Transcript Dias nummer 1

Department of Anthropology
Treatment with medical prescribed heroin –
experiences from Denmark
Katrine Schepelern Johansen
Post.doc
Department of Anthropology
University of Copenhagen
Oslo 21st of June 2011
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Department of Anthropology
Program
•The research project on the Danish program for medical
prescribed heroin
•Short presentation of the Danish program
•Why a program for medical prescribed heroin in Denmark?
•What has influenced the Danish program?
•Experiences this far
• Organization
• Staff
• Clients
•The future
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Department of Anthropology
The research project on the Danish program
for medical prescribed heroin
•Anthropological research project on the process,
implementation and execution of the treatment
•From August 2008 to July 2012
•A broad, holistic picture of the program for medical prescribed
heroin in Denmark – including all five clinics
•No qualitative dimension in any of the other research projects
→ filling out a gab in knowledge on clients’ and staffs’ views on
the treatment, and on the everyday life at the clinics
•A better picture of the relation between heroin and the social
treatment
•Specific knowledge on the organization in a Danish context
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Short presentation of the Danish program
•The final legislation was accepted in the Danish parliament
spring 2008
•Target group
• Clients who, despite maintenance treatment with
methadone, continue to have an injectable abuse of
illegal opioids
• No serious, un-treated, psychiatric disorders
• Over 18 years old
• Women who are pregnant or who plan to become
pregnant can not be accepted in the program
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Department of Anthropology
Short presentation of the Danish program
•The heroin can only be administered through injection
•Clients should be able to inject themselves; either iv or im
•Clients can receive two doses a day (morning and afternoon)
and will receive methadone for the late evening and night
•Max dose of heroin is 450 mg x 2 (but individual suspension
from this has been given in a few cases)
•The treatment with heroin should be supplemented with social
treatment
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Department of Anthropology
Short presentation of the Danish program
•Five clinics: Copenhagen, Hvidovre (the old Copenhagen
municipality (amt)), Odense, Esbjerg and Århus
•The decision was taken with reference to a number of
international research projects which all had shown a superior
effect of heroin compared to methadone on ao physical health,
mental health, use of street drugs, criminality…
•Contrary to other countries the introduction of heroin in
Denmark was not done as a trial but as a regularly treatment
mode (except in Århus)
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Department of Anthropology
Why a program for medical prescribed heroin
in Denmark?
•Has been discussed since the first Swiss projects in the mid
1990s
•Continued rejection – last time after a hearing in the
parliament in 2007 (Teknologirådets høring)
•Could the same result be obtained by optimized – medical and
social – treatment with methadone?
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Department of Anthropology
Why a program for medical prescribed heroin
in Denmark?
•Accepted in the spring 2008; after newspaper articles in
Berlingske Tidende and Pia Kjærsgaard’s visit at Vesterbro (the
open drug scene in Copenhagen). The dominant history was
the humiliating, degrading lives of heroin users
•The envisioned target group of the politicians was people
living on the streets, selling drugs, prostituting themselves,
breaking in to apartment and houses
•Expected effects on these parameters
•In the subsequent bureaucratic work with the guidelines the
actual target group chanced slightly: From hard to reach to
hard to treat
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Department of Anthropology
What has influenced the Danish program?
Literature review:
•Treatment with heroin can have superior effect compared to
treatment with methadone – especially drawing on the results
from The Netherlands and Germany (the review being
published before the results from RIOTT)
•The effect is probably not due to the pharmacological effect of
the heroin but rather because treatment with heroin makes the
treatment more attractive to clients engaged in heavy drug
abuse
•That it will be treatment for a small group of clients
•Second line treatment (subutex and methadone being first
line)
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Department of Anthropology
What has influenced the Danish program?
•Based on the treatment principles documented to be efficient
in the international research (injecting, supplementing
methadone ordination) – but excluding other wishes
•The Danish policy has been worried about criminality directed
towards the clinics and the transport of the drug → high level of
security, surveillance – and control
•The Danish planners have had close contact to the British
RIOTT, and the guidelines draw heavily on the protocol from
RIOTT
•The local planners on the municipality level have also been
inspired by the set up used in Germany, ao in relation to rules
and regulations
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Department of Anthropology
What has influenced the Danish program?
Medicalization
• Focus in the official guidelines is on the health issues,
control with the drug, safety…(thus transforming the
morally suspect substance heroin into a technical
problem)
• Nurses and doctors are the primary staff groups in this
treatment
• Drug (ab)users → patients
• ”Medical specialist task”
• Heroin → DAM (Diacetylmorphin)
• The decision to introduce the treatment mode is based
on a range of positive results from abroad – but is also
limited by them
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Department of Anthropology
Experiences this far – organization
•Five clinics: Esbjerg, Århus, Odense, København and Hvidovre
•Clinic only for heroin (København) or together with clinics for
methadone (others)
•The group of other users in the clinics
•Possibilities and limits for being intoxicated
•Supervision and scoring of the clients before, under and after
the injection
•The supplementing social treatment
•The differences – to a large extent – mirror existing
differences in treatment approach more generally
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Department of Anthropology
Experiences this far – staff
•Intoxication – how much is acceptable?
•Intoxication – should there be sanctions?
•Intoxication → over dose (→ potentially death)
•Groin-injection – is that acceptable?
•Groin-injection – what would be the consequences if not
allowed?
•What aspects of the treatment is most important (and should
therefore be prioritized in the daily work with limited resources)
– the medical or the social dimensions of the treatment?
•What is the overall goal for the treatment?
•Harm reduction
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Department of Anthropology
Experiences this far – clients
•Clients enrolled in the program are generally very pleased with
the program
•Most clients state their reason for enrolling in the program as
dissatisfaction with methadone treatment
•Thus ascribing the positive effect to the heroin in it self
•Clients tell about less criminality and prostitution
•And better health
•And a less stress-full life
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Department of Anthropology
Experiences this far – clients
Complains:
•Control and supervision
•Still needing to take methadone
•Very demanding to show up two times a day – difficult to find
time and energy to anything else
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The future
•Still only few clients enrolled in the program – app. 120 –
expected 3-400
•Change in dispensing method or take home doses?
•Very expensive treatment (app. 200.000 dkr pr year pr client)
•Are the effects worth the cost?
•What about clients not within physical range of the few clinics?
•Is it to late? Most clients today are involved in poly drug use
that includes cocaine and benzodiazepines. Can heroin (and
structure) also address those ailments?
•Will the introduction of heroin as a treatment drug lead to a
change in the perception of heroin – among drug users and
among the general population?
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Department of Anthropology
Thank you for your attention!
For futher information, feel free to contact:
[email protected]
Newsletters about the project (in Danish):
http://www.kabs.dk/organisation/kabsviden/heroinforskning.aspx
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