Transcript Substitution Treatment for Opiate Addiction 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)
• 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
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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
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nl
Fi
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ar
UK
m
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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
• Hepatitis B immunisation
42