Abstract: Le bilan du développment de QuaThéDa est positif au point de vue professionnel, mais les problèmes de financement ainsi que de transfert de compétences de la Confédéreation aux cantons pourraient mettre en péril les acquis d’une politique qulaité au sein des institutions. Selon les auteures, seule une mise en place de conditions cadres valables pour tous les canton permettra le maintien de thérapies résidentielles de qualité.

Abstract: Die Frage nach der Wirksamkeit von Suchtbehandlungen ist für Institutionen, die sich mit Abhängigkeiten von psychoaktiven Substanzen befassen, in den Vordergrund gerückt. Gefordert werden die Auswertung von Behandlungsergebnissen sowie verlässliche Daten über die Entwicklung der Klienten nach erfolgter Behandlung. Bei der Beurteilung der Behandlungsergebnisse geht es nicht nur um den Konsum der Substanz, die zum Problem geführt hat, sondern um alle Umstände, die mit der Lebenssituation des Klienten in Beziehung stehen. Die Walliser Liga gegen die Suchtgefahren (LVT) ist verantwortlich für die Betreuung von Personen im Kanton Wallis, die vom Konsum psychoaktiver Substanzen betroffen sind. Diese Arbeit berichtet über die von der LVT gesetzten Schwerpunkte sowie die verschiedenen durchgeführten Studien und liefert eine Auswahl der ersten Ergebnisse. Les questions de l’évaluation des résultats des traitements et de la connaissance du devenir précis des clients après la période d’exposition au traitement sont devenues importantes pour les institutions spécialisées dans la prise en charge des problèmes de consommation de substances psychoactives. Les résultats des traitements ne se limitent plus seulement à l’usage qui est fait de la substance posant problème, mais touchent l’ensemble des problèmes qui y sont associés. La Ligue Valaisanne contre les Toxicomanies, organisme responsable de la prise en charge des personnes ayant un problème de consommation de substances psychoactives dans le canton du Valais, a déployé des moyens spécifiques pour augmenter sa connaissance des résultats de ses propres traitements. Ces moyens sont, par exemple, l’introduction d’un instrument d’évaluation de la clientèle (ASI/IGT) ou la mise en place d’une étude de catamnèse dans son secteur résidentiel. Les choix opérés par la LVT, les différentes études conduites et une sélection des premiers résultats obtenus sont présentés. The question of the effectiveness of addiction treatments has become a central focus of institutions dealing with psychoactive substance dependencies. Here, both the evaluation of therapeutic results and reliable data on the post-treatment progress of the patients are required. The assessment of the therapeutic results must go beyond simply looking at the consumption of the substance that caused the problem in the first place, but should include all circumstances that are linked to the life situation of the patient. The Valaisan League against Drug-addiction LVT (Ligue Valaisanne contre les Toxicomanies) is responsible for the care of persons in the Canton Valais who have problems with the consumption of psychoactive substances. The League has developed specific instruments for expanding its knowledge concerning the effectiveness of its own addiction therapies. These instruments include, for example, a patient addiction severity index (ASI/IGT) and a systematic evaluation of inpatient follow-ups. This article reports on the main priorities defined by the LVT and on the various studies that have been conducted and presents a selection of the initial results.

Abstract: Die gesundheitspolitischen Zielsetzungen des ungehinderten Leistungszugangs, der Versorgungsgerechtigkeit, der Wirksamkeit und der Effizienz sind unmittelbar verbunden mit der Verfassung der Finanzierungswege in Versorgungssystemen. Die Mittelallokation von den Leistungseinkäufern zu den Leistungserbringern kann nach drei Systematiken mit jeweils unterschiedlichen Anreizwirkungen unterschieden werden: Variabilität versus Fixierung von Kosten, prospektive versus retrospektive Bezahlungsform und unterschiedlicher Pauschalisierungsgrad der Erstattungseinheiten. Für die Suchttherapien ist zudem ein unübersichtlicher Mix aus leistungsbezogenen Entgelten und institutioneller Förderung fast schon typisch und erschwert Evaluationen. Die gegenwärtigen Reformen der Gesundheitssysteme bemühen sich zumeist um fixe Kosten, die prospektiv erstattet werden und einen zunehmend höheren Pauschalisierungsgrad für das entgoltene Paket von Dienstleistungen annehmen. Dies soll der Kostenbegrenzung und Effizienzsteigerung dienen. Methodisch suffiziente Evaluationen sind in überraschend geringer Zahl vorgelegt worden, so dass die Wirkungen der Finanzreformen erst nach und nach beschrieben werden können. Mit der Integration aller Finanzierungsformen der stationären Suchttherapien in ein einheitliches System wird in der Schweiz gegenwärtig ein radikaler und zukünftig beachtenswerter Systemwechsel vorbereitet. Health policy goals of access, equity, effectiveness and efficiency are linked to the financing of the health care system. Three different categorisations of modes for allocating resources to the providers are usual: variable vs. fixed costs, prospective vs. retrospective payment and different levels of defining lump sums to be reimbursed. The field of substance abuse can additionally be characterised by a mixture of performance-based fees and institutional subventions which makes evaluation of financial incentives almost impossible. Current changes in the health care system mostly strive for fixed costs, prospective payment and high levels of defining services. The goal of such changes is to limit costs and increase efficiency. However, there have been surprisingly few evaluations with good methodology. For inpatient addiction therapies Switzerland has created a radical change of financing system which should be taken into consideration for future developments.

Abstract: Imaging studies have revealed neurochemical and functional changes in the brains of drug-addicted subjects that provide new insights into the mechanisms underlying addiction. Neurochemical studies have shown that large and fast increases in dopamine are associated with the reinforcing effects of drugs of abuse, but also that after chronic drug abuse and during withdrawal, brain dopamine function is markedly decreased and these decreases are associated with dysfunction of prefrontal regions (including orbitofrontal cortex and cingulate gyrus). The changes in brain dopamine function are likely to result in decreased sensitivity to natural reinforcers since dopamine also mediates the reinforcing effects of natural reinforcers and on disruption of frontal cortical functions, such as inhibitory control and salience attribution. Functional imaging studies have shown that during drug intoxication, or during craving, these frontal regions become activated as part of a complex pattern that includes brain circuits involved with reward (nucleus accumbens), motivation (orbitofrontal cortex), memory (amygdala and hippocampus), and cognitive control (prefrontal cortex and cingulate gyrus). Here, we integrate these findings and propose a model that attempts to explain the loss of control and compulsive drug intake that characterize addiction. Specifically, we propose that in drug addiction the value of the drug and drug-related stimuli is enhanced at the expense of other reinforcers. This is a consequence of conditioned learning and of the resetting of reward thresholds as an adaptation to the high levels of stimulation induced by drugs of abuse. In this model, during exposure to the drug or drug-related cues, the memory of the expected reward results in overactivation of the reward and motivation circuits while decreasing the activity in the cognitive control circuit. This contributes to an inability to inhibit the drive to seek and consume the drug and results in compulsive drug intake. This model has implications for therapy, for it suggests a multi-prong approach that targets strategies to decrease the rewarding properties of drugs, to enhance the rewarding properties of alternative reinforcers, to interfere with conditioned-learned associations, and to strengthen cognitive control in the treatment of drug addiction.

Abstract: Whilst urban-dwelling individuals who seek out parks and gardens appear to intuitively understand the personal health and well-being benefits arising from ‘contact with nature’, public health strategies are yet to maximize the untapped resource nature provides, including the benefits of nature contact as an upstream health promotion intervention for populations. This paper presents a summary of empirical, theoretical and anecdotal evidence drawn from a literature review of the human health benefits of contact with nature. Initial findings indicate that nature plays a vital role in human health and well-being, and that parks and nature reserves play a significant role by providing access to nature for individuals. Implications suggest contact with nature may provide an effective population-wide strategy in prevention of mental ill health, with potential application for sub-populations, communities and individuals at higher risk of ill health. Recommendations include further investigation of ‘contact with nature’ in population health, and examination of the benefits of nature-based interventions. To maximize use of ‘contact with nature’ in the health promotion of populations, collaborative strategies between researchers and primary health, social services, urban planning and environmental management sectors are required. This approach offers not only an augmentation of existing health promotion and prevention activities, but provides the basis for a socio-ecological approach to public health that incorporates environmental sustainability.