Transcript Netherlands

INSIGHTS
Heroin Assisted Treatment (HAT)
Professor John STRANG
and Dr Teodora GROSHKOVA
16th November 2010, Lisbon
Aims of the presentation
1.
2.
3.
4.
5.
Why do we need the Insights on HAT?
What did we do and where are we at?
The evidence base for HAT
Current clinical practice
Next steps
Acknowledgements
International HAT Trials PIs/co-ordinators
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Professor dr Ambros Uchtenhagen
Contributors, Pharmaceutical companies
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Simon Bryson
Auralis Ltd, UK
University of Zurich, Switzerland
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Professor dr. Wim van den Brink
Amsterdam Institute for Addiction Research,
the Netherlands
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Professor Dr Christian Haasen
Department of Psychiatry, Hamburg, Germany

Albert Hills
Teva UK
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Gordon Urquhart
Wockhards, UK
Professor Marty Schechter
University of British Columbia, Canada

Dr Eugenia Oviedo-Joekes
University of British Columbia, Canada
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Dr Nicola Metrebian
National Addiction Centre, UK
Other collaborators

Dr Helle Petersen
Sundhedsstyrelsen, National
Board of Health,
Copenhagen, Denmark
1. Why Insights on HAT?
Background to the HAT Insights
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Renewed interest in prescribing diamorphine for
heroin addiction
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Growing evidence base for HAT
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Policy and practice challenges
HAT trials to date
Main paper
Hartnoll et al., 1980
Country
England
Perneger et al., 1998
Switzerland
Van den Brink et al.,
2003 (a and b)
Netherlands
March et al., 2006
Haasen et al., 2007
(a and b)
Spain
Germany
Oviedo-Joekes et al.,
2009 (+)
Canada
Strang et al., 2010
(+)
England
2. What did we do? and where are
we now?
Insights Structure
(1) Review of the scientific literature on HAT trials
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Retention
“Street” heroin and other drug use
Health, health-related quality of life, social functioning
Criminal offence
Safety
Cost-effectiveness
Long-term trajectories
Patients’ perspective
Impact of HAT clinics and service provision on local
communities
(2) Commercial pharmaceutical diamorphine products
Insights Structure (cont.)
(3) HAT initiatives in Europe and beyond
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Historical background:
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Description of implementation
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Types of clinic models, settings, capacity
Service provision and related cost
Supply, storage and administration of diamprphine
Laboratory methods
Description of clinical practice and operational issues
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Legislation around HAT
Government/local direction & involvement
Description of operational delivery
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National policy/drug strategy
Rationale for HAT
Use of clinical guidelines
Admission, discharge; social reintegration
Staff and staffing structure
What worked and challenges of implementing HAT
3. The evidence base for HAT
Six randomised trials in 6 countries
involving >1000 patients over 12 years:
Synthesis of findings.
Retention
Perneger et
al., 1998
Van den
Brink et al.,
2003
March et
al., 2006
Haasen et
al., 2007
OviedoJoekes et
al., 2009
Strang et
al., 2010
Switzerland
Netherlands
Spain
Germany
Canada
England
Time to
follow up
6 months
12 months
9 months
12 months 12 months 6 months
SIH
(O)OM
93%,
92%
72%,
85%
74%,
68%
67%,
40%
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88%,
54%
88%,
69%
Patients receiving HAT appear to be more likely to be
retained in treatment than those engaging in oral
methadone substitution therapy. This effect, however,
varied across the trials.
retention
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Specified primary outcome
Perneger
et al., 1998
Van den Brink
et al., 2003
March et al.,
2006
Haasen et al.,
2007
OviedoJoekes et
al., 2009
Strang et
al., 2010
Switzerland
Netherlands
Spain
Germany
Canada
England
Measure
Selfreported
illicit heroin
use
Self-reported
40%
improvement
(physical, social,
mental)
Self-reported
heroin use in
past 30 days
Self-reported
(or UDS)
reduction in
illegal drug use
Selfreported
reduction in
drug use
50% or
more
negative
UDS during
wk 14-26
SIH
(O)OM
22%,
67%
(p=0.002)
56%,
31%
(p=0.002)
8.3 days,
16.9 days
(p=0.02)
69%,
55%
(p<0.001)
67%,
48%
(p=0.004)
66%,
19%
(p<0.0001)
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Compared to OM substitution, HAT brings about
additional reductions in illicit heroin use, although in
both treatments this is markedly reduced
primary outcome
4. Current HAT clinical practice across
Europe and beyond
Key features
of the new HAT approach
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Consistently (almost entirely, but not completely)
now considered as second-line treatment
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Direct medical or nursing supervision of all
injectable doses
The supervised injecting heroinprescribing clinics
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7 days per week (Spain week-days only); typically
2-3 blocks of opening hours
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Higher daily doses; no take-home injections
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Oral take-home supplements
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Flexible prescribing - oral take-home conversion on
request
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Dedicated facility - specific function
Mean treatment dose mg/day*
Country
SIH (+OM)
OM
Switzerland
509
n/a
Netherlands
548 (+71)
60
Spain
275 (+43)
105
Germany
442 (+8)
99
Canada
366 (+34)
96
England
399 (+46)
107
* trial data
Current features HAT practice
Country
Number
of clinics
Total
capacity
(range)
Catchment
area
Routine
practice
Switzerland
23
1,454
(15-210)
German-speaking part (22 clinics)
& Geneva (1 clinic)
Yes
Netherlands
17
650
(20-75)
Country-wide
Yes
Spain
1
56
(17
in tx, July 2010)
Granada city
No
Germany
7
300
(12-70)
7 towns across Germany
Yes
Canada
2
140
Vancouver and Montreal
No
England
3
100
(30-40)
SE London, Brighton, and the NorthEast of England
Yes
Denmark
3
300
(25
in tx, July 2010)
Municipalities of Copenhagen,
Odense, and Glostrup
Yes
5. Next steps
Key tasks
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Finalising the HAT Insights publication
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Drafting completed
Chapters to be sent off for checks by international HAT PIs
Launch July 2011
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Collaborative paper with EMCDDA
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Discussions with EMCDDA around developing a set
of minimum clinical standards ands and link to
quality assurance process
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Thank you