National Guidelines for Substitution Treatment of Opiate Addiction in the Czech Republic

1. National Guidelines for Substitution Treatment of Opiate Addiction in the Czech Republic Petr Popov Apolinar – Addiction Treatment Centre General Faculty Hospital Prague Czech Republic

2. Substitution Treatment Standard(Order of the Czech Ministry of Health; part 6/2000, part 4/2001) • drug dependence diagnostic criteria (ICD - 10) • substitution treatment definition • substances for substitution treatment • substitution treatment typology • indications, contra-indications • therapy(dosage, non-pharmacological components, assessment)

3. F11.2, F11.3(ICD – 10) F11.22 : „At present abstain in clinical controlled maintenance or substitute treatment“ (e.g.. methadone; nicotine) „abstinence-oriented treatment“

4. Substitution Treatment Definition(Substitution Treatment Standard, Czech Ministry of Health ) • Standard treatment (therapy) • time unlimited (open-end) therapy (maintenance therapy) • harm reduction

5. Personal Requirements • Diagnosis and indication made by psychiatrist or adictologist • Substitution treatment performed in specialised centre (with the exception of minimal substitution treatment) • External supervision for facilities is required

6. Substitution Treatment of Opiate Addiction in the Czech Republic- legal substances 1. methadone (HCl) 2. buprenorphine (HCl) (Order of the Czech Ministry of Health; part 6/2000, part 4/2001)

7. Substitution Treatment of Opiate Addiction in the Czech Republic methadone (pharmacopoeia substance) (Order of the Czech Ministry of Health part 6/2000, part 4/2001)

8. Substitution Treatment of Opiate Addiction in the Czech Republic buprenorphine Subutex® (tbl. subl. 0,4mg, 2mg, 8mg) Temgesic® (tbl. subl. 0,2mg, inj.0,3mg) (Order of the Czech Ministry of Health part 6/2000, part 4/2001)

9. Buprenorphine in Substitution Therapy general purpose: • short-term treatment - detox (heroin, methadone) • „half-life“ treatment - stabilization • long-term treatment – maintenance (event. undated/time-unlimited maintenance)

10. Substitution Treatment of Opiate Addiction in the Czech Republic- treatment typology • Complete substitution treatment • Basic substitution treatment • Minimal substitution treatment

11. 1. Complete substitution treatment Administration (provision under control, expense, and/or prescribing) of substitution substance and services, provided within institution: - treatment of somatic and psychic disorders - detoxification - group psychotherapy - individual psychotherapy - family therapy - counselling - health-risk education etc. (see your copy)

12. 2. Basic substitution treatment Administration (provision under control and/or prescribing) of substitution substanceplus services, provided within institution (dtto)

13. 3. Minimal substitution treatment(in health institutions with other specializations) Administration (provision under control and/or prescribing) of substitution substance • short-term - acute states of patients coming from different types of substitution treatment - planned diagnostics or treatment of patients from different types of substitution treatment - travels (work, holiday) • long-term (maintenance) - psychiatric ambulatory - GP´s

14. Methadone treatment indications • heavy and long-term dependency on high doses of opioid substances • repetitive unsuccessful abstinence-oriented treatment Supporting factors : • Positive experience with substitution treatment • HIV+ • pregnancy

15. Methadone treatment contra-indications • possibility and suitability of abstinence-oriented treatment • prevalence of non-opioid dependence • absence of physical dependence • age under 16 • serious hepatic disorders (hepatic failing) • acute/chronic alcohol intoxication

16. Buprenorphine treatment indications opioid type dependence (daily dosage equivalent max. 60mg methadone)

17. Buprenorphine treatment contra-indications • prevalence of non-opioid dependence • age under 15 • serious hepatic disorders (hepatic failure) • IMAO therapy, incl.14 days after termination • acute/chronic alcohol intoxication

18. Relative contra-indications of substitution treatment • alcohol addiction • disability to stop psychoactive substances intake in despite of adequate dose of substitution substance • forthcoming imprisonment

19. Outlook • Corrections and changes of Standards is continuous • based on practical experiences • according to changes of the system (e.g. accreditations) • with regard to the future (involvement of the GPs)

20. Still interested? Still some time? What about the recent numbers?

21. Clients of substitution centres in the Czech republic Institute of Health Information - ÚZIS (10.3.2003) 382 clients (V/2000 - III/2003: 1268/886)

22. Clients of substitution centres in the Czech republic (ÚZIS, 10.3.2003) methadone active: 319 intake(V/2000 - III/2003): 1140 terminated (V/2000 - III/2003) 821

23. Clients of substitution centres in Czech republic (ÚZIS, 10.3.2003) buprenorphine active: 63 admission(V/2000 - III/2003): 128 termination (V/2000 - III/2003) 65

24. Reasons fortreatment termination • other centre • different treatment • breaking rules • imprisonment • death • other

25. Substitution centres in the Czech republic • Apolinář – VFN Praha 2 • AT ordinace Hradec Králové • AT ordinace Mělník • FN Olomouc • Masarykova nemocnice Ústí n. Labem • DPS Elysium Brno • DROP IN o.p.s. Praha 1 • DROP IN o.p.s. Praha 4 • FN Ostrava - Poruba

26. Substitution centres in the Czech republic (Zdroj: MPK, 2001)

28. Substitution treatment- problem drug users in Czech republic Prevalence of problem heroin and other opioid users in the Czech republic (2000): 12.000 – 18.000 (PAD, 2001) Methadone maintenance in CR (2000): 190 clients (< 2%) actual (2003): 2,5 – 6%