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Injectable Opioid Treatment (IOT)

Injectable Opioid Treatment (IOT). The UK experience Rob van der Waal. Contents. Introduction Supervised IOT; rationale and guidelines Clinical Practice: experiences, concerns, lessons learned, dilemma’s Reflection & summary. IOT in the UK. Unsupervised / partly supervised (>40yrs)

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Injectable Opioid Treatment (IOT)

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  1. Injectable Opioid Treatment(IOT) The UK experience Rob van der Waal

  2. Contents Introduction Supervised IOT; rationale and guidelines Clinical Practice: experiences, concerns, lessons learned, dilemma’s Reflection & summary

  3. IOT in the UK Unsupervised / partly supervised (>40yrs) RIOTT (2005): 3 pilot clinics Pilot services to operate until a decision has been made to fund clinics (politicians)

  4. Guidelines • Supervised • Integrated with other treatment approaches • Not a first line treatment • optimised oral methadone, then • injectable methadone / heroin maintenance treatment

  5. Why prescribe injectables? • A small proportion of patients do not make major improvements even though they are in treatment • Ongoing heroin (+other drug) use most days • Ongoing health problems (e.g. HIV, hepatitis, overdoses) • Ongoing crime (90% of crime committed by 10% patients) • Ongoing social & personal costs

  6. Why not? • Make current treatment work better • more counselling & support, ‘better’ doses of methadone, better linkages with other services • Is not cost effective (specifically supervised) • Doesn’t work • Is wrong • Or ...deliver unsupervised..

  7. Who is it for? • In maintenance treatment (continuous > 6 month) • Regular injecting heroin use (>3yrs) • Age 18 years or over Caution • Alcohol use • Benzodiazepine use

  8. Who are the patients? • Mostly male between 30-40 yrs old • Entrenched opiate drug injectors • Multiple treatment experiences • Multiple periods of imprisonment • Not benefiting from conventional treatment and • Poly drug use & alcohol use!

  9. How is it delivered? Integrated within community drug service Specialist teams 7 days week 2 sessions day Fully supervised

  10. What are the characteristics? Structure Psycho social support Frequent contact with staff High doses of prescribed opioids

  11. Treatment stages • Induction - • Stabilisation - • Maintenance - • Reduction - of frequency and/or dose • Exit

  12. Injecting room activities • Monitoring of safety • Observing and advising on hygiene, injecting sites & technique • Dealing with (potential) emergencies

  13. How about recruitment In all trials, recruitment was slower than expected Is for some lax methadone treatment more attractive than structured IOT treatment? Some injecting patients are ambivalent about injecting

  14. What is adherence like? Overall very good in both groups Diamorphine is apparently sufficiently rewarding to tolerate daily dispensing However Injectable Methadone not so popular (but tolerable if pathway leads to diamorphine)

  15. Conduct Overall very good Special status? Group dynamics Signed agreement -No congregation outside clinic Impact study ( Miller et al., 200 )

  16. How about clinical outcomes Overall very significant reduction of street heroin use, health problems, injecting complications For some life changing experience For others change may be less obvious (are there clear objective criteria?)

  17. What constitutes a good outcome?

  18. How to achieve good outcomes Prescribe sufficient doses of injectable diamorphine and oral medication Set clear goals around reduction street drugs/alcohol, benzodiazepine prescribing and harmful injecting Use the ‘carrot’ of diamorphine as leverage

  19. Clinical concerns • Treatment is not working, e.g. continued street heroin use • Treatment is jeopardised by other drug use e.g. benzodiazepine, alcohol use, crack use • Treatment continuation is jeopardised by injecting problems

  20. How did we address concerns Stopped all benzodiazepine prescribing Controlled drinking or detox & disulfiram Peripheral iv or im/sc injecting Exit - Back to oral

  21. Approach Supportive Boundaries Consistent Clear goals

  22. How long is IOT for? Is it maintenance? If so what are the criteria to remain in treatment Or a time limited intensive treatment? If so how long for?

  23. Exit strategy-oral pathway Is there a feasible pathway back to oral maintenance? Methadone vs Slow Release Oral Morphine Patient anxiety – what if it doesn’t work? Gradual reduction/trial period

  24. Exit strategy-oral pathway Not just about providing oral alternative Requires commitment & activities important enough to be able to compete with diamorphine Perhaps more difficult than some patients (and clinicians!) anticipate

  25. Reflections & Summary Continuous daily attendance provides structure and routine Structure and monitoring are integral to effectiveness – for those who tolerate it And can provide the foundation for patients to address issues like drug use, health, housing, family, education, work etc

  26. Change comes in many ways Drug use- stopping heroin (and other) Occupational- e.g. work (voluntary), study, Service user involvement Personal- increased confidence, Accommodation- from hostel to rented Social- re establish family relations Health- e.g. HCV, HBV

  27. Thank You

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