Transcript Technological advances in the delivery of methadone

FUTURE RESEARCH IN SUBSTANCE MISUSE
AN OVERVIEVW PERSPECTIVE
Michael Farrell
PHRN Manchester
20th October 2006
Political and moral
values of the social
system
SERVICE
Provider
AND USER
VIEW
A model for evidence-based clinical decisions
Research
Evidence
(from Haynes et al, 1996)
AIDS cases by transmission group* and year of diagnosis (1987-2003) adjusted for
reporting delays, European Union, data reported by 31 December 2003
10000
8000
Injecting
6000
4000
2000
0
1987
1989
1991
1993
1995
1997
1999
2001
2003
Year of diagnosis
HBM
IDU
HC
Transmission group
not reported
NOTE
Excluding France, Netherlands (data not available for the w hole period) and Cyprus (no data available)
source EuroHIV
HIV infections newly diagnosed in injecting drug users in selected EU
countries, Russia and Ukraine, by year of report, cases per million population
(EUROHIV)
1000
900
Cases per million population
800
700
600
500
400
300
200
100
0
1994
1995
1996
1997
1998
Estonia
Latvia
Lithuania
Portugal
Russia
Ukraine
1999
2000
2001
2002
2003
Note: no data available from tw o EU countries w ith
highest AIDS incidence among IDUs (Spain, Italy)
HIV prevalence among IDUs in
the EU
EMCDDA 2004
Notes:
Colour indicates midpoints
Local data shown in ()
HIV in IDUs in Europe
 Marked difference between countries and
within some countries
– High prevalence countries (old MS) Italy, Spain,
Portugal, followed by France
– Some high prevalence estimates from new MS
(Latvia, Estonia), and worries about others
(Poland)
– Low prevalence countries in both old and new MS
including countries with high prevalence IDU
– Cautious assessment is the long term trend
appears to be stable or downwards
 Some small increases in recent data in some countries or
in specific subpopulations
 Data quality problems so analysis must be made with
A note on HCV prevalence in
IDUs
 Prevalence estimates higher and more
convergent than for HIV
 Clear need to finding effective prevention
strategies
 Routine disease surveillance sources of
limited value
 Drug injecting principle route of transmission
for HCV in Europe
Long term trend in acute drug-related
deaths (1985-2003)
300
Index % (1985=100%)
250
200
150
100
50
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003*
INDEX 100,0 104,5 118,7 136,9 153,7 181,0 216,4 223,5 201,8 212,2 225,4 252,4 230,1 235,6 241,1 255,4 240,1 205,8 194,9
EU 15, 1985 to 2003 index year 1985=100
Introduction of MMT & NSP,
1967 to 2001
(EU, Norway and Bulgaria)
30
EE
NO
Cumulative number of countries
25
BE
HU
LV
FR, LT, HU, BU
EL
20
BG
LV, LT,FI
SI
PL
EL, IE,CZ
SK
15
DE
SI
LU
MT
10
ES
FR
LU, PT
DE
CZ
AT, IT
AT
IE, PL
PT
IT
NO
FI
5
BE,
EE
DK
MT, UK
NL, UK
DK, NL, SE
SE
ES
0
1967
1969
1971
1973
1975
1977
1979
1981
Year first publicly funded NSP
1983
1985
1987
1989
1991
1993
Methadone treatment first available
1995
1997
1999
2001
Estimated number of drug users in
substitution treatment in 29 European
countries (2003) per 100.000 population
aged 15-64
450
400
350
300
250
200
150
100
50
0
LU UK ES IE MT FR PT IT SI DK EU DE NL NO SE EL BE CZ LT
+4
FI HU BG LV PL RO
10-year trend in the number of substitution treatment clients
in Europe (EU-15)
600,000
537,000
500,000
400,000
351,000
265,000
300,000
207,000
200,000
100,000
73,400
0
1993
1995
1997
2000
2003
Proportion of substitution
drugs used in medically
assisted treatment in Europe,
2003
Buprenorphine
20%
Other
1%
Methadone
79%
Prevalence of HIV in Injecting
Drug Users some country
estimates
 European Union, Northern Europe low





prevalence, Southern European countries
higher prevalence but declining
Central and Eastern European countries
upward trend, especially Ukraine, Russia,
USA and Canada generally stable low levels,
outbreak Vancouver British Columbia related
to cocaine injecting
Australia less than 2%
India Manipur Estimated at 50% plus
China Yunnan Province 10% to 70% in three
years
HIV prevalence in injecting drug users
90
Myanmar
80
HIV prevalence, %
70
Manipur &
Yunnan
60
Edinburgh
50
Ho Chi Minh
City
Bangkok
40
Lithuania
Odessa
30
20
10
Jakarta
0
1983
1984
1985
1986
1987
1988
1989
1990
1991
Year
1992
1993
1994
1995
1996
1997
1998
1999
HIV infection rates in and out of
substitution treatment (Metzger et al.
1993)
35
36
36
39
39
42
48
49
51
27
21
Out %
13
15
16
17
17
18
18
19
19
20
21
In %
ne ths ths ths ths ths ths ths ths ths ths
i
l
se 6 m 2 m 8 m 4 m 0 m 6 m 2 m 8 m 0 m 2 m
a
1
1
2
3
3
4
4
6
7
b
Drug Overdose and Mortality
 Mean of 5+ non fatal overdoses in heroin
using cohorts
 Mortality 1 to 2%
 In methadone treatment down to 0.2%
 Recent Hser 33 year longitudinal study
reports over 50% mortality in cohort
 Suicide completion rates high and significant
contributor to overall suicide
Excess mortality ratio
Excess mortality ratio for different time periods post-release by
cause of death (Singleton, Farrell, Marsden et al 2003)
45
40
35
30
25
20
15
10
5
0
U
Drug-related deaths
o1
t
p
3
6
2
1
2
5
o2
o4
o8
t
t
t
o
o
o
t
t
t
p
p
p
p
up
up
1u
2u
4u
8u
3
6
1
2
Time since release (w eeks)
Not drug-related
2
5
>=
l
a
t
To
The odds of a drug-related death in
the first week of release
among women
10
 70

over
times greater than that observed at one year (OR 10.6; 95%CI 4.8-22.0)
times higher than age matched general population
among men

around
 30
8
times greater than at one year (OR 8.3: 95%CI 5.0-13.3).
times higher than age matched general population
(Singleton, Farrell et al 2003)
 IN SUMMARY A 8-10 FOLD INCREASED RISK OF
MORTALITY IN THE EARLY RELEASE PERIOD
Substitution in prisons
 Estimated that over 30 million imprisoned annually
 Major risk for blood borne virus spread
 In most countries where measured between one
third and half have drug dependence
 RCT of methadone in prison (Dolan et al)
demonstrates role in reduction of blood borne
virus, and general improvement, and post release
reduction in mortality for those who continue
 Rapid expansion in Europe in substitution in
prisons
 Huge challenge for Asia pacific region where
insitutional incarceration standard response to
opioid dependence
Drug Substitution Treatment
 Strong evidence for the benefits of oral
methadone treatment RCTs +++
REASONABLE EFFECT SIZE
 REDUCES DRUG CRIME .70
 REDUCES OPIATE CONSUMPTION .35
 REDUCES INJECTING & RISK TAKING 0.22
 Now good evidence for buprenorphine and
LAAM RCTs ++ (LAAM CURRENTLY UNDER
REVIEW)
 Use of injectable diamorphine and other
drugs building evidence base for comparative
Gunne & Gronbladh (1981) RCT:
Methadone versus no methadone
 34 subjects using heroin by injection
 17 experimental (methadone)
 17 controls (no methadone)
 Controls not allowed to enter MMT for 2 years
 Followed up at 2 years and again at 4 years
Gunne & Gronbladh (1981): Baseline
Experimental Group
(methadone)
Control group
(no methadone)
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U
U – ongoing daily heroin Use
U
Gunne & Gronbladh (1981): 2 years
Experimental group
(methadone)
Control group
(no methadone)
A
A
A
A
U
U
U
A
A
A
A
A
U
U
U
U
A
A
A
A
U
U
U
U
U
U
U
U
U
U
U
D
U
A – Abstinent
U – on-going daily Use
D – Deceased
D
Gunne & Gronbladh (1981): 4 years
Experimental Group
(methadone)
Control group
(methadone)
Control group
(no methadone)
A
A
A
A
U
U
U
A
A
A
A
A
A
A
U
U
A
A
A
A
A
A
U
D
U
U
U
A
A
A
D
D
U
A – Abstinent
U – on-going daily Use
D – Deceased
D
A 33 year follow-up of narcotic
addicts
Unknown
Dead
(Hser et al., 2001)
Incarcerated
Daily use
MMT
Occasional use
Abstinence
100
22%
2%
6%
7%
4%
80
60
40
48%
20
12%
0
56
N
Age
60
64
581
24.5 (3.9)
68
72
76
439
36.8 (5.4)
80
84
88
354
47.6 (5.1)
92
96
242
57.4 (4.0)
A 33 year follow-up of narcotic
addicts
Unknown
Dead
(Hser et al., 2001)
Incarcerated
Daily use
MMT
Occasional use
Abstinence
100
22%
2%
6%
7%
4%
80
60
40
48%
20
12%
0
56
N
Age
60
64
581
24.5 (3.9)
68
72
76
439
36.8 (5.4)
80
84
88
354
47.6 (5.1)
92
96
242
57.4 (4.0)
COMPOSITE SLIDE
3-Year Reincarceration Rates
DE
TX
CA
100
Percent
80
60
40
*
20
0
No Tx
Prison Tx
* * *
Prison+Parole
Methadone maintenance for prisoners
Location
No. MMT
Prison
Population
Rate %
NSW
Austria
Denmark
1000
345
290
8150
6915
3150
12.26
4.9
9.2
France
Germany
Spain
(Bup 879) 157
800
18000
50714
78707
50656
0.3
1.0
35.5
400
180
67065
4985
0.5
3.6
New York
Switzerland
Source: NSW DCS Inmate Census, UK Home Office, World Prison Population List 4th Ed, US Department of Justice
NSW prison methadone program
1986 as a pilot pre release program by Department of
Corrective Services (DCS)
Criteria
 3-6 months prior to release
 Past or present history of opiate dependence
 History of returning to injecting and crime on previous
releases
 3 designated community clinics
1990 those entering custody on MMT were continued
Since 1990 12% NSW MMT received in custody
NDARC Methadone Study
NSW prison methadone maintenance
– Randomised control trail of 384 IDUs in 1997 and
re-interviewed in 1998
– Heroin use was significantly less for those
receiving methadone, as measured by hair
analysis.
Source: Dolan & Wodak
RCT Results
MMT
HCV incidence %
Control
24.3
31.7
Heroin (hair) %
27
42
Heroin (SR) %
33
78
No cases of HIV
NDARC Methadone Study
Follow up after release from gaol study of
above 384 IDUs examining rate of:
– Incarceration
– Mortality
– Hepatitis C
Mortality rates (Intent)
1
0.99
0.98
MMT
Non MMT
0.97
0.96
0.95
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54
HCV incidence (Intent)
MMT (N=52)
CONTROL (N=56)
Cases
14
23
Rate per 100 person
18.3
36.5
10 - 31
23 - 55
years
95% CI
Previous rate at 5 months was 24 CI: 7-62 vs 31 CI: 9-81
Source: Dolan, K
Re- incarceration up to May 2002
Continuous
n=45
NonContinuous
p
n= 216
Mean total
weeks in prison
41
67
.007
(sd)
Source: Dolan, K
Re- incarceration
1.0
.8
.6
Treatment exposure
.4
continuous
.2
non continuous
0.0
0
400
Days of follow up
800
1200
1600
Source: Dolan, K
Need for upscaling of treatment
 Urgent need in many regions for concerted
effort to expand treatment
 Discussions and research required on the
challenge of upscaling
 IDTS a major development within English
Prisons
 Major expansion in substitution treatment
and psychosocial treatment







NEED TO EVALUATE IDTS
Implementation assessment
Cost Effectiveness
Environmental Impact
Individual Outcome
Impact on Recidivism
Impact on Post Release Mortality
Research Framework
 Need pragmatic studies in prison context
 More longitudinal studies
 A 10 year mortality outcome study from the
National Psychiatric Morbidity Survey
 Consider a longitudinal Study of Young Offenders
and exploration of trajectory of drug histories
within the criminal justice system
 Prisons ideal enviroments for exploration of issues
of psychiatric comorbidity and substance use
 Studies linked to community studies
 Linking treatment in prison up to the
National Drug Treatment Monitoring System
 Currently Outcomes Monitoring Project
Underway, Important to have Prison
Treatment Linked into this.
 Infectious Diseases remain a big threat
especially BBVs
Conclusions
 The huge challenge in all settings is to
develop a comprehensive range of
interventions that are humanitarian, effective
and impactful for the all those who require
interventions
 To ensure that ethical and humane
treatment is delivered as effectively as
possible in all settings