None INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Yes Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths Yes / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes Yes – – – Yes Yes Yes Drug use Yes Yes – – – Yes Yes Yes 83 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 6 530 Population in urban areas (%), 2013 83 Adult literacy rate (15–24 years) % 93 Life expectancy at birth (years), 2012 74 Income group (World Bank) Upper middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health and interior Ministries of health and interior Unit/entity responsible for policies No No Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment Yes Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Stand-alone facilities for substance use disorders Mental health facilities Community-based self- support groups Drug use disorders Stand-alone facilities for substance use disorders Mental health facilities Community-based self- support groups Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes – – Main substance reported at treatment entry First Alcohol Second Opioids Third Sedatives Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Jordan Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 84 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence 50%–90% Cannabis dependence 1%–10% Cocaine dependence Unknown Alcohol dependence 50%–90% Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence – – – Buprenorphine/naloxone (tablets) for opioid dependence – – – Buprenorphine/naloxone (films) for opioid dependence – – – Naltrexone (tablets) for opioid dependence – – – Methadone (liquid) for opioid dependence Yes For detoxification treatment – Methadone (tablets) for opioid dependence – – – Clonidine (tablets) for opioid withdrawal – – / Lofexidine (tablets) for opioid withdrawal – – / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence – – / Diazepam (tablets) for alcohol withdrawal Yes Yes – Disulfiram (tablets) for alcohol dependence – – – Naltrexone (tablets) for alcohol dependence – – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes – Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 61%–100% HIV (ARV) treatment 61%–100% Hepatitis testing and counselling 61%–100% Hepatitis vaccination 61%–100% Hepatitis treatment 61%–100% Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women Yes – – For children and adolescents Yes – – 85 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes Some (1%–30%) Some (1%–30%) Workplace programmes None None Parenting programmes Some (1%–30%) Some (1%–30%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Few (1%–10%) None Drug use Few (1%–10%) None WORKFORCE Availability of postgraduate training programmes Prevention Unknown Treatment Unknown National standards of care for professionals For psychiatrists, psychiatric nurses, psychologists and social workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Unknown Substance use indicators as a part of the health information system Yes Unknown Monitoring of substance use related deaths Unknown / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes – Yes – Yes Yes – Yes Drug use Yes – Yes – Yes Yes – Yes 86 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2012 3 806 Population in urban areas (%), 2013 100 Adult literacy rate (15–24 years) % 95 Life expectancy at birth (years), 2012 78 Income group (World Bank) High income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health Ministry of health Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering health promotion This unit is also responsible for policies covering mental health and criminal justice Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment Yes Yes Drug courts Most jurisdictions FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities Therapeutic communities Community-based self-support groups Drug use disorders Mental health facilities Therapeutic communities Community-based self-support groups Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Opioids Second ATS Third Sedatives Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Kuwait Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 87 Country profiles Access to treatment for substance dependence Opioid dependence 99%–100% Cannabis dependence 99%–100% Cocaine dependence 99%–100% Alcohol dependence 99%–100% Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No – Buprenorphine/naloxone (tablets) for opioid dependence No No – Buprenorphine/naloxone (films) for opioid dependence Yes Yes for detoxification only – Naltrexone (tablets) for opioid dependence No – – Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes No / Lofexidine (tablets) for opioid withdrawal No – / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No – / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence No – – Naltrexone (tablets) for alcohol dependence No – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 61%–100% HIV (ARV) treatment 61%–100% Hepatitis testing and counselling 61%–100% Hepatitis vaccination 61%–100% Hepatitis treatment 61%–100% Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users Yes Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women Yes Yes Yes For children and adolescents No No No 88 Atlas: substance use in the Eastern Mediterranean Region 2015 Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines Yes Yes Web-based interventions Yes Yes Mobile phone–based interventions Yes Yes Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes Yes No Yes Yes Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes High (31%–60%) High (31%–60%) Workplace programmes – – Parenting programmes High (31%–60%) High (31%–60%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention Unknown Treatment Unknown National standards of care for professionals For psychiatrists, psychiatric nurses, psychologists and social workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes Yes Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes – – – Yes Yes – Yes Drug use Yes – – – Yes Yes – Yes 89 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 4 168 Population in urban areas (%), 2012 85 Adult literacy rate (15–24 years) % 99 Life expectancy at birth (years), 2012 80 Income group (World Bank) Upper middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health, interior and social welfare Ministry of health Unit/entity responsible for policies No Yes for drugs only Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment No No Compulsory treatment No No Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities General health care facilities General health care services Drug use disorders Standalone facilities for SUDs Mental health facilities General health care facilities Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes No No Main substance reported at treatment entry First Sedatives Second Cannabis Third Opioids Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Lebanon Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Employer financing Households Yes Yes Yes Nongovernmental organizations and other external financing Yes Global Fund financing 90 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence Unknown Cannabis dependence 11%–20% Cocaine dependence Unknown Alcohol dependence Unknown Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Yes For detoxification and maintenance treatment Yes Buprenorphine/naloxone (tablets) for opioid dependence No No No Buprenorphine/naloxone (films) for opioid dependence No No No Naltrexone (tablets) for opioid dependence No No No Methadone (liquid) for opioid dependence Yes No No Methadone (tablets) for opioid dependence Yes No No Clonidine (tablets) for opioid withdrawal No No / Lofexidine (tablets) for opioid withdrawal No No / Naloxone (for injection) for opioid overdose Yes No / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal Yes No Yes Disulfiram (tablets) for alcohol dependence No No No Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes No Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling None HIV (ARV) treatment None Hepatitis testing and counselling 1%–10% Hepatitis vaccination 1%–10% Hepatitis treatment 1%–10% Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop–in services No Naloxone distribution programmes Yes Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No 91 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self–help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes Some (1%–30%) Some (1%–30%) Workplace programmes None None Parenting programmes None None Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None Few (1%–10%) Drug use None Few (1%–10%) WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists and psychologists Treatment For psychiatrists National standards of care for professionals For psychiatrists, addiction medicine specialists, psychiatric nurses, psychologists and social workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Unknown Substance use indicators as a part of the health information system No Unknown Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – Yes – – – – – Yes Drug use – Yes – – – – – Yes 92 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 6 028 Population in urban areas (%), 2013 86 Adult literacy rate (15–24 years) % 90 Life expectancy at birth (years), 2012 75 Income group (World Bank) Upper middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health Ministry of health Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health This unit is also responsible for policies covering mental health Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment Yes Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities – – Drug use disorders Mental health facilities – – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas – Yes – Main substance reported at treatment entry First Opioids Second Cannabis Third Sedatives Treatment coverage for substance dependence Opioid dependence None Cannabis dependence None Cocaine dependence – Alcohol dependence None Libya Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 93 Country profiles Access to treatment for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence – Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/ overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No No Buprenorphine/naloxone (tablets) for opioid dependence No No No Buprenorphine/naloxone (films) for opioid dependence No No No Naltrexone (tablets) for opioid dependence No No No Methadone (liquid) for opioid dependence No No No Methadone (tablets) for opioid dependence No No No Clonidine (tablets) for opioid withdrawal Yes Yes / Lofexidine (tablets) for opioid withdrawal No No / Naloxone (for injection) for opioid overdose No No / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal Yes Yes No Disulfiram (tablets) for alcohol dependence No No No Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes No Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 61%–100% HIV (ARV) treatment 61%–100% Hepatitis testing and counselling 61%–100% Hepatitis vaccination – Hepatitis treatment – Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop–in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No 94 Atlas: substance use in the Eastern Mediterranean Region 2015 Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help–lines No No Web–based interventions No No Mobile phone based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual) based programmes – – Work place programmes – – Parenting programmes – – Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use – Unknown Drug use None Unknown WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals – INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No No Substance use indicators as a part of the health information system No No Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use – – – – Yes – – – 95 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 32 950 Population in urban areas (%), 2013 59 Adult literacy rate (15–24 years) % 67 Life expectancy at birth (years), 2012 71 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health Ministry of health Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health, noncommunicable diseases, tobacco and health promotion This unit is also responsible for policies covering mental health, noncommunicable diseases, tobacco and health promotion Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment Yes Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Standalone facilities for substance use disorders Mental health facilities Mental health services Drug use disorders Stand-alone facilities for substance use disorders Mental health facilities Mental health services Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Cannabis Second Sedatives Third Alcohol Treatment coverage for substance dependence Opioid dependence Limited (11%–20%) Cannabis dependence Very limited (1%–10%) Cocaine dependence Limited (11%–20%) Alcohol dependence Very limited (1%–10%) Morocco Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Employer financing Households Yes Yes Nongovernmental organizations and other external financing Global Fund financing Yes 96 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence 11%–20% Cannabis dependence 1%–10% Cocaine dependence 1%–10% Alcohol dependence 1%–10% Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/ overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No Unknown Buprenorphine/naloxone (tablets) for opioid dependence Yes – Yes Buprenorphine/naloxone (films) for opioid dependence Unknown Unknown Yes Naltrexone (tablets) for opioid dependence Yes Yes Yes Methadone (liquid) for opioid dependence Yes For maintenance treatment Yes Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes Yes / Lofexidine (tablets) for opioid withdrawal Unknown Unknown / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Unknown Unknown / Diazepam (tablets) for alcohol withdrawal Yes Yes No Disulfiram (tablets) for alcohol dependence Unknown Unknown Unknown Naltrexone (tablets) for alcohol dependence Yes Yes / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes No Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 1%–10% HIV (ARV) treatment 61%–100% Hepatitis testing and counselling 1%–10% Hepatitis vaccination None Hepatitis treatment 11%–30% Harm reduction programmes Needle/syringe exchange programmes Yes Outreach services for injecting drug users Yes Drop-in services Yes Naloxone distribution programmes – Condom distribution programmes Yes Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No 97 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual) based programmes Some (1%–30%) Some (1%–30%) Work place programmes Some (1%–30%) Some (1%–30%) Parenting programmes – Some (1%–30%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists, medical doctors and nurses Treatment For psychiatrists, medical doctors and nurses National standards of care for professionals For psychiatrists, addiction medicine specialists and other medical doctors INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes Yes Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – Yes – – – Yes – – Drug use Yes – Yes – Yes Yes – Yes 98 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 3 855 Population in urban areas (%), 2010 75 Adult literacy rate (15–24 years) % 88 Life expectancy at birth (years), 2012 76 Income group (World Bank) High income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health Ministry of health Unit/entity responsible for policies Yes Yes Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes No Compulsory treatment Yes Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities Mental health services – Drug use disorders Mental health facilities Mental health services – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes – – Main substance reported at treatment entry First Cannabis Second Opioids Third Sedatives Treatment coverage for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence More than 40% Access to treatment for substance dependence Opioid dependence 99%–100% Cannabis dependence 99%–100% Cocaine dependence Unknown Alcohol dependence 99%–100% Oman Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 99 Country profiles Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/ overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No – Buprenorphine/naloxone (tablets) for opioid dependence No No – Buprenorphine/naloxone (films) for opioid dependence No No – Naltrexone (tablets) for opioid dependence No – – Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence Yes – Yes Clonidine (tablets) for opioid withdrawal No – / Lofexidine (tablets) for opioid withdrawal No – / Naloxone (for injection) for opioid overdose No – / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No – / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence No – – Naltrexone (tablets) for alcohol dependence No – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 1%–10% HIV (ARV) treatment 1%–10% Hepatitis testing and counselling 1%–10% Hepatitis vaccination None Hepatitis treatment 1%–10% Harm reduction programmes Needle/syringe exchange programmes Unknown Outreach services for injecting drug users Unknown Drop-in services Unknown Naloxone distribution programmes Unknown Condom distribution programmes Unknown Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women Yes – – For children and adolescents – – – Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No 100 Atlas: substance use in the Eastern Mediterranean Region 2015 Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines Yes Yes Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes Yes – – – Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes None High (31%–60%) Workplace programmes None Some (1%–30%) Parenting programmes None High (31%–60%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention Unknown Treatment Unknown National standards of care for professionals For psychiatrists, addiction medicine specialists, other medical doctors, nurses, psychologists and social workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes Yes Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths Unknown / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes – – – Yes – – Yes Drug use Yes – – – Yes Yes – Yes 101 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 184 350 Population in urban areas (%), 2013 38 Adult literacy rate (15–24 years) % 58 Life expectancy at birth (years), 2012 65 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health and of narcotics control board Ministries of health and of narcotics control board Unit/entity responsible for policies Yes Yes Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment Yes Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders General hospitals Other general health care services Community-based self-support groups Drug use disorders General hospitals Other general health care services Community-based self-support groups Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes – Main substance reported at treatment entry First Cannabis Second Opioids Third Sedatives Treatment coverage for substance dependence Opioid dependence Very limited (1%–10%) Cannabis dependence Very limited (1%–10%) Cocaine dependence Very limited (1%–10%) Alcohol dependence Very limited (1%–10%) Pakistan Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Employer financing Households Yes Nongovernmental organizations and other external financing Yes Yes Global Fund financing Yes 102 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence 1%–10% Cannabis dependence 1%–10% Cocaine dependence 1%–10% Alcohol dependence 11%–20% Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Yes – – Buprenorphine/naloxone (tablets) for opioid dependence No No – Buprenorphine/naloxone (films) for opioid dependence No No – Naltrexone (tablets) for opioid dependence No No No Methadone (liquid) for opioid dependence No No No Methadone (tablets) for opioid dependence No No No Clonidine (tablets) for opioid withdrawal Yes No / Lofexidine (tablets) for opioid withdrawal Unknown No / Naloxone (for injection) for opioid overdose No No / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Unknown No / Diazepam (tablets) for alcohol withdrawal Yes Yes No Disulfiram (tablets) for alcohol dependence Unknown No No Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes No Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 1%–10% HIV (ARV) treatment 1%–10% Hepatitis testing and counselling 11%–30% Hepatitis vaccination 1%–10% Hepatitis treatment 1%–10% Harm reduction programmes Needle/syringe exchange programmes Yes Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No 103 Country profiles Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No Yes Web-based interventions No Yes Mobile phone–based interventions No Yes Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes Yes No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes None None Workplace programmes None None Parenting programmes None None Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals For psychiatrists INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes Yes Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes – Yes – – – – – Drug use Yes – Yes – – – – – 104 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 2 003 Population in urban areas (%), 2013 100 Adult literacy rate (15–24 years) % 98 Life expectancy at birth (years), 2012 79 Income group (World Bank) High income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health, education, interior and social welfare Ministries of health and social welfare Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health, tobacco, noncommunicable disease and health promotion This unit is also responsible for policies covering mental health, tobacco, noncommunicable disease and health promotion Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Unknown Unknown Compulsory treatment Unknown Unknown Drug courts Unknown FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Stand-alone facilities for substance use disorders Mental health facilities General health care facilities Drug use disorders Stand-alone facilities for substance use disorders Mental health facilities – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes – – Main substance reported at treatment entry First Alcohol Second Cannabis Third Opioids Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Qatar Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 105 Country profiles Access to treatment for substance dependence Opioid dependence 90%–98% Cannabis dependence 99%–100% Cocaine dependence Unknown Alcohol dependence 90%–98% Pharmacological treatment Guidelines on pharmacological treatment Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling Unknown HIV (ARV) treatment Unknown Hepatitis testing and counselling Unknown Hepatitis vaccination Unknown Hepatitis treatment Unknown Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services Unknown Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents Yes – – Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Yes For detoxification and maintenance treatment – Buprenorphine/naloxone (tablets) for opioid dependence Yes For detoxification and maintenance treatment – Buprenorphine/naloxone (films) for opioid dependence Yes For detoxification and maintenance treatment – Naltrexone (tablets) for opioid dependence Unknown Unknown Unknown Methadone (liquid) for opioid dependence Yes For detoxification and maintenance treatment – Methadone (tablets) for opioid dependence Yes For detoxification and maintenance treatment – Clonidine (tablets) for opioid withdrawal Yes – / Lofexidine (tablets) for opioid withdrawal Yes Yes / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Yes Yes / Diazepam (tablets) for alcohol withdrawal Yes Yes – Disulfiram (tablets) for alcohol dependence Unknown – Unknown Naltrexone (tablets) for alcohol dependence Unknown No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes – 106 Atlas: substance use in the Eastern Mediterranean Region 2015 Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No – Web-based interventions Unknown Unknown Mobile phone–based interventions Unknown Unknown Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Unknown Unknown Unknown Unknown Unknown Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes Some (1%–30%) Some (1%–30%) Workplace programmes Some (1%–30%) Some (1%–30%) Parenting programmes Some (1%–30%) Some (1%–30%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Unknown Unknown Drug use Unknown Unknown WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals For psychiatrists INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Unknown Unknown Substance use indicators as a part of the health information system Unknown No Monitoring of substance use related deaths Yes / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes – – – Yes Yes Yes Yes Drug use Yes – – – Yes Yes Yes Yes 107 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 29 994 Population in urban areas (%), 2012 83 Adult literacy rate (15–24 years) % 99 Life expectancy at birth (years), 2012 76 Income group (World Bank) High income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health and interior Ministries of health and interior Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health and health promotion This unit is also responsible for policies covering mental health and health promotion Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment Yes Yes Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Stand-alone facilities for substance use disorders Mental health facilities – Drug use disorders Stand-alone facilities for substance use disorders Mental health facilities – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Cannabis Second ATS Third Alcohol Treatment coverage for substance dependence Opioid dependence Substantial (21%–40%) Cannabis dependence Substantial (21%–40%) Cocaine dependence Substantial (21%–40%) Alcohol dependence Substantial (21%–40%) Saudi Arabia Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 108 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Pharmacological treatment Guidelines on pharmacological treatment Yes Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Yes For detoxification and maintenance treatment Yes Buprenorphine/naloxone (tablets) for opioid dependence Yes For detoxification and maintenance treatment Yes Buprenorphine/naloxone (films) for opioid dependence Yes For detoxification and maintenance treatment Yes Naltrexone (tablets) for opioid dependence Yes Yes No Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes – / Lofexidine (tablets) for opioid withdrawal No – / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence – – / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence Yes – – Naltrexone (tablets) for alcohol dependence Yes Yes / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal – – – Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling Unknown HIV (ARV) treatment Unknown Hepatitis testing and counselling Unknown Hepatitis vaccination Unknown Hepatitis treatment Unknown Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services Yes Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women Yes Yes – For children and adolescents Yes Yes – 109 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services Yes Yes – Employment services Yes Yes – Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines Yes Yes Web-based interventions Yes Yes Mobile phone–based interventions Yes Yes Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes – – – Yes Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes High (31%–60%) – Workplace programmes High (31%–60%) High (31%–60%) Parenting programmes High (31%–60%) High (31%–60%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None Unknown Drug use None Unknown WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals For psychiatrists, addiction medicine specialists, other medical doctors, psychiatric nurses, psychologists, social workers, and community health workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes Unknown Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths Yes / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes – – – – – Yes – Drug use Yes – – – – – Yes – 110 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 10 195 Population in urban areas (%), 2009 37 Adult literacy rate (15–24 years) % – Life expectancy at birth (years), 2012 53 Income group (World Bank) Low income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) – Ministries of health, interior and justice Unit/entity responsible for policies No – Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment No – Compulsory treatment No – Drug courts None FINANCING Main financing method for treatment services for substance use disorders SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders – – – Drug use disorders – – – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas No No No Main substance reported at treatment entry First Alcohol Second Opioids Third Cocaine Treatment coverage for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence – Access to treatment for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence – Somalia Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 111 Country profiles Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No No Buprenorphine/naloxone (tablets) for opioid dependence No No No Buprenorphine/naloxone (films) for opioid dependence No No No Naltrexone (tablets) for opioid dependence No No No Methadone (liquid) for opioid dependence No No No Methadone (tablets) for opioid dependence No No No Clonidine (tablets) for opioid withdrawal No No / Lofexidine (tablets) for opioid withdrawal No No / Naloxone (for injection) for opioid overdose No No / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal No No No Disulfiram (tablets) for alcohol dependence No No No Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal No No No Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 1%–10% HIV (ARV) treatment 1%–10% Hepatitis testing and counselling 1%–10% Hepatitis vaccination 1%–10% Hepatitis treatment – Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No 112 Atlas: substance use in the Eastern Mediterranean Region 2015 Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes None None Workplace programmes None None Parenting programmes None None Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals – INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No No Substance use indicators as a part of the health information system No No Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use – – – – – – – – 113 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 36 163 Population in urban areas (%), 2012 30 Adult literacy rate (15–24 years) % 50 Life expectancy at birth (years), 2012 63 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of interior Ministry of interior Unit/entity responsible for policies Yes, for drugs only Yes This unit is also responsible for policies covering health promotion, noncommunicable diseases, tobacco and mental health This unit is also responsible for policies covering mental health Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment No No Compulsory treatment No No Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders General hospitals – – Drug use disorders General hospitals – – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas No No No Main substance reported at treatment entry First Alcohol Second Cannabis Third Opioids Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Sudan Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Employers financing Households Yes Yes Yes Yes Yes Yes Nongovernmental and other external financing Global Fund financing 114 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence 1%–10% Cannabis dependence 21%–50% Cocaine dependence 1%–10% Alcohol dependence 50%–90% Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Unknown Unknown Unknown Buprenorphine/naloxone (tablets) for opioid dependence Unknown Unknown Unknown Buprenorphine/naloxone (films) for opioid dependence Unknown Unknown Unknown Naltrexone (tablets) for opioid dependence No No – Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal No No / Lofexidine (tablets) for opioid withdrawal No No / Naloxone (for injection) for opioid overdose No No / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence Unknown Unknown / Diazepam (tablets) for alcohol withdrawal Yes – Yes Disulfiram (tablets) for alcohol dependence No No – Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes – Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling None HIV (ARV) treatment None Hepatitis testing and counselling None Hepatitis vaccination None Hepatitis treatment None Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No 115 Country profiles Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual)-based programmes None None Workplace programmes None None Parenting programmes None None Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None None Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals For psychiatrists, psychologists and social workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No No Substance use indicators as a part of the health information system No No Monitoring of substance use related deaths Yes / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use – – – – – – – – 116 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 21 639 Population in urban areas (%), 2012 54 Adult literacy rate (15–24 years) % 86 Life expectancy at birth (years), 2012 68 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health Ministry of health Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health This unit is also responsible for policies covering mental health Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment No No Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health facilities General health care facilities Mental health services Drug use disorders Mental health facilities General health care facilities Mental health services Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes – – Main substance reported at treatment entry First Opioids Second Prescription opioids Third Alcohol Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Syrian Arab Republic Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Employers financing Households Yes Yes Nongovernmental and other external financing Global Fund financing 117 Country profiles Access to treatment for substance dependence Opioid dependence 21%–50% Cannabis dependence 21%–50% Cocaine dependence 21%–50% Alcohol dependence 21%–50% Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No – Buprenorphine/naloxone (tablets) for opioid dependence No No – Buprenorphine/naloxone (films) for opioid dependence No No – Naltrexone (tablets) for opioid dependence No No – Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes No / Lofexidine (tablets) for opioid withdrawal No No / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal Yes – No Disulfiram (tablets) for alcohol dependence No No – Naltrexone (tablets) for alcohol dependence No No / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes No Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 31%–60% HIV (ARV) treatment – Hepatitis testing and counselling 31%–60% Hepatitis vaccination – Hepatitis treatment – Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes No Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No 118 Atlas: substance use in the Eastern Mediterranean Region 2015 Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual) based-programmes – – Workplace programmes – – Parenting programmes – – Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Few (1%–10%) Few (1%–10%) Drug use Few (1%–10%) Few (1%–10%) WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals – INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Yes Substance use indicators as a part of the health information system Yes Yes Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – Yes – – – Drug use – – – – Yes – – – 119 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2012 10 886 Population in urban areas (%), 2012 66 Adult literacy rate (15–24 years) % 97 Life expectancy at birth (years), 2012 74 Income group (World Bank) Upper middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health Ministry of health Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health and tobacco This unit is also responsible for policies covering mental health and tobacco Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes Yes Compulsory treatment No No Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Mental health services General health care services – Drug use disorders Mental health services General health care services Nongovernmental organizations Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Cannabis Second Volatile inhalants Third Sedatives Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Very limited (1%–10%) Cocaine dependence None Alcohol dependence Very limited (1%–10%) Tunisia Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 120 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No No Buprenorphine/naloxone (tablets) for opioid dependence No No No Buprenorphine/naloxone (films) for opioid dependence No No – Naltrexone (tablets) for opioid dependence No – – Methadone (liquid) for opioid dependence No No – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes No / Lofexidine (tablets) for opioid withdrawal No – / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No – / Diazepam (tablets) for alcohol withdrawal Yes No – Disulfiram (tablets) for alcohol dependence No – – Naltrexone (tablets) for alcohol dependence No – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes No – Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 61%–100% HIV (ARV) treatment None Hepatitis testing and counselling 61%–100% Hepatitis vaccination None Hepatitis treatment None Harm reduction programmes Needle/syringe exchange programmes Yes Outreach services for injecting drug users No Drop-in services No Naloxone distribution programmes No Condom distribution programmes Yes Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No 121 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual) based-programmes None High (31%–60%) Workplace programmes None Some (1%–30%) Parenting programmes None Some (1%–30%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None Unknown Drug use Few (1%–10%) Unknown WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists, medical doctors and psychologists Treatment For psychiatrists, medical doctors and psychologists National standards of care for professionals For psychiatrists, addiction medicine specialists and psychologists INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Yes No Substance use indicators as a part of the health information system No Yes Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use Yes – Yes – Yes Yes – Yes 122 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2012 9 206 Population in urban areas (%), 2013 – Adult literacy rate (15–24 years) % 94 Life expectancy at birth (years), 2012 76 Income group (World Bank) High income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health, education, interior and the national rehabilitation centre Ministries of health, interior, justice and the national rehabilitation centre Unit/entity responsible for policies Yes Yes This unit is also responsible for policies covering mental health, tobacco, noncommunicable diseases, health promotion and criminal justice This unit is also responsible for policies covering mental health, tobacco, noncommunicable diseases, health promotion and criminal justice Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Yes – Compulsory treatment Yes Unknown Drug courts Some jurisdictions FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders Stand-alone facilities for substance use disorders Mental health facilities General health care facilities Drug use disorders Stand-alone facilities for substance use disorders Mental health facilities General health care facilities Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas Yes Yes Yes Main substance reported at treatment entry First Prescription opioids Second Alcohol Third Sedatives United Arab Emirates Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Yes Yes Yes Yes Yes Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 123 Country profiles Treatment coverage for substance dependence Opioid dependence Substantial (21%–40%) Cannabis dependence – Cocaine dependence None Alcohol dependence Very limited (1%–10%) Access to treatment for substance dependence Opioid dependence 1%–10% Cannabis dependence 1%–10% Cocaine dependence – Alcohol dependence 11%–20% Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No – Buprenorphine/naloxone (tablets) for opioid dependence No No – Buprenorphine/naloxone (films) for opioid dependence No No – Naltrexone (tablets) for opioid dependence No – – Methadone (liquid) for opioid dependence – – – Methadone (tablets) for opioid dependence Yes For detoxification treatment – Clonidine (tablets) for opioid withdrawal Yes Yes / Lofexidine (tablets) for opioid withdrawal – – / Naloxone (for injection) for opioid overdose No – / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal Yes Yes Yes Disulfiram (tablets) for alcohol dependence – – – Naltrexone (tablets) for alcohol dependence No – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes Yes Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling 1%–10% HIV (ARV) treatment – Hepatitis testing and counselling 1%–10% Hepatitis vaccination 1%–10% Hepatitis treatment 1%–10% Harm reduction programmes Needle/syringe exchange programmes No Outreach services for injecting drug users No Drop-in services Unknown Naloxone distribution programmes No Condom distribution programmes No 124 Atlas: substance use in the Eastern Mediterranean Region 2015 Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women – – – For children and adolescents – – – Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services Yes Yes No Employment services Yes Yes – Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines Yes Yes Web-based interventions – Unknown Mobile phone based interventions – Unknown Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups Yes Yes – – – Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual) based-programmes Some (1%–30%) Some (1%–30%) Workplace programmes – – Parenting programmes None Some (1%–30%) Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use None – Drug use None None WORKFORCE Availability of postgraduate training programmes Prevention None Treatment None National standards of care for professionals For psychiatrists INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No – Substance use indicators as a part of the health information system No No Monitoring of substance use related deaths – / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use Yes – – – Yes Yes Yes Yes Drug use Yes – – – Yes Yes – Yes 125 Country profiles DEMOGRAPHIC INFORMATION Total population (000), 2013 4 485 Population in urban areas (%), 2013 73 Adult literacy rate (15–24 years) % 96 Life expectancy at birth (years), 2012 72.9 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministries of health and interior Ministry of health Unit/entity responsible for policies Yes, for drugs only Yes, for drugs only Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment No No Compulsory treatment No No Drug courts None FINANCING SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders – – – Drug use disorders – – – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas No No No Main substance reported at treatment entry First – Second – Third – Treatment coverage for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence – West Bank and Gaza Strip Main financing method for treatment services for substance use disorders Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 126 Atlas: substance use in the Eastern Mediterranean Region 2015 Access to treatment for substance dependence Opioid dependence – Cannabis dependence – Cocaine dependence – Alcohol dependence – Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence Yes – – Buprenorphine/naloxone (tablets) for opioid dependence – – – Buprenorphine/naloxone (films) for opioid dependence – – – Naltrexone (tablets) for opioid dependence Yes – – Methadone (liquid) for opioid dependence Yes For maintenance treatment – Methadone (tablets) for opioid dependence No No – Clonidine (tablets) for opioid withdrawal Yes – / Lofexidine (tablets) for opioid withdrawal Unknown Yes / Naloxone (for injection) for opioid overdose Yes Yes / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence – – / Diazepam (tablets) for alcohol withdrawal Yes Yes – Disulfiram (tablets) for alcohol dependence Yes – – Naltrexone (tablets) for alcohol dependence Yes – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal Yes Yes – Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling – HIV (ARV) treatment Unknown Hepatitis testing and counselling Unknown Hepatitis vaccination – Hepatitis treatment Unknown Harm reduction programmes Needle/syringe exchange programmes Yes Outreach services for injecting drug users – Drop-in services – Naloxone distribution programmes – Condom distribution programmes Yes Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No 127 Country profiles Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone–based interventions No No Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual) based-programmes None None Workplace programmes None None Parenting programmes None None Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Unknown Unknown Drug use Unknown Unknown WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists, psychologists, social workers and nurses Treatment For psychiatrists, psychologists, social workers and nurses National standards of care for professionals For psychiatrists, nurses, psychologists and social workers INFORMATION SYSTEMS Collected Reported Epidemiological substance use data No Unknown Substance use indicators as a part of the health information system No Unknown Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – Yes – – – Yes Drug use Yes – – Yes – – – Yes 128 Atlas: substance use in the Eastern Mediterranean Region 2015 DEMOGRAPHIC INFORMATION Total population (000), 2013 25 235 Population in urban areas (%), 2013 29 Adult literacy rate (15–24 years) % 34 Life expectancy at birth (years), 2012 64 Income group (World Bank) Lower middle income LEADERSHIP AND GOVERNANCE Prevention Treatment Principal ministry(ies) Ministry of health Ministry of health Unit/entity responsible for policies Unknown Unknown Diversion schemes from criminal justice to health care system As an alternative to criminal sanctions In addition to criminal sanctions Voluntary treatment Unknown Unknown Compulsory treatment Unknown Unknown Drug courts Unknown FINANCING Main financing method for treatment services for substance use disorders SERVICE ORGANIZATION AND DELIVERY Service provision and coverage Main providers of treatment services First Second Third Alcohol use disorders – – – Drug use disorders – – – Availability of specialized treatment facilities for substance use disorders In the capital city In other major cities In other areas No No No Main substance reported at treatment entry First – Second – Third – Treatment coverage for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Access to treatment for substance dependence Opioid dependence Unknown Cannabis dependence Unknown Cocaine dependence Unknown Alcohol dependence Unknown Yemen Outpatient detoxification Inpatient detoxification Outpatient treatment Inpatient treatment Rehabilitation OAMT Government financing Employer financing Households Nongovernmental organizations and other external financing Global Fund financing 129 Country profiles Pharmacological treatment Guidelines on pharmacological treatment No Registration and availability of medications For opioid dependence/withdrawal/overdose Registration Availability Daily supervised dosing available for outpatients Buprenorphine (sublingual tablets) for opioid dependence No No No Buprenorphine/naloxone (tablets) for opioid dependence No No No Buprenorphine/naloxone (films) for opioid dependence No No No Naltrexone (tablets) for opioid dependence – – No Methadone (liquid) for opioid dependence – – No Methadone (tablets) for opioid dependence – – No Clonidine (tablets) for opioid withdrawal No – / Lofexidine (tablets) for opioid withdrawal – – / Naloxone (for injection) for opioid overdose – – / For alcohol dependence/withdrawal Acamprosate (tablets) for alcohol dependence No No / Diazepam (tablets) for alcohol withdrawal No – No Disulfiram (tablets) for alcohol dependence – – No Naltrexone (tablets) for alcohol dependence – – / For benzodiazepine withdrawal Diazepam (tablets) for benzodiazepine withdrawal No – No Special programmes and services HIV and hepatitis testing, counselling and treatment availability (percentage of total in specialized facilities and services for substance use disorders) HIV testing and counselling Unknown HIV (ARV) treatment Unknown Hepatitis testing and counselling Unknown Hepatitis vaccination – Hepatitis treatment – Harm reduction programmes Needle/syringe exchange programmes Unknown Outreach services for injecting drug users Unknown Drop-in services Unknown Naloxone distribution programmes Unknown Condom distribution programmes Unknown Special treatment programmes for women, children and adolescents with substance use disorders In the capital city In other major cities In other areas For women No No No For children and adolescents No No No Social services for people with substance use disorders In the capital city In other major cities In other areas Special housing services No No No Employment services No No No Open access interventions for substance use problems Alcohol use Drug use Telephone help-lines No No Web-based interventions No No Mobile phone based interventions No No 130 Atlas: substance use in the Eastern Mediterranean Region 2015 Prevention activities Prevention programmes Coverage for alcohol use Coverage for drug use School (manual) based-programmes None None Workplace programmes None None Parenting programmes None None Screening and brief interventions for substance use In primary health care services In antenatal services Alcohol use Unknown Unknown Drug use Unknown Unknown WORKFORCE Availability of postgraduate training programmes Prevention For psychiatrists, medical doctors, psychologists, social workers, nurses, counsellors and community health workers Treatment For psychiatrists, medical doctors, psychologists, social workers, nurses, counsellors and community health workers National standards of care for professionals For psychiatrists INFORMATION SYSTEMS Collected Reported Epidemiological substance use data Unknown No Substance use indicators as a part of the health information system Unknown No Monitoring of substance use related deaths No / Prevention programmes for specific populations Prisoners Pregnant women Commercial sex workers Refugees People with HIV/ AIDS Children and adolescents Persons with mental health disorders Young adults Alcohol use – – – – – – – – Drug use – – – – – – – – Mutual support/self-help groups Alcoholics Anonymous Narcotics Anonymous Cocaine Anonymous Al-Anon/ Alateen Family support groups No No No No No Mental disorders have a profound effect on individuals, their families and society, and are responsible for 11% of disease burden in the Eastern Mediterranean Region yet. WHO’s Project Atlas 2014 has collected and compiled information about mental health resources in countries around the world. This regional review incorporates region-specific data, presenting comparisons with other regions, analysing countries with similar health system characteristics within the Region, and providing concise summary sheets for each country that provided data for the Atlas 2014 Project. It is hoped that this will assist stakeholders in the countries of the Region to identify gaps in current provision and inform decisions around increasing resources to scale up services for mental health.

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Publications

Дата принятия 1 марта 2017 г.

Источник Всемирная организация здравоохранения