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WANTED!!
PARTNERS FOR EURO-METHWORK’s 2006 PILOTS
Euro-Methwork is developing a project for 2006 with the aim to develop new
methodologies to improve substitution treatment in the European Region. The project
focuses on three major areas:
1. To ameliorate the quality of treatment by
a. Skill training
b. Networking for exchange of information
c. Optimizing logistics (housing, hygiene, computers, software, methadone
dispensers, good quality medication etc.)
2. To improve continuity of care through better cooperation between treatment
centres, hospitals and prisons and through the use of specific software
3. To simplify data collection
The idea is to develop 4 pilots in different parts of Europe. We are looking for centres
that are interested to cooperate in this project. To qualify for participation the centre has
to:
- Be interested in training of the staff
- Be willing to use a standard form of liquid methadone
- Be willing to use automated methadone dispensers
- Be willing to use specific software
- Be prepared to act as a regional training centre after the project has finished
We will try to arrange the project in such a way, that extra costs for the collaborating
centres are limited. Extra information about this project can be found in the addendum.
If you are interested please contact us, so we can discuss further details.
Ernst Buning, coordinator Euro-Methwork
Addendum
Information
regarding
Euro-Methwork’s 2006 pilots
Providing methadone in Europe:
Ameliorate quality,
improve continuity of care
&
simplify data collection
For more information:
Euro-Methwork/Q4Q
Vijzelstraat 77
1017 HG Amsterdam, NL
tel: + 31 20 3303 449
email: [email protected]
web: www.euromethwork.org
1.
INTRODUCTION
On April 28, 2005, a meeting took place in Rome, where possibilities were discussed to
start an European project which aims to (1) improve the quality of methadone treatment,
(2) guarantee the continuity of care and (3) simplify the collection of data.
Participants in this meeting were Federico Seghi Recli (Molteni), Francesco Summo
(Molteni), Ernst Buning (Euro-Methwork), Annette Verster (Euro-Methwork) and Andrew
Kubik (consultant). It was agreed that a discussion paper would be written to further
elaborate these ideas, to look at the feasibility and make a proposal for a possible
project.
The discussion paper was discussed in a meeting in Milan on June 7th.
2.
BACKGROUND
The quality of methadone treatment
Methadone is now available in 24 of the 25 countries of the European Union (exception
is Cyprus). Because the number of heroin addicts is rather stable in Western Europe, the
expansion of methadone treatment has meant that more heroin addicts have now access
to treatment. However, sometimes the scaling up was done at costs of professionalism
and personal attention to patients.
In Eastern Europe, the number of centers which provide substitution treatment has
increased (source: Central and Eastern European Harm Reduction Network; see website
www.ceehrn.org). However, the scale is of treatment provision is not sufficient, especially
because the number of heroin addicts is still growing. Mistakes as made in Western
Europe with the scaling-up process should be prevented.
There are around 400.000 people in prison in the European Union, of which 200.000
have a history of drug addiction. Whether heroin addicted prisoners receive substitution
treatment varies from prison to prison and from country to country. According to the
ENDIPP1, substitution treatment in the prison system is not state of the art and in many
places problematic2.
In the last decade, Euro-Methwork has been active to improve the quality of
Substitution Treatment (ST) in Europe. This was done through the development of
various documents, such as Newsletters, the Methadone Guidelines, a training manual for
practitioners, a booklet for policymakers and a booklet about buprenorphine, workshops
at conferences, training courses and a website with the Methadone Assistance Point
(MAP), a virtual clinic, FAQ and a helpdesk(see www.euromethwork.org).
There are many other (both local as well as international) initiatives, which aim to
improve the quality of ST. Both AATOD and Europad organize specific conferences on
1
ENDIPP (European Network on Drugs and Infections Prevention in Prisons) is active in 27 European countries, most of
the current EU Member States and the remaining acceding countries. The ambitious work plan covers the period until
December 2006 and focuses, as before, on the exchange of good practices and information on models of intervention
with drug users and infections within the prison systems of Europe and beyond. The new Network will also focus on
epidemiological multicentre research and health monitoring. For country reports see: www.endipp.net
2
SUBSTITUTION TREATMENT IN EUROPEAN PRISONS A study of policies and practices of substitution in prisons in
18 European countries Heino Stöver, Laetitia C. Hennebel and Joris Casselmann, Cranstoun Drug Services Publishing
2004.
substitution treatment where data are presented and the exchange of experience is
stimulated. IHRA (The International Harm Reduction Association) always gives ample
space to ST in their yearly International Conferences, which attract over 1000 experts
from all over the world. An other example of an active organization is The International
Center for Advancement of Addiction Treatment. They have an extended website
with excellent information (http://www.drugaddictionrx.com).
Another prerequisite for good quality methadone programs, which is often taken for
granted, is high quality medication of a stable concentration. Some programs have
ensured this, whilst in other places the dosages are prepared on the spot with the risk of
fluctuation in the dose or even contamination. It goes without saying that the provision
of a sterile medication of stable concentration is a must for any treatment program.
In summary, we could say that a lot of work still needs to be done to improve the quality
of ST treatment throughout Europe. We believe that the work should be concentrated on
four areas:
- Information transfer (websites, e-newsletters, seminars, conference)
- Skill training
- Networking for exchange of information
- Optimizing logistics (housing, hygiene, computers, software, methadone dispensers,
good quality medication etc.)
Continuity of care
Not all patients in substitution treatment stick to the program. They might drop-out of
treatment, move to another program, be arrested, be admitted to a hospital, move to
another city or even another country. Such migration often leads to a termination of
treatment. It goes without saying that for a patient who receives a maintenance
medication, discontinuation of treatment can lead to great distress. For patients who
receive HIV medication besides their methadone, continuity of treatment is even more
essential, since inappropriate use of medication might lead to resistance to the HIV
medication. The World Health Organization (WHO) gives high priority to measures, which
ensure continuity of medicinal treatment of HIV.
Australian research has shown that the chance for rehabilitation for prisoners with a
heroin dependence is much better when they receive methadone while in prison and if
this treatment is continued after release (Kate Dolan et al 3). Most prisons can not provide
continuity of care: if a drug addicted prisoner is brought in on a Friday night, it is very
unlikely that he will receive medication before Monday. Regarding treatment after
release: still many prisoners leave prison without good agreements for follow-up
treatment.
Euro-Methwork contributes to the issue of continuity of care with MAP, the Methadone
Assistance Point on the internet. MAP provides information about substitution treatment
3
BMJ 1996;312:1162 (4 May) Kate Dolan, Wayne Hall, Alex Wodak
Conclusion: The results suggest that the reduction of injecting and syringe sharing that occur with methadone
maintenance treatment in community settings also occur in prisons. However, inmates need a daily dose of at least 60
mg of methadone and treatment is required for the duration of incarceration for these benefits to be realised in prison.
Methadone maintenance treatment has an important role to reduce the spread of HIV and hepatitis in prison.
program all over Europe, gives advice to prescribing doctors and assists patients in
finding a suitable ST program when moving to another city.
It can be said that continuity of care is NOT guaranteed in most places in Europe. If this
can be ameliorated, it would be a great step forwards: it would save money, prevent a
lot of distress for patients and be good for society at large. Drug addicted patients who
do not relapse into the use of illicit substances will encounter less problems such as
infectious diseases, hospitalization or even mortality and create less problems for their
environment through criminality and public nuisance.
Data collection
Most drug treatment programs collect data about their patients. These data include:
1. general information about the patient (basic demographic data such as name,
birth date and address, data on the medical history, data on the drug history,
social anamneses, diagnoses, co-morbidity etc),
2. data about the treatment (prescribed medication, treatment plan, treatment
progress),
3. data for insurance companies (which patients receives which kind of services and
what should be paid for that) and
4. aggregated data for policy makers (how many people in treatment, profile of
patient group, migration patterns etcetera).
Some programs work with sophisticated software, whilst others still have to do a lot by
hand or don’t collect data on all the above mentioned areas. Problems encountered in
this area are: (1) costs of automation, (2) medical and social staff is not equipped or
willing to handle software, and (3) no protocol for privacy protection of patients.
3.
ELABORATION OF THE PLAN
The 2006 project entails 4 pilots in various European regions and aims at (1)
ameliorating the quality of methadone treatment, (2) improving the continuity of care in
each region and (3) simplifying the collection of data.
Conditions for participation are:
- During the pilot, centers will provide high quality methadone with guaranteed
constant purity, which is purchased from Molteni. In order to motivate centers to
do this, administrative and bureaucratic hassle will be minimized and the price
should be competitive with what they pay now.
- Participating organizations will use software provided free of charge by the
project. This software will keep record of medication, the treatment process,
migration of patient. It will have an interface to existing software
- Participating organizations will use automated methadone dispensers
To optimize the communication between all parties, an active network and a special
website will be created. E-newsletters will keep track of the progression of the project.
Structure
The organizational structure entails a small executive group and a steering group
(maximum 10 persons). The project is coordinated by Euro-Methwork.
Each pilot region will have a key-person who will develop a regional organizational
structure, which fits the specific local conditions. These regional networks will include
treatment centers, prisons, hospitals, general practitioners, pharmacists, patient
organizations, (local) governments, research institutes, etc.
Executive
group
Steering group
Key-person
PILOT
Key-person
PILOT
Key-person
PILOT
Key-person
PILOT
Regions for the pilots
Four pilots will be done in 2006: two in Western Europe and two in Central and Eastern
Europe. Each pilot will be in a region where there is a serious problem with heroin
addiction and where there is some experience with substitution treatment, and at the
same time a general feeling that ST could be ameliorated. Each pilot should include at
least one prison.
In choosing the pilots, it is of vital importance to have a good key contact person who is
committed and who has an excellent local network. Support is also needed from funding
agencies, such as insurance companies and (local) authorities, which should bare certain
costs of the pilot. Finally, there should be a research agency (for example University) in
each region, which is willing and capable to do the evaluation.
4. EVALUATION
It is important to evaluate the four pilots. The evaluation will be an outcome as well as a
process evaluation. The evaluation will be set up in such a way that data from the four
pilots can be compared and that results provide clear guidelines for a possible follow-up.
The evaluation should be of good scientific scrutiny and be designed in such a way that
Universities or research institutes in the specific regions can carry it out without
problems.