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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) • Methadone Guidelines European Commission (EC)/ EuroMethwork – Annette Verster & Ernst Buning 2 Outline • Part 1: – Introduction – Epidemiology of opiate addiction – Substitution Treatment • Part 2: – Methadone: pharmacology, evidence – Best practice of methadone treatment – Conclusions 3 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 4 (EMCDDA 2000) 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 5 Estimated numbers of problem opiate users per 100,000 population aged 15 - 64 Lowest Germany Finland Sweden Netherlands Austria Greece Belgium Denmark Ireland France 200 – 400 per 100,000 population 0.2 – 0.4% High Portugal Spain United Kingdom 400 – 600 per 100,000 population 0.4 – 0.6% Highest Italy Luxembourg >600 per 100,000 population >0.6% 6 Prevalence of HIV (%) infection among IDU’s in EU member states Belgium - French 1.6 Belgium – Flemish 2.2 Denmark (0 – 3.4) Germany 3.8 Greece 0.5 – 3.2 Spain 32 France 15.5 – 17.3 Ireland 3.5 Italy 16.2 Luxembourg 3.0 Netherlands (1 – 26) Austria 0 – (2) Portugal 14 – (48) Finland (3) Sweden 2.6 UK (England and Wales) 1 Source: EMCDDA 2000 7 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, levoalpha-acetyl-methadol (LAAM), dihydrocodeine, slow-release morphine and heroin 8 Launch of substitution treatments in the 15 EU member states Country Methadone treatment first available Introduction of other forms of substitution treatment Sweden 1967 None Netherlands 1968 Heroin (1997) UK 1968 Buprenorphine (1999) Denmark 1970 LAAM and buprenorphine (1998) Finland 1974 Buprenorphine (1997) Italy 1975 Buprenorphine (1999) Portugal 1977 LAAM (1994) Spain 1983 LAAM (1997) Austria 1987 Buprenorphine (1997) slow-release morphine (1998) Luxemburg 1989 Methadone (1989) Buprenorphine (2000) Ireland 1992 None Greece 1993 None France 1995 Buprenorphine (1996) Belgium 1997 None Source: EMCDDA 2000 9 Estimated number of drug users in methadone treatment in the 15 EU member states (1997) per 100,000 population aged 16 - 60 250 200 150 100 50 0 e g ec re our G b m xe Lu d an nl Fi en ed Sw ce an Fr al g rtu Po ria st Au ark m en y D an m er G n ai UK m iu lg Be s ly Ita land er th Ne nd la Ire Sp Source: Farrell et al EMCDDA 1998 10 Increase in the numbers of drug users receiving methadone in the 15 EU member states (1993-1997) 2500 2000 1500 1000 500 0 1993 1995 1997 Source: EMCDDA 1998 and others 11 National Methadone Consumption (kg) per 100,000 population aged 16-60 (1996) 4 3.5 3 2.5 2 1.5 1 0.5 0 d an nl Fi e ec re G ce an Fr l ga rtu Po en ed Sw y an m s er G nd la er th Ne nd la ly Ita Ire k ar UK m iu lg Be n ai m en Sp D Source: International Narcotics Control Board 12 The balance between methadone maintenance and detoxification treatment 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:Farrell et al, EMCDDA 2000 (estimates) 13 Prescription practice in the 15 EU member states Country Prescription Practice Greece Finland Sweden Specialised centres, limited number Denmark Spain France(methadone) Italy Netherlands Portugal Specialised centres Belgium Germany France (buprenorphine) Ireland Luxembourg Austria United Kingdom General practitioners Source:Farrell et al EMCDDA 2000 14 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 15 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 16 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 17 Conclusions 1 • Opiate addiction highly prevalent • Substitution treatment all over Europe • Predominantly methadone substitution treatment • Wide variety in practice accross countries 18 Part 2: Methadone • Pharmacology • The evidence • Best practice • Conclusions 19 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 20 Process • Draft guidelines • Working group of European experts from different professional and national background • Second draft to wider audience • Final report 21 Pharmacology • Synthetic opioid agonist methadone hydrochloride similar to morphine (6-dimethylamino-4, 4-diphenyl-3hepatone hydrochloride) • Elimination half-life of 24-36 hours • Oral administration • 1 daily dose 22 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 23 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). 24 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. 25 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 26 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). 27 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 28 High threshold programmes More difficult to enter Abstinence oriented No flexible treatment options Adopt regular (urine) controls Inflexible discharge policy Compulsory counselling and psychotherapy 29 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 30 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 31 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 32 Special groups • • • • • • • Pregnant women Young people People with HIV/AIDS People in hospital People with mental health problems Minority ethnic groups Multiple-drug users 33 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 34 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 35 Induction 2 • Assessment of opioid dependence – personal interview – medical assessment – urinalysis • The severer the dependence, the higher the dosage and the longer the treatment 36 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 37 Evaluation • Monitoring activities integral part • Clear definition of goals • Evaluations of outcomes • Qualitative measures • Cost-benefit analysis 38 Conclusions 1 • Opiate addiction highly prevalent • Substitution treatment all over Europe • Predominantly methadone substitution treatment • Wide variety in practice accross countries 39 Conclusions 2 • Large scientific body of evidence of effectiveness • Comprehensive treatment • Maintenance rather than detoxification • Higher rather than lower dosages • Public health approach 40 Conclusions 3 • Methadone treatment proven effective in containing: – Spread of HIV – Overdose mortality – Drug related social harm – Criminal activity – Cost-benefit 41 Abstinence Relapse Prevention Relapse • Residential (drug-free) • Outpatient (drug-free) • Psychological counselling • Support group • Antagonist (eg. naltrexone) Cessation Detoxification • Agonist assisted • Partial agonist assisted • Symptomatic treatment • Rapid detoxification Substitution Treatment • Methadone • Buprenorphine • LAAM • Tincture of Opium Harm Reduction Heroin use Dependence Ali and Gowing 2001 • Education about overdose 42 • Hepatitis B immunisation