In Spain, the overall policy for drug treatment is guided by the National Strategy on Addictions. At the same time, the implementation, management and evaluation of the resources and programmes for providing care for drug users come under the authority of the 17 autonomous communities and two autonomous cities. Each autonomous community is entitled to organise and deliver health interventions in accordance with its own plans, budgets and personnel. Some have integrated treatment for drug use-related problems within primary care units or mental health services, and some have a separate treatment network that retains a connection with the general healthcare system. As a general rule, care is organised on three levels.
The public sector is the primary provider of treatment, followed by non-governmental organisations and private organisations. Drug treatment is mostly funded by the public budget of the central government, autonomous communities and cities and by some municipalities, usually the big cities.
Primary care acts as a gatekeeper to services, the secondary level provides integrated treatment services and tertiary-level care units supply highly specialised and long-term care. A specific drug dependence care network is widely distributed throughout the country. Therapeutic provision comprises outpatient and inpatient treatment networks.
The outpatient network includes low-threshold services, mainly operating at the first care level and providing mental health screening for clients, and specialised drug treatment centres, including mental health units, operating at the secondary level and providing the backbone of the treatment system. A team of multidisciplinary staff usually manages clients in those settings, providing psychosocial treatment, case management and referral to other services.
The inpatient networks include hospital detoxification units, support apartments for treatment and social reintegration, therapeutic communities and penitentiary centres. In Spain, a wide variety of social reintegration programmes and activities are also available, including (i) leisure and social relationship programmes, (ii) training programmes, (iii) residential support programmes and resources (both transitory and permanent) and (iv) employment grants.
In Spain, opioid substitution treatment (OST) is available at around 2 000 specialised outpatient centres, at other health and mental health centres, at inpatient facilities and in prisons. Pharmacies are involved in dispensing medication to patients. Methadone was introduced and licensed as a treatment in 1990, and the treatment is free for clients. Buprenorphine-based medication is offered by the National Health Service, but clients have to contribute to the cost of the medication.
In Spain, nearly 190 000 clients received drug treatment in 2016, the majority of whom were treated in outpatient settings. Over the last decade, the number of clients entering treatment each year has ranged between 47 000 and 53 000. Heroin users remain the largest population receiving drug treatment in Spain, many of whom are long-term recipients of OST. Cocaine is the most commonly reported as the primary drug for which clients enter drug treatment. The long-term trend indicates that the proportion of people entering treatment as a result of heroin use was on the decline up until 2013 and has been stable since then. An increase in cocaine treatment demands was reported in 2015 and 2016.
Methadone maintenance treatment remains the most frequent form of OST, while combined buprenorphine/naloxone is mainly used at low doses for clients who were stabilised on methadone. In 2016, over 58 500 people were prescribed OST in Spain. Since 2002, a declining trend in the number of clients receiving OST in Spain has been reported, which is consistent with other data indicating an overall decline in the number of heroin users in the last two decades.