What types of substitution treatment to develop ?

1. V4 Seminar - OSI- Bratislava March 12./13. 2003 Univ.Prof. Dr. Gabriele Fischer University of Vienna 1090 Vienna What types of substitution treatment to develop ?

2. Vienna

3. AKH - General Hospital Vienna

4. Expert center? GP ? Together Special indications for expert center WHICH SYSTEM

6. Advantages: multidisciplinary Psychiatrist Pharmacist Nurses Psychologist Social worker Disadvantages High treshold - selected group Centralized in large cities Limited capacity Expensive Stigma-“addiction“ clinic Specialist clinic

7. General practitioner

8. „family doctor“-prevention & early treatment initiation Low treshold More capacity Decentralized Cost effective Disadvantages Limited knowledge ? Time for education Advantages

9. Modell Local pharmacy ADDICTION CLINIC visits: 1-7 times a week Clinical pharmacist psychiatrists socialworkers psychologists nurses GP`S

10. OFFICE BASED PRESCRIPTION STUDY WITH BUPRENORPHINEAddiction Clinic – GP`sVienna Week 1 Week 2 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Treatmentphase 1 Clinic Treatment phase 2 General Practitioner End oftherapy Clinic Number of patients: 120 Number of participating GPs: 12 GPs • prior to study: addiction education in target GP`s & pharmacists

11. 3 weeks treatment at addiction clinic12 weeks at the GP`s office, stabilised dose Visits every 14 days at GP`s officeNarcotic prescription and buprenorphine provided through pharmaciesFirst month: daily intake at the pharmacySecond month: intake twice a week at the pharmacy with take home dosesThird month: supervised intake at the pharmacy only once a week

12. Retentionrate Addiction Clinic GPs 100% 80% 60% 40% 20% 0% Week 03 Week 15 Week 01 Week 05 Week 07 Week 13 Week 09 Week 11 Week 02 Induction

13. HOW TO ACHIEVE MAXIMUM SUBSTITUTION EFFICIENCY ?

14. Abstinence • Relapse Prevention • Residential (drug-free) • Outpatient (drug-free) • Psychological counselling • Support group • Antagonist (eg. naltrexone)  Relapse • Substitution Treatment • Methadone • Buprenorphine • LAAM • Slow-release morphine • Detoxification • Agonist assisted • Partial agonist assisted • Symptomatic treatment • Rapid detoxification Cessation  • Harm Reduction • Education about overdose • Hepatitis B immunisation • Pregnancy counselling Heroin use Dependence

15. Clinical Expertise and Policy Context Patient Preference Research Evidence A model for evidence-based clinical decisions (from Haynes et al, 1996)

16. Human rights- Right for treatment Right for choice who needs to be notified ? Addiction Psychiatric comorbidity Somatic comorbidity Legislation Opioid selection Quality assurance Background

17. Urinalysis - cost intensive When useful ? Treatment adjustment Detoxification ?-how useful ? Labaratory parameters

18. Chronic disease Adjustment over time-different stages Life events Comorbidity Social integration As early & individual adjusted as possible And like in any other disease for some clients we won`t be of any help - at least not at the moment, maybe later To be aware-patients are human beings-the ydon`t behave all the time as we - „doctors“ want & patients with diabetes don`t behave always and so ........ Expectations

19. Methadone, LAAM, buprenorphine, SR-morphine aren`t different religions, but medication. Diversification of medication as in any others disease. Treatment works

20. Balance of overregulation & laissez-faire Thank you