1. Substitution Treatment for Opiate Dependence in Europe Annette Verster Montego Bay August 2001

2. 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. 3 Outline Part 1: –Introduction –Epidemiology of opiate addiction –Substitution Treatment Part 2: –Methadone: pharmacology, evidence –Best practice of methadone treatment –Conclusions

4. 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. 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. 6 Estimated numbers of problem opiate users per 100,000 population aged 15 - 64 LowestGermany Finland Sweden Netherlands Austria Greece Belgium Denmark Ireland France 200 – 400 per 100,000 population 0.2 – 0.4% HighPortugal Spain United Kingdom 400 – 600 per 100,000 population 0.4 – 0.6% HighestItaly Luxembourg >600 per 100,000 population >0.6%

7. 7 Prevalence of HIV (%) infection among IDU’s in EU member states Belgium - French1.6 Belgium – Flemish 2.2 Denmark(0 – 3.4) Germany3.8 Greece0.5 – 3.2 Spain32 France15.5 – 17.3 Ireland3.5 Italy16.2 Luxembourg3.0 Netherlands(1 – 26) Austria0 – (2) Portugal14 – (48) Finland(3) Sweden2.6 UK (England and Wales)1 Source: EMCDDA 2000

8. 8 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

9. 9 Launch of substitution treatments in the 15 EU member states CountryMethadone treatment first available Introduction of other forms of substitution treatment Sweden1967None Netherlands1968Heroin (1997) UK1968Buprenorphine (1999) Denmark1970LAAM and buprenorphine (1998) Finland1974Buprenorphine (1997) Italy1975Buprenorphine (1999) Portugal1977LAAM (1994) Spain1983LAAM (1997) Austria1987Buprenorphine (1997) slow-release morphine (1998) Luxemburg1989Methadone (1989) Buprenorphine (2000) Ireland1992None Greece1993None France1995Buprenorphine (1996) Belgium1997None Source: EMCDDA 2000

10. 10 Estimated number of drug users in methadone treatment in the 15 EU member states (1997) per 100,000 population aged 16 - 60 Source: Farrell et al EMCDDA 1998

11. 11 Increase in the numbers of drug users receiving methadone in the 15 EU member states (1993-1997) Source: EMCDDA 1998 and others

12. 12 National Methadone Consumption (kg) per 100,000 population aged 16-60 (1996) Source: International Narcotics Control Board

13. 13 The balance between methadone maintenance and detoxification treatment CountryMaintenance 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)

14. 14 Prescription practice in the 15 EU member states CountryPrescription 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

15. 15 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

16. 16 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

17. 17 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

18. 18 Conclusions 1 Opiate addiction highly prevalent Substitution treatment all over Europe Predominantly methadone substitution treatment Wide variety in practice accross countries

19. 19 Part 2: Methadone Pharmacology The evidence Best practice Conclusions

20. 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. 21 Process Draft guidelines Working group of European experts from different professional and national background Second draft to wider audience Final report

22. 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

23. 23 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. 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).

25. 25 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. 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. 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. 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. 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. 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

31. 31 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. 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. 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. 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. 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. 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. 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. 38 Evaluation Monitoring activities integral part Clear definition of goals Evaluations of outcomes Qualitative measures Cost-benefit analysis

39. 39 Conclusions 1 Opiate addiction highly prevalent Substitution treatment all over Europe Predominantly methadone substitution treatment Wide variety in practice accross countries

40. 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. 41 Conclusions 3 Methadone treatment proven effective in containing: –Spread of HIV –Overdose mortality –Drug related social harm –Criminal activity –Cost-benefit

42. 42