VISITING EXPERTSʼ PAPERS
INTERNATIONAL STANDARDS FOR THE TREATMENT OF DRUG USE
DISORDERS
Anja Busse＊

I. INTRODUCTION
This article describes the policy background, purpose, content as well as the dissemination process of theInternational Standards for the Treatment of Drug use Disorders (UNODC/WHO, 2016).
Drug Use Disorders (DUDs) are a public health, developmental and security problem both inindustrialized and developing countries. They are associated with health problems, poverty, violence, criminal
behaviour and social exclusion. Prevention of illicit drug use and treatment of drug use disorders are essential
demand reduction strategies of significant public health importance. Therefore, the implementation ofadequate programmes is key in ensuring an appropriate response to the need for evidence-based prevention
and treatment interventions of people at risk or affected by drug use disorders and their negative health andsocial consequences.
The International Standards for the Treatment of Drug Use Disorders1 (the Standards) were prepared in
the framework of the UNODC-WHO Programme on Drug Dependence Treatment and Care2 to support UN
Member States in their efforts to develop and implement effective and ethical services and systems for thetreatment and care of drug use disorders. The Standards were launched as a draft for field testing during the2016 Commission on Narcotic Drugs (CND).
Prior to the Standards, UNODC and WHO had already jointly published the Principles of Drug
Dependence Treatment (the Principles)3 (UNODC/WHO, 2008) which specify general requirements forcomprehensive drug dependence treatment that is accessible, affordable, evidence-based, diverse andcompliant with human rights and ethical standards. Building on the Principles, the Standards describe arange of effective treatment interventions that can be implemented in a variety of settings (outreach,outpatient treatment, short-term inpatient treatment, longer-term residential treatment to sustainedrecovery management) with a view to the implementation of a full continuum of care for the treatment ofdrug use disorders at the service and the systems levels.
About 275 million people worldwide or 5.6% of the global population aged 15-64 years have used drugs at
least once in the year 2016 and 31 million people globally suffer from drug use disorder. Cannabis remains themost widely used illicit drug worldwide while opioids are responsible for most of the negative health impactof drug use. There are an estimated 11 million people who inject drugs (PWID) and are thus exposed tofurther health and social risks. 1 in 8 persons who inject drugs is living with HIV, and every second person
who injects drugs has Hepatitis C. There remains a discrepancy between the number of people who actually
receive treatment for drug use disorders and the number of people who need it as globally only 1 in 6 personsin need of drug use disorder treatment has access to it4. Women with drug use disorders are even more
underrepresented in treatment. 1 in 3 persons who use drugs is a woman, but women account only for 1 in 5Ms. Anja Busse is Programme Officer at the Prevention, Treatment and Rehabilitation Section at the United Nations Office onDrugs and Crime. She can be contacted at anja.busse@un.org. The information and views set out in this article are those of theauthor(s) and do not necessarily reflect the official opinion of the UNODC.
1UNODC/WHO (2016). International Standards for the Treatment of drug use Disorders. Draft for Field Testing. Available
online at: http://www.unodc.org/documents/International_Standards_2016_for_CND.pdf
2
http://www.unodc.org/unodc/en/treatment-and-care/our-projects.html
3United Nations Office on Drugs and Crime and the World Health Organization, Principles of Drug Dependence Treatment(Vienna, Austria, 2008).
4
United Nations Office on Drugs and Crime, World Drug Report 2018 (Vienna, Austria, 2018).
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people in treatment5.
Limitations inherent in the data regarding drug use in general, and treatment specifically, must be
considered. Reporting practices on drug use tend to be weak, and the data for drug use disorder treatment isgreatly affected not only by the demand for it but also by the extent to which treatment services areavailable and accessible, and supported through public funding.

II. DEVELOPMENT OF THE STANDARDS AS PART OF THE INTERNATIONALDRUG POLICY CONTEXT
A. Commission on Narcotic Drugs (CND) Political Declaration and Plan of Action 20096
In the Political Declaration and Plan of Action on International Cooperation towards an Integrated andBalanced Strategy to Counter the World Drug Problem (2009), Member States expressed great concern
regarding the consequences of drug use and drug use disorders for people who use drugs, their families andtheir communities. Member States restated their commitment to work towards the goal of universal accessto comprehensive prevention programmes and treatment, care and related support services and recognizedthat a lack of quality standards hinder the effective implementation of demand reduction measures based on
scientific evidence, therefore requesting the development and adoption of appropriate health-care standards.
In response, the UNODC and WHO jointly created a Global Programme on Drug Dependence Treatment
and Care in 20097. This programme supports UN Member States in their efforts to develop effective
treatment policies, systems services through capacity building and technical assistance. As part of theircollaboration, UNODC and WHO developed initially the Principles and then the Standards as guidance toMember States on the provision of ethical and evidence-based drug-use-disorder treatment and careinterventions to be implemented as a continuum of care in a variety of settings within a comprehensive druguse-disorder treatment system.
B. CND Resolution 59/4 ‒ Development and Dissemination of International Standards for the Treatment of Drug Use Disorders
The Standards were released as a draft for field testing at the 59th session of the Commission on Narcotic
Drugs in April 2016. In resolution 59/4 Member States noted with appreciation the work of the United
Nations Office on Drugs and Crime and the World Health Organization in developing the international
standards for the treatment of drug use disorders, and encouraged all Member States to consider expanding
the coverage and improving the quality of drug treatment systems, interventions and policies based on
scientific evidence, using the scientific evidence-based international standards for the treatment of drug use
disorders developed by the UNODC and the WHO.
C. Outcome Document of the 2016 United Nations General Assembly Special Session on the World Drug
Problem8
The United Nations General Assembly conducted a Special Session on Drugs in April 2016, during which
it clearly recognized drug dependence as a complex, multifactorial health disorder characterized by a chronic
and relapsing nature with social causes and consequences that can be prevented and treated throughscientific evidence-based treatment, care and rehabilitation. It furthermore recommended to promote andimplement the standards on the treatment of drug use disorders developed by UNODC and WHO along witha range of other concrete suggestions to improve treatment and care for people affected by drug use
disorders, for example, to encourage the voluntary participation of persons with drug use disorders intreatment programmes, with informed consent.

Ibid.
United Nations Office on Drugs and Crime, Political Declaration and Plan of Action on International Cooperation towards an
Integrated and Balanced Strategy to Counter the World Drug Problem (Vienna, Austria, 2009).
7More information available from: http://www.unodc.org/unodc/en/frontpage/unodc-and-who-launch-joint-drug-dependencetreatment-programme.html; http://www.unodc.org/unodc/en/treatment-and-care/our-projects.html
8United Nations General Assembly, Outcome Document of the 2016 United Nations General Assembly Special Session on theWorld Drug Problem – Our Joint Commitment to Effectively Addressing and Countering the World Drug Problem (New York,2016).
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D. Sustainable Development Goals
The Standards support the implementation of the Sustainable Development Goals (SDG), especially SDG 39‒ Ensure healthy lives and promote well-being for all at all ages; particularly target 3.5 ‒ to strengthen thetreatment of substance abuse, and 3. 8 ‒ to achieve universal health coverage, access to quality essential
health-care services and affordable essential medicines for all.

III. INTERNATIONAL STANDARDS FOR THE TREATMENT OF DRUG
USE DISORDERS10
A. Key Principles and Standards for the Treatment of Drug Use Disorders
Seven key principles have been outlined in the Standards as a cross-cutting requirement for the deliveryof treatment of drug use disorders, to1
11Principle 1.
Principle 2.
Principle 3.

1Principle 4.

1
1Principle 5.
Principle 6.

1Principle 7.

Be available, accessible, attractive and appropriate;
Ensure ethical standards of care in treatment services;
Promote treatment of drug use disorders by effective coordination between thecriminal justice system and health and social services;
Be based on scientific evidence and respond to specific needs of individuals withdrug use disorders;
Respond to the needs of specific populations;
Ensure good clinical governance of treatment services and programmes for druguse disorders;
Ensure an integrated treatment approach where linkages to complementary
services must be constantly monitored and evaluated.

B. Comprehensive Treatment Modalities and Interventions
The Standards then describe how a range of evidence-based interventions needs to be implemented
throughout a continuum of care including modalities such as outreach, screening and brief interventions,outpatient treatment, short-term inpatient treatment, longer-term residential treatment and sustained
recovery management.
Assessment and treatment planning are considered relevant for all settings, as drug use disorders can bedescribed on a spectrum from lower to higher severity and complexity. Treatment plans, to be developedwith the patients, would therefore need to count on a diversity of treatment and care approaches taking into
account the overall life situation of the patient including health, social, legal, educational, financial and otheraspects. It is recommended that treatment plans be developed with the help of a multi-professional team withpatient involvement. Treatment plans should be individualized and consistent with the management of otherchronic illnesses.
DUDs are often associated with other mental and somatic disorders. A comprehensive assessment should
be administered upon entry into any treatment programme that includes a full medical history, presence ofchronic and acute diseases and related pharmaceutical therapies, as well as a routine documentation of
infectious diseases including HIV, tuberculosis, and hepatitis. It is also critical to distinguish independent
metal health disorders from substance-induced disorders that will improve with abstinence.
1. Community-Based OutreachCommunity-based outreach services approach and engage with people who use drugs (PWUD) in theircommunity in an unconditional way. Outreach specifically targets PWUDs who, because of the unavailability,inaccessibility or unacceptability of existing services are not currently receiving treatment. This treatment
modality aims to identify affected populations, engage them, provide community-based care including for thereduction of the negative health and social consequences of drug use and dependence, and link people tooutpatient and inpatient health and social services according to their needs.

https://sustainabledevelopment.un.org/SDG3The Standards are available for download at https://www.unodc.org/documents/commissions/CND/CND_Sessions/CND_59/ECN72016_CRP4_V1601463.pdf
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Outreach depends heavily on community workers; often peer workers, as they are knowledgeable of thelocal communities they serve. They should have adequate basic training in relevant health conditions andhealth and social services available in the community.
2. Screening, Brief Interventions, and Referral to Treatment
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used toidentify, reduce, and prevent drug use disorders and can be applied in different non-specialized contexts.
Health service providers, which are not specialized in the treatment of drug use disorders, can be trained todeliver SBIRT in a rapid and cost-efficient manner that causes minimal interference with the provision ofother services (WHO, 2012). For people who screen positive for drug use, a brief intervention carried out in a
non-judgmental and motivational style can be effective in altering the trajectory of people at risk ofdeveloping drug use disorders or experiencing other severe negative complications related to their drug use.
Screening may also identify a smaller subset of persons with already more significant, chronic or complex
substance use problems who will require a more extensive assessment and referral for specialized drug use
disorder treatment.
3. Short-Term In-Patient Treatment
The short-term inpatient treatment setting is ideal for persons likely to experience a severe withdrawal
syndrome following cessation of drug use, and for people whose current drug use is causing a significant riskof harm and who might only have limited social support. Short-term inpatient treatment typically takes placein an environment in which 24-hour care is available to manage the symptoms and complications likely tooccur following the cessation of drug use (management of withdrawal) or acute symptoms related to othercomorbid disorders.
There are established withdrawal protocols usually employing pharmacotherapy combined with rest,nutrition and motivational counselling. Staff should be knowledgeable about withdrawal and able to prescribe
effective medication. They should also be prepared to offer psychological support to motivate the patient tomove past the withdrawal phase. Detoxification alone cannot be considered an effective treatment response
as the risk of relapse is high following detoxification and the risk of overdose due to decreased tolerance
increases significantly after discharge. An effective follow-up treatment plan should therefore include
strategies for patients to successfully transition to the next level of care and maximize the chances tomaintain medical and psychological health.
4. Outpatient Treatment
Outpatient treatment requires persons with drug use disorders to visit the treatment facility only fortreatment interventions. It is intended to help patients stop or reduce drug use; to minimize medical,psychiatric and social problems associated with drug use; to reduce the risk of relapse; and improve general
well-being as part of a long-term recovery process. Its components vary considerably in terms of the level ofintensity and the interventions offered, but is nonetheless usually performed in health and social services
specializing in the treatment of substance use disorders, or within the broader context of community mental
health services. The range of treatment offered in the outpatient setting include psychological andpharmacological interventions, and social support. Treatment objectives can be best accomplished by using a
combination of evidence-based pharmacological and psychosocial interventions. Ideally, outpatient treatment
programmes for drug use disorders offer a comprehensive range of services to manage various problems
affecting patients across several life domains. Routine cooperation with allied care services is essential andshould include integration of outpatient treatment with medical services for HIV, viral hepatitis, TB andsexually transmitted infections. Routine cooperation with social support and other agencies, including
education, employment, welfare, housing, or legal assistance should also be present. Outpatient treatment andcare services can help patients in establishing a level of stability and resources in their lives that makes it
easier to follow a course of ambulatory health interventions.
5. Long‒Term Residential Treatment
Long‒term residential treatment can take place in a hospital environment, typically a psychiatric hospital,
or for example in a therapeutic community. Although traditional models of long-term residential treatment
include only psychosocial treatment methods, modern approaches may involve the use of medications todecrease drug cravings and manage comorbid psychiatric symptoms. The primary focus of treatment is onlearning skills to control cravings and on developing new interpersonal skills, personal accountability,
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responsibility, and improving self-esteem. Additionally, the structured activities and the rules of theresidential programme help patients develop better impulse control and delay gratification while learning
skills to deal with frustration and to cope with stress. Comprehensive services including vocational skills andemployment training may also be provided in the residential setting.
Patients who are unlikely to maintain abstinence outside of a structured environment or to participate inhealth and social integration are most likely to benefit the most from long-term residential treatment. Staying
long-term in a residential setting allows patients to take a break from the chaotic and stressful environmentthat might have contributed to their drug use. At the end of a long-term residential treatment programme
the transition to the community must be carefully planned and supported. The duration of treatment
necessary to consolidate and internalize behavioural change and prepare to live a drug-free life varies foreach resident; however residents who stay at least 3 months in treatment usually have better outcomes.
Residential treatment which intends to promote therapeutic change must be distinguished from supported
accommodation that primarily functions as a housing intervention that is not providing active treatment.
6. Sustained Recovery Management
Post-discharge relapse and eventual re-admission in treatment are very common; sustainable recovery,
however, is possible, and up to 40% of persons with DUDs achieve it. Recovery management describes a longterm recovery-oriented model that follows the stabilization of abstinence achieved during outpatient orresidential treatment. The primary goal of recovery management is to maintain benefits obtained in earlier
treatment: it focuses on reducing the risk of relapse to drug use by comprehensively supporting social
functioning, well-being, and social reintegration.
Ideally, both long-term residential and intensive outpatient care should be followed by a step down to aless intensive level of care that continues long-term. Recovery-oriented continuing care is an approach tolong-term management of patients within the network of community-based supports and services. Instead ofa discharge process, in recognition of the chronic and relapsing nature of this complex disorder, there is poststabilization monitoring, recovery education, recovery and coaching, active linkage to communities ofrecovery, recovery community resource development, and early re-intervention when needed. Given thechronic and relapsing nature of drug use disorders, recovery management approaches include long-term
pharmacological, psychosocial, and environmental interventions targeted at maintaining reductions insubstance use and contact with the criminal justice system as well as maintained improvements in physicaland mental health, and social functioning.
C. Treatment Systems
An effective national system for the treatment of drug use disorders requires a coordinated and7

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integrated response of many actors to implement policies and interventions based on scientific evidence inmultiple settings and targeting different groups at different stages with regard to the severity of their druguse disorders. The public health system is best placed to take the lead in the provision of effective treatment
services for people affected by drug use disorders, often in close coordination with social care services andother community services. Case management is a strategy to support patients in accessing various services
offered in a network of community-based health and social services. Treatment services should be available,accessible, affordable, evidence-based, and diversified. When developing a comprehensive treatment systemthat wisely allocates available resources and responds best to patientʼs needs, the key public health principle
to apply is offering the least invasive intervention possible with the highest level of effectiveness and thelowest cost possible. Investments of public funds should therefore be made according to the frequency oftreatment services needed as shown in the service organization pyramid.

IV. FIELD TESTING AND IMPLEMENTATION OF THE STANDARDSFollowing the launch of the Standards and their wide policy level acknowledgement, a process of fieldtesting was initiated in the framework of the UNODC/WHO Programme on Drug Dependence Treatment
and Care to assess further the comprehensiveness, appropriateness, feasibility, utility and evaluation
capability of the Standards in different contexts. Data so far were formally collected from 9 countries,
involving about 1,000 survey respondents, results from more than 30 focus groups, 40 expert reviews and 30
site visits. Data analysis has begun, and a comprehensive field testing report will accompany the future
dissemination of the Standards. In parallel, the Standards have already been applied by countries in thedevelopment of national level quality assurance mechanisms for drug-use-disorder treatment services.
Quality Assurance Tools for Drug Treatment Services and Systems were developed and piloted by UNODC tofurther support UN Member States in the operationalization and putting the Standards into practice.

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