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2
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
3
Outline
• Part 1: – Introduction– Epidemiology of opiate addiction– Substitution Treatment
• Part 2: – Methadone: pharmacology, evidence– Best practice of methadone treatment– Conclusions
4
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 (EMCDDA 2000)
5
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
6
Estimated numbers of problem opiate users per 100,000 population aged 15 - 64
Lowest GermanyFinlandSwedenNetherlandsAustriaGreeceBelgiumDenmarkIreland France
200 – 400 per 100,000 population0.2 – 0.4%
High PortugalSpainUnited Kingdom
400 – 600 per 100,000 population0.4 – 0.6%
Highest ItalyLuxembourg
>600 per 100,000 population>0.6%
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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
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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, levo-alpha-acetyl-methadol (LAAM), dihydrocodeine, slow-release morphine and heroin
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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
10
Estimated number of drug users in methadone treatment in the 15 EU member states (1997) per 100,000 population aged
16 - 60
0
50
100
150
200
250
Spain
Ireland
Netherlands
ItalyBelgium
UK Germ
any
Denmark
Austria
Portugal
France
Sweden
Finland
Luxembourg
Greece
Source: Farrell et al EMCDDA 1998
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Increase in the numbers of drug users receiving methadone in the 15 EU member
states (1993-1997)
0
500
1000
1500
2000
2500
1993 1995 1997
Source: EMCDDA 1998 and others
12
National Methadone Consumption (kg) per 100,000 population aged 16-60 (1996)
0
0.5
1
1.5
2
2.5
3
3.5
4
Denmark
Spain
Belgium
UK Ireland
ItalyNetherlands
Germ
any
Sweden
Portugal
France
Greece
Finland
Source: International Narcotics Control Board
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The balance between methadone maintenance and detoxification treatmentCountry Maintenance or detoxification
FranceIrelandPortugalSweden
Primarily maintenance (75-100% of treatment aimed at maintenance)
DenmarkGermanySpainNetherlandsAustriaFinlandUK
50 – 75% of treatment aimed at maintenance
GreeceItaly
Primarily detoxification (under 30% of treatment aimed at maintenance)
Source:Farrell et al, EMCDDA 2000 (estimates)
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Prescription practice in the 15 EU member states
Country Prescription PracticeGreeceFinlandSweden
Specialised centres, limited number
DenmarkSpainFrance(methadone)ItalyNetherlandsPortugal
Specialised centres
BelgiumGermanyFrance (buprenorphine)IrelandLuxembourgAustriaUnited Kingdom
General practitioners
Source:Farrell et al EMCDDA 2000
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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
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Heroin Treatment
• UK: Mid 80s IV Heroin to oral methadone (Mitcheson et al 1983)
• Switzerland : Study results publishedpermanent monitor study on comorbidity Status: new legislation pending
• The Netherlands : IV Heroin/smoked vs Methadone p.o. 3 cities, n=1100Status : results by 2002
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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
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Conclusions 1
• Opiate addiction highly prevalent• Substitution treatment all over
Europe• Predominantly methadone
substitution treatment• Wide variety in practice accross
countries
20
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
21
Process
• Draft guidelines
• Working group of European experts from different professional and national background
• Second draft to wider audience
• Final report
22
Pharmacology
• Synthetic opioid agonist methadone hydrochloride similar to morphine (6-dimethylamino-4, 4-diphenyl-3-
hepatone hydrochloride) • Elimination half-life of 24-36 hours• Oral administration• 1 daily dose
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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
24
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).
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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.
26
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
27
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).
28
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
29
High threshold programmes
More difficult to enter Abstinence oriented No flexible treatment options Adopt regular (urine) controls Inflexible discharge policy Compulsory counselling and
psychotherapy
30
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
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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
32
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
33
Special groups
• Pregnant women• Young people• People with HIV/AIDS• People in hospital• People with mental health problems• Minority ethnic groups• Multiple-drug users
34
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
35
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
36
Induction 2
• Assessment of opioid dependence– personal interview– medical assessment– urinalysis
• The severer the dependence, the higher the dosage and the longer the treatment
37
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
38
Evaluation
• Monitoring activities integral part• Clear definition of goals• Evaluations of outcomes• Qualitative measures • Cost-benefit analysis
39
Conclusions 1
• Opiate addiction highly prevalent• Substitution treatment all over
Europe• Predominantly methadone
substitution treatment• Wide variety in practice accross
countries
40
Conclusions 2
• Large scientific body of evidence of effectiveness
• Comprehensive treatment• Maintenance rather than
detoxification• Higher rather than lower dosages• Public health approach
41
Conclusions 3
• Methadone treatment proven effective in containing:– Spread of HIV– Overdose mortality– Drug related social harm– Criminal activity– Cost-benefit
42
AbstinenceAbstinence
Heroin useHeroin use
Rel
apse
Ces
satio
n
Dependence Dependence
Substitution TreatmentSubstitution Treatment•Methadone•Buprenorphine•LAAM•Tincture of Opium
DetoxificationDetoxification•Agonist assisted•Partial agonist assisted•Symptomatic treatment•Rapid detoxification
Harm ReductionHarm Reduction•Education about overdose•Hepatitis B immunisation
Relapse PreventionRelapse Prevention•Residential (drug-free)•Outpatient (drug-free)•Psychological counselling•Support group•Antagonist (eg. naltrexone)
Ali and Gowing 2001