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Substitution Treatment for Opiate Dependence in Europe

Substitution Treatment for Opiate Dependence in Europe. Annette Verster Montego Bay August 2001. Acknowledgements. Reviewing Current Practice in Drug Substitution Treatment in Europe European Monitoring Centre for Drug and Drug Addiction (EMCDDA) Michael Farrell et al. (2000)

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Substitution Treatment for Opiate Dependence in Europe

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  1. Substitution Treatment for Opiate Dependence in Europe Annette Verster Montego Bay August 2001

  2. Acknowledgements • Reviewing Current Practice in Drug Substitution Treatment in Europe European Monitoring Centre for Drug and Drug Addiction (EMCDDA) Michael Farrell et al. (2000) • Methadone Guidelines European Commission (EC)/ EuroMethwork – Annette Verster &Ernst Buning

  3. Outline • Part 1: • Introduction • Epidemiology of opiate addiction • Substitution Treatment • Part 2: • Methadone: pharmacology, evidence • Best practice of methadone treatment • Conclusions

  4. Prevalence of problem opiate use in the European Union (EU) • Estimates interpreted with caution • Sources include national surveys, capture-recapture studies, extrapolation of treatment and criminal justice indicator data • Injecting rates 70 - 80% (Greece, Italy) to 14% (Netherlands) Sources: Annual report on the state of the drugs problems in the European Union (EMCDDA 2000)

  5. Introduction of epidemic • Late 60’s and early 70’s among young people in NW Europe • Late 70’s and early 80’s in S Europe • 90’s in C and E Europe

  6. Estimated numbers of problem opiate users per 100,000 population aged 15 - 64

  7. Prevalence of HIV (%) infection among IDU’s in EU member states Source: EMCDDA 2000

  8. Substitution Treatment in EU • In many countries as a response to the HIV epidemic • 1993 to 1999 - treatment places tripled • 2000 - more than 300,000 drug users in treatment • General practitioners, treatment centres, methadone clinics, ‘methadone buses’ and pharmacies • Methadone but also buprenorphine, levo-alpha-acetyl-methadol (LAAM), dihydrocodeine, slow-release morphine and heroin

  9. Launch of substitution treatments in the 15 EU member states Source: EMCDDA 2000

  10. Estimated number of drug users in methadone treatment in the 15 EU member states (1997) per 100,000 population aged 16 - 60 Source: Farrell et al EMCDDA 1998

  11. Increase in the numbers of drug users receiving methadone in the 15 EU member states (1993-1997) Source: EMCDDA 1998 and others

  12. National Methadone Consumption (kg) per 100,000 population aged 16-60 (1996) Source: International Narcotics Control Board

  13. The balance between methadone maintenance and detoxification treatment Source:Farrell et al, EMCDDA 2000 (estimates)

  14. Prescription practice in the 15 EU member states Source:Farrell et al EMCDDA 2000

  15. Use of alternatives to methadone for opiate substitution • Buprenorphine becoming increasingly popular • LAAM currently unavailable but a few individuals using it • Slow-release morphine used very rarely

  16. Heroin Treatment • UK: Mid 80s IV Heroin to oral methadone (Mitcheson et al 1983) • Switzerland : Study results published permanent monitor study on comorbidity Status: new legislation pending • The Netherlands : IV Heroin/smoked vs Methadone p.o. 3 cities, n=1100 Status : results by 2002

  17. Prerequisites for introducing heroin assisted treatment as an additional therapeutic option • Adequate problem size and problem awareness • Acceptable level of other treatment options within the region • Realistic rationale and goals for the new option

  18. Conclusions 1 • Opiate addiction highly prevalent • Substitution treatment all over Europe • Predominantly methadone substitution treatment • Wide variety in practice accross countries

  19. Part 2: Methadone • Pharmacology • The evidence • Best practice • Conclusions

  20. Methadone Guidelines • European Commission • General character • background, history, state of the art of methadone in Europe • evidence of effectiveness • best clinical practice • programme organisation • monitoring and evaluation

  21. Process • Draft guidelines • Working group of European experts from different professional and national background • Second draft to wider audience • Final report

  22. Pharmacology • Synthetic opioid agonist methadone hydrochloride similar to morphine (6-dimethylamino-4, 4-diphenyl-3-hepatone hydrochloride) • Elimination half-life of 24-36 hours • Oral administration • 1 daily dose

  23. Scientific Evidence 1 • Safe substitution treatment • Effective in retaining people in treatment • Reduces the risk of HIV infection • Improves both physical and mental health and the quality of life of the patients and their families • Reduces criminal activities

  24. Scientific Evidence 2 • Cost-effective 1:3 (NTORS-UK) • Positive results over different cultural contexts, including the US, Europe, Australia, SE Asia (Hong Kong, Thailand) (Preston, 1996; Farrell, 1994; Mattick, 1996; Ward, 1998, WHO, 1998).

  25. Treatment plans and goals (WHO, 1990) • Short-term detoxification: decreasing doses over one month or less • Long-term detoxification: decreasing doses over more than one month • Short-term maintenance: stable prescribing over six months or less • Long-term maintenance: stable prescribing over more than six months.

  26. Detoxification or maintenance? • Historically as maintenance thearpy • Assessment of level of dependence • Treatment plan • individual decision between doctor and patient • assessing the needs of the patient • goal should be to maximise patient’s health

  27. Benefits of MT can be maximised by • retaining clients in treatment • prescribing higher dosages of methadone • orientating programmes towards maintenance rather than abstinence • offer counselling, assessment and treatment of psychiatric co-morbidity (Preston, 1996; Farrell, 1994; Mattick, 1996; Ward, 1998).

  28. Low threshold programmes • Are easy to enter • Harm reduction oriented • Have as primary goal to relieve withdrawal symptoms and craving and improve the quality of life of patients • Offer a range of treatment options

  29. High threshold programmes • More difficult to enter • Abstinence oriented • No flexible treatment options • Adopt regular (urine) controls • Inflexible discharge policy • Compulsory counselling and psychotherapy

  30. Comprehensive treatment • Not an isolated intervention • Identify and address other problems (medical, social, mental health or legal) • Staff or through liaison with other services • A multidisciplinary approach is essential

  31. Staff requirements • Specific (continuous) training on the pharmacological, toxicological, medical and psycho-social aspects of the treatment • Non-judgmental attitude • Supervision and regular team meetings • Multi-disciplinary team and collaboration • Clear division of tasks

  32. Service requirements • A safe place • Easily accessible (centrally located and flexible opening hours) and clean • Confidentiality of patient information • A good rapport between staff and patient • Clear rules and regulations

  33. Special groups • Pregnant women • Young people • People with HIV/AIDS • People in hospital • People with mental health problems • Minority ethnic groups • Multiple-drug users

  34. Best clinical practice • Assessment of addiction and the degree of dependence • Induction, treatment plan and initial dosage determined with care • Information about the pharmacological effects of methadone and about the potential risk of overdose

  35. Induction 1 • What’s the right dose? • Purity of heroin varies • Methadone is a long acting opiate • Too much methadone can be fatal • Insufficient methadone is not effective

  36. Induction 2 • Assessment of opioid dependence • personal interview • medical assessment • urinalysis • The severer the dependence, the higher the dosage and the longer the treatment

  37. Maintenance or detoxification • Assessment of level of dependence • Treatment plan: • individual decision between doctor and patient • assessing the needs of the patient • goal should be to maximise patient’s health

  38. Evaluation • Monitoring activities integral part • Clear definition of goals • Evaluations of outcomes • Qualitative measures • Cost-benefit analysis

  39. Conclusions 1 • Opiate addiction highly prevalent • Substitution treatment all over Europe • Predominantly methadone substitution treatment • Wide variety in practice accross countries

  40. Conclusions 2 • Large scientific body of evidence of effectiveness • Comprehensive treatment • Maintenance rather than detoxification • Higher rather than lower dosages • Public health approach

  41. Conclusions 3 • Methadone treatment proven effective in containing: • Spread of HIV • Overdose mortality • Drug related social harm • Criminal activity • Cost-benefit

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