Table 3.
Framework for the development of indicators for quality monitoring of harm reduction services, with a focus on opioid agonist therapy (OAT) and needle and syringe programmes (NSP); priority indicators are in italics
| Specific OAT indicators may includea: |
| Coverage of estimated opioid user population (%, see Fig. 1 ) |
| Waiting time to first treatment admission (months) |
| Methadone/buprenorphine dosage (grams) |
| OAT available (including new initiation) in prisons (in all /in some /no) |
| OAT medicine covered by state /health insurance (yes /partly /no) |
| Illicit drug consumption tolerated (after dose induction phase) (yes /no) |
| Diagnosis or detailed assessment of current substance use, individualised treatment planning (yes /no) |
| Take home OAT available (yes /no) |
| Counselling required (yes /no) |
| Specific NSP indicators may includea: |
| Coverage of estimated PWID population (syringes /PWID /year, see Fig. 2 ) |
| Annual number of needles /syringes distributed and collected (administrative data, and /or estimated by weight) b |
| Provision of drug use equipment and injecting paraphernalia (including for non-injected use e.g. foils for heroin chasing, stems and filters for crack smoking) (in all /in some /no) |
| NSP available in prisons (in all /in some /no) |
| Coverage of all undertaken injections (syringes /100 injections) |
| Restrictions in numbers of syringes distributed per contact (yes /no) |
| Type of syringes (% low dead space, acceptance by users) |
| Modality (specialised NSP, outreach, pharmacy, other, e.g. drug treatment service) |
| Brief opportunistic motivational interventions provided (yes /no) |
| Generic cross-cutting indicators for harm reduction (and other drug services) may includea: |
| Infectious diseases counselling, testing, vaccination and referrals (e.g. HIV, HCV, HBV, TB) (in all /in some /no) |
| Take away naloxone provided (in all /in some /no) |
| Information provided on safer use, injecting and safer sex (in all /in some /no) |
| Condoms provided (in all /in some /no) |
| Accessibility: opening times and geographic coverage, outreach activities, costs to clients, no age limits, no parental consent requirements, targeted programmes for special populations (e.g. (pregnant) women, sex workers, underage users) (to construct overall index score: high /medium /low) |
| Integration /cooperation with other services and continuity of care: e.g. shared location /referrals to NSP, OAT, infectious diseases counselling and testing, antiviral and other medical treatment and care, overdose prevention, social support, housing, education, employment services (in all /in some /no) |
| Regular consultation with law enforcement /community /neighbourhood: avoiding nuisance and conflict, improving safety for both clients and community (index: high /medium /low) |
| Regular consultation with the users of the service: feedback, evaluation, client satisfaction (index: high /medium /low) |
| Assessment procedures: risk behaviours, needs, health status, informed consent, data confidentiality, written client records (index: high /medium /low) |
| Psycho-social interventions provided (with or without medication): (yes /no) |
| Frequency of contact with a counsellor /social worker (times per month) |
| Staff qualification, multidisciplinarity, education and (ongoing) training (index: high /medium /low) |
| Case /contact management follows protocol /guidelines (yes /no, specify which) |
| Type of funding source: private /public; national /international, etc.; and security of funding (per client, grant-based, etc.), utilisation monitoring (treatment slots used), peer support /aid (to construct an overall index score on funding continuity and reliability: high /medium /low) |
aThe quality indicators listed are mostly structural and procedural [56]. Outcome indicators are limited to OAT and NSP coverage estimates. Other outcome indicators may be considered (e.g. client retention and return rates, reductions in drug use, crime, improvements in health, etc.), but given their complexity, this may be more appropriate to assess in detailed service evaluation studies at national or local level [171] (although note [110]). Further work may be needed to link up more strongly with recently adopted EU quality standards [68]. Other harm reduction and drug interventions to be considered for monitoring may include antiviral and antibacterial therapy (e.g. HIV, HCV, HBV, TB), heroin-assisted treatment, drug consumption rooms/safer injecting facilities, testing drug content and handing out water at rave parties and similar events, police interactions with drug users affecting service utilisation, interventions in special settings (e.g. prisons, mobile or outreach interventions), social interventions, e.g. relating to children or family of PWUD, and monitoring and may even extend to drug policy indicators (e.g. minimum quantities of drugs allowed for personal use, sentencing practise, medical use of cannabis, decriminalisation/liberalisation of drug laws, drug treatment regulations, e.g. allowing opioid agonist therapy through primary caregivers), continuity of care following prison release or treatment discharge
bMeasuring infection rates in returned syringes may form an important and cost-effective method for monitoring prevalence and incidence of infection in the population [135, 136].
Measures of central tendency (e.g. mean, median) may be complemented by measures of variability (e.g. range, interquartile range) to better capture intra- and inter-national variation.