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Module 1
General introduction to substitution
treatment
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What is opiate dependence?
• Opiate consumption versus addiction
• Dependence is a complex condition:
– Metabolic, biological, psychosocial
aspects
– Chronic relapsing
• Varying prevalence across countries
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Neurobiology of opiate dependence
• Craving is a symptom of a deficiency in the
function of the natural opiate-like substances in
the brain
• The brain adapts to repeated exposure of narcotic
drugs and becomes pharmacologically dependent
• For some people, this adaptation becomes fixed
• From this perspective, substitution treatment is a
replacement therapy when taken in adequate
doses compensating for the impairment in
function of the natural opiate receptor system
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Is there a cure for opiate
dependence?
• Different forms of treatment: residential,
drug-free, outpatient, psychosocial, medically
assisted
• Substitution treatment has proven to be the
most effective form of treatment for the
majority of people with an opiate
dependence
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Prevalence of problem drug use in the EU per 100.000 population,
aged 16-65 (EMCDDA, 2002)
Germany
Netherlands
Austria
Denmark
Finland
France
Ireland
Spain
Norway
Italy
Luxembourg
Portugal
UK
200 - 300
(0.2 – 0.3%)
400 - 600
(0.4 – 0.6%)
600 - 900
(0.6- 0.9%)
HIV prevalence amongst IDU in the EU
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(EMCDDA, 2002) * (local data between brackets)
Austria
Belgium
Denmark
Finland
France
Greece
Ireland
Italy
Luxemburg
The Netherlands
Portugal
Spain
Sweden
UK: England and Wales
UK: Scotland
0 – 4.9
0.5 (5.9)*
(0 – 3.4)
(0 – 7.9)
15.9 – 19.3
0.0 – 2.2
3.5 – 8.7
15.8 (2.3 – 32.8)
3.6
(0.5 – 25.9)
(9.2 - 48)
33.5
2.6
0.3 – 2.9
0.6
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Substitution treatment
•
•
•
•
•
•
Use of safe medication: Agonist
Acts in a similar way as opiates
Longer half-life
Alleviates withdrawal symptoms
Long-term treatment
Maintenance versus detoxification
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Agonist
• Substitution treatment
• Acts in similar way as
opiates
• Stimulates opiate
reception
• Alleviates craving for
opiates
• Does not produce a
rush
• Can produce physical
dependence
• Methadone, LAAM,
morphine, heroin
Antagonist
• Blocking or aversion
treatment
• Blocks the action of opiates
• Blocks opiate reception
• Does not produce a rush
• Does not produce physical
dependence
• Naltrexone, naloxone
(emergency OD)
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Heroin use and methadone dose
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The aims of substitution treatment
• To reduce risk behaviour
• Injecting
• use of illegal drug use
• To improve physical and social well-being
• Improve participation in medical care
• Give health education
• Deal with social problems
• To reduce criminal activity
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Methadone
• Synthetic opiate
• Introduced in the sixties in the USA
• Half a million people worldwide
• In Europe, 90% of opiate substitution
treatment with methadone
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Increase in the numbers of drug users (times
100) receiving methadone in the 15 EU member
states (1993-2000)
3500
3000
2500
2000
1500
1000
500
0
1993
1995
1997
2000
Source: EMCDDA 2000
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Other opiate substitution medication
•
•
•
•
Buprenorphine
LAAM
Diamorphine
Slow-release morphine
History of substitution treatment in the EU
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EMCDDA 2002
Country
1st availability of
methadone
Austria
1987
Buprenorphine (1997) slow-release
morphine (1997)
Belgium
1994
Dihydrocodeine
Denmark
1970
Buprenorphine (1998)
Finland
1974
Buprenorphine (1997)
France
1995
Buprenorphine (1996)
Germany
Greece
Ireland
1992
1993
1992
Dihydrocodeine (1985), heroin (2002),
Buprenorphine (2000)
-
Italy
1975
Buprenorphine (1999)
Luxemburg
The
Netherlands
Portugal
1989
1968
1977
Dihydrocodeine (1994), Mephenon (1989)
Heroine (1997)
Buprenorphine (2000)
Spain
Sweden
UK
1983
1967
1968
Heroin (2002)
Buprenorphine (2000)
Buprenorphine (1999), Heroin (1926)
Introduction of other substitute
medications
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Extent of treatment
Country
Estimated prevalence
of problem drug use^
Estimated number of clients in
substitution treatment
Belgium
Denmark
20 200
12 752–15 248
Germany
Greece
Spain
France
80 000-152 000
n.a.
83 972–177 756
142 000–176 000
Ireland
Italy
Luxembourg
4 694–14 804
277 000–303 000
1 900–2 220
7 000 (1996)
4 398 (4 298 methadone + 100
st
Buprenorphine)(1 January 1999)+
50 000+ (2001)
st
966 (1 January 2000)+
72 236 receiving methadone (1999)
71 260 (62 900 receiving buprenorphine and 8
360 receiving methadone)(December 1999)+
st
5 032 (31 December 2000)+
80 459 (1999)+
864 (164 in the official program and +/- 700
prescribed mephenon (methadone in pill form)
by GPs) (2000))+
11 676 (1997)
1100 (2001)
st
4 232 (1 January 2000)+
st
6 040 (1 January 2000)
240 (170 buprenorphine and 70 methadone)
st
621 (31 May 2000)+
19 630
Netherlands
Norway
Austria
Portugal
Finland
Sweden
UK
25 000–29 000
9 000–13 000
15 984–18 731
n.a.
2 300–3 280*
1 700–3 350*
88 900–341 423
Substitution
coverage
#
rate
35 %
27–34 %
33–63 %
-41–86 %
40–50 %
34–100 %
27–29 %
38–45 %
¤
40–47 %
8–12 %
23–26 %
-7–10 %
19–37 %
6–22 %
^ For more details on national prevalence and problem drug use see online table 1OL at www.emcdda.org.
# Estimated proportion of problem drug users in substitution treatment
+ Information collected directly from National Focal Point
* Opiate users
¤ A substitution coverage rate of 100 % seems implausible, which suggests that the prevalence estimate of 4694 (1195) may
underestimate current prevalence
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Types of treatment
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
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The balance between methadone maintenance
and detoxification treatment in EU in 2000
Country
Maintenance or detoxification
France
Ireland
Portugal
Sweden
Primarily maintenance (75-100% of treatment aimed
at maintenance)
Denmark
Germany
Spain
Netherlands
Austria
Finland
UK
50 – 75% of treatment aimed at maintenance
Greece
Italy
Primarily detoxification (under 30% of treatment
aimed at maintenance)
Source:EMCDDA 2000 (estimates)
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Types of programme
• Low threshold programmes
» Easy to enter
» Harm reduction oriented
» Primary goal improve quality of life and alleviate
withdrawal symptoms
» Offer a wide range of treatment options
• High threshold programmes
»
»
»
»
»
Selective intake criteria
Abstinence oriented
No flexible treatment options
Compulsory counselling and psychotherapy
Urine controls and inflexible discharge policy
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Organisation of substitution treatment
• General practitioner’s:
Austria, Belgium, France
(buprenorphine), Germany,
Ireland, Luxembourg, UK,
Denmark
• Specialised centres:
Denmark, France (methadone),
Italy, the Netherlands,
Portugal, Spain
• Specialised centres,
limited number:
Finland, Greece,
Sweden, Norway
(EMCCDA, 2002)
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Conclusion
• Opiate dependence is a complex and often
chronic condition
• It is prevalent across Europe
• Substitution treatment valuable form of
treatment
• Various forms and types of treatment
programmes (detoxification-maintenance),
medications, etc across the EU.