Table A8.

Overview of the most important law changes related to the provision of specialized narcological treatment since 2009. Source: Consultant.ru.

2010	The Ministry of Health and Social Development of the Russian Federation adopts the Order No. 225an: On approval of the Procedure for the provision of narcological treatment to the population of the Russian Federation”, which provides a national legislative base for the provision of narcological treatment. Prior to this national legislation, provision of drug and alcohol treatment was regulated by various laws and regulations, including regional laws and legal acts of regional authorities. About 20 orders specify the provisions carried out by the narcological services (diagnosis, treatment, detoxification, medical examination, medical and social rehabilitation, etc.) as well as structural units (departments, offices) of other medical organizations providing narcological treatment. The new legislation provided a new nation-wide legislation framework, according to which narcological treatment was now provided to citizens with mental and behavioral disorders due to the use of psychoactive substance, namely the ICD-10 codes F10–F19 and F-63. Different modes of narcological treatment were introduced: prehospital (primary and emergency medical care) and inpatient care. Narcological emergency care was provided at the prehospital and inpatient settings. A recommendation was made to organize specialized drug treatment teams at stations (substations) within ambulance and emergency departments at district and central district hospitals. When patients with alcohol use disorders presented to narcological offices with acute illnesses and conditions, the psychiatrist/narcologist had to assess the general condition of the patient as well as the mental status, had to decide on the need for additional laboratory testing, provide emergency outpatient narcological medical care, and, if medically indicated, send the patient to the narcological department of medical organizations. After a course of treatment with a patient with narcological diseases, medical and social rehabilitation was carried out first in a hospital, then in an outpatient clinic. After undergoing rehabilitation in an outpatient clinic or refusing it, it was recommended that medical dynamic observation in the narcological office continue. After narcological treatment, medical and social rehabilitation was carried out: first in a hospital, then in an outpatient clinic. After undergoing rehabilitation in an outpatient clinic or refusing it, it was recommended to continue medical monitoring in the narcological office. Narcological monitoring was carried out in accordance with the order of the Ministry of Health of the USSR of 12.09.1988 No. 704 “On the timing of dispensary observation of patients with alcoholism, drug addiction and substance abuse”, which was partly contradicting the legislation of the Russian Federation). For all patients with established AUD diagnoses as well as people at risk, a medical record of an outpatient narcological patient (f. N 025-5/y-88) and a control card of dispensary observation of psychiatric patient (f. N 030-1/y) were filled out. The terms of dispensary registration were set as follows: for patients with “chronic alcoholism”—3 years, for preventive observation of “alcohol abusers”—1 year. A repeal of the registration and monitoring procedures was carried out for the following reasons: stable remission (recovery), change of permanent place of residence, which was no longer covered by the narcological institution, including the transfer of the patient under narcological monitoring to another narcological institution, conviction with imprisonment for a term of over 1 year, or in the case of the patient’s death. Patients with “chronic alcoholism” were classified as per different observation groups: Group I—remission up to a year, examination at least once per month (in case the patient is in outpatient care), Group II—remission from one to two years, examination once every two months, Group III—remission over two years, examination once every three months.
2011	Order of the Ministry of Healthcare and Social Development of the Russian Federation of 15 March 2011 No. 200n “On Amendments to Appendices No. 1–7 to the Procedure for the Provision of Narcological Assistance to the Population of the Russian Federation, approved by order of the Ministry of Healthcare and Social Development of the Russian Federation No. 225an “ https://www.garant.ru/products/ipo/prime/doc/12085489/ amends the main narcological provisions. The new legislation expands provisions from medical treatment and rehabilitation and now includes prevention, counseling, and regular examination into the scope of narcological treatment.
2012	Order of the Ministry of Health of the Russian Federation of 15 November 2012 No. 929n “On approval of the Procedure for the provision of medical care in the profile of “narcology” invalidates the 2011 Order No. 225. According to the new legislation, narcological treatment is provided in the following conditions: outpatient, day hospital and inpatient. In case of detecting a potential substance use disorder, a general practitioner refers the patient to the narcological office of a medical organization to provide primary specialized medical care by a narcologist. Also, the patient could reach out to the narcologist and the narcological office as within a primary healthcare facility. If indicated, the patient can be referred to specialized medical narcological care. The referral of a patient to a specialized medical organization could be carried out by an ambulance team. When providing emergency care, the ambulance team delivers patients to medical organizations providing round-the-clock treatment in the areas of “anesthesiology and resuscitation”, “toxicology”, “psychiatry”, and “narcology”. Upon admission, the patient is examined in the admission department by a narcologist and, if medically indicated, is sent to the narcological department. The patient could be sent for rehabilitation in inpatient as well as outpatient settings. No changes in narcological monitoring procedures occur.
2014	Order of the Ministry of Health of Russia No. 263 “On Approval of the Concept of Modernization of the Narcological Service of the Russian Federation until 2016”, adopts a modernization concept of the narcology services of the Russian Federation until 2016. The main measures of the concept are: (a) developing prevention, (b) improving the provision of treatment, (c) improving the personnel policy in the organization of treatment, (d) improving interdepartmental interaction in the provision of treatment, (e) improving the legal regulation of the organization of treatment. The concept features stable remission rates for different substance use disorders among adults and youth as registered within narcological services as target indicators (indicators) of modernizing the narcological services.
2015/2016	Order of the Ministry of Health of the Russian Federation of 30 December 2015 N 1034n “On Approval of the Procedure for the Provision of Medical Care in the Profile of Psychiatry-Narcology and the Procedure for Dispensary Monitoring of Persons with Mental Disorders and (or) Behavioral Disorders Associated with the Use of Psychoactive Substances” invalidates the 2012 Order No. 929n, in connection with the adoption of new legislative acts in various other fields of the healthcare system. The new document gives priority to prevention and expands the responsibility of screening for risky alcohol use to health professionals in primary healthcare facilities. General practitioners or pediatricians can send a person with risky substance use to a medical prevention office (department) or a health center for individual in-depth preventive counseling. Primary specialized medical care is provided by a narcologist when the patient seeks out help independently, is referred by a specialist or by a court decision. Neurological monitoring is carried out only following a written informed consent. For all narcological patients as well as people at risk, a medical record of an outpatient narcological patient (f. N 025-5/y-88) and a control card of dispensary observation of a psychiatric patient (f. N 030-1/y) is filled out. Regular check-ups by the narcologist are changed: during the first year of remission—at least once a month, during a remission lasting from one to two years—at least once every six weeks, or in remission for more than two years—at least once every three months. During narcological monitoring, an in-depth medical examination is carried out at least once every three months. A repeal of the registration and monitoring procedures can be carried out in the case of: confirmed stable remission of at least three years in patients with a diagnosis of alcohol-dependence, at least a year of confirmed stable remission in patients with a diagnosis of harmful alcohol use, if the medical organization cannot provide an examination of the patient within one year, despite all measures being taken, in the case of the death of the patient, in the case of conviction of the patient to imprisonment for a period of more than one year, in the case of change by the patient of permanent place of residence, when leaving the district that is served by the narcological service provider.
2019	Order of the Ministry of Health of the Russian Federation of July 30, 2019 No. 573n “On Amendments to Appendices No. 1 and 2 to the Order of the Ministry of Health of the Russian Federation No. 1034n of December 30, 2015 ‘On Approval of the Procedure for the Provision of Medical Care in Psychiatry-Narcology “and the Procedure for dispensary observation of persons with mental disorders and (or) behavioral disorders associated with the use of psychoactive substances’” amends the main narcology law. Changes have been made to narcological monitoring procedures, granting patients the right to choose a medical organization where the monitoring can be carried out. Changes to the informed consent form are made, specifying that monitoring is also carried out for persons under the age of fifteen and minors with the informed consent of one of the parents or other legal representatives. If a person is recognized as legally incapable and unable to give consent to medical intervention, informed consent is given by a legal representative. While carrying out the monitoring, the narcologists is not only keeping records of patients under monitoring, but also sends requests for information about the patients’ health and associated diagnoses to other medical organizations, where the patient has been treated. Regulations on the repeal of registration and monitoring procedures are loosened for patients with stable confirmed remission. According to the new legislation, registration will be removed in the case of a stable confirmed remission of at least two years for patients with alcohol-dependence, who have self-referred to a narcological facility (and not by a court decision). Otherwise, a stable remission of at least three years is required. For patients with the diagnosis “harmful use of alcohol” a stable remission of at least one year is required. Also, monitoring can be removed following a written refusal of the patient to be monitored as per the new legislation.