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Treatment demand and drug related deaths: results and hints from the VEdeTTE study Patrizia Schifano EMCDDA - 2006 Annual expert meeting Lisbon.

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Presentation on theme: "Treatment demand and drug related deaths: results and hints from the VEdeTTE study Patrizia Schifano EMCDDA - 2006 Annual expert meeting Lisbon."— Presentation transcript:

1 Treatment demand and drug related deaths: results and hints from the VEdeTTE study Patrizia Schifano EMCDDA - 2006 Annual expert meeting Lisbon

2 ObjectivesObjectives the effectviness of treatments offered in public treatment centers in preventing overdose mortality among heroin users in Italy The VEdeTTE Study has been designed to evaluate

3 ObjectivesObjectives to describe treatment offer tipology lenght therapeutic aim and differences among services and…. to evaluate retantion in treatment according to type of treatment and….

4 Design:Design: National Multicenter Longitudinal Prospective Study: Target population: heroin users seeking for treatment, >18 yrs old 115 (out of 554) PTCs (NHS) Enrollment and follow-up: October 1998 - March 2000 Vital status ascertainment: March 2001 Study population: 10454 subjects

5 The cohort 86% males 12% new clients Average age: 31 yrs 80% intravenous users 41% had previous overdose episodes 8.2% HIV positive (33.6 MV)

6 The Treatments Pharmacological therapies residential community semi-residential community emergency center Therapeutic community psychoterapy support counselling orientation and work fellowship Psychosocial therapies methadone detoxification naltrexone detoxification with syntomatic not-substitutive syntomatic methadone maintenance

7 The Treatments Total time in treatment: 10,208 p-yrs (78%) Total time out of treatment: 2,914 p-yrs (22%) Median lenght of follow-up: 547 days (99%) Average number of treatments per person: 3.1

8 The Treatments Methadone Maintenance Detoxification Methadone Psychosocial Therapies Other Pharmacological N trt N subjects Average n per person Median lenght (days) Therapeutic Community 1830 11311 10684 5931 1876 1.2192.5 2.3 28.0 1.7120.06837 4764 1274 1563 3582 1.7 1.5 30.0 32.0

9 The sequence of treatments: starting with MMT ……………. The sequence of treatments: starting with MMT ……………. 2nd treatment % MMT6,3 MD74,7 TC1,7 Other12,2 No treatment5,1 MMT40,6 MD12,9 TC0,9 Other25,8 No treatment19,8 concluded (33.2%) drop-out (20.4%) MMT N=4412

10 MD N=1718 2nd treatment % MMT34,5 MD34,6 TC1,7 Other26,6 No treatment5,6 MMT23,1 MD47,0 TC1,1 Other21,5 No treatment7,3 concluded (66.7%) drop-out (20.4%) The sequence of treatments: starting with MD.……………. The sequence of treatments: starting with MD.…………….

11 Dose Average: 40.9 mg/day Median: 39.7 mg/day 19% of subjects >60mg/day Methadone Manteinance

12 Mortality analysis Study population: 10258 Observed deaths: 189 36.8% overdose 20.0% AIDS 15.8% violent causes

13 Males Females Rate /1000 p-y 95% CI 12.7 8.4 12.0 4.9 – 20.5 4.7 – 12.2 5.4 – 18.6 Mortality analysis Total

14 in treatment out of treatment SMR 95% CI 3.9 22.8 9.9 5.7 – 7.8 8.6 – 11.4 Mortality analysis total 16.7-27.4

15 Mortality and treatment Study period: 18 months Deaths: 100 (53% of the total) Overdose deaths: 41(59% of the total)

16 Mortality by overdose and treatment Mortality by overdose and treatment

17 Mortality by overdose and treatment Mortality by overdose and treatment

18 Is no treatment better than a short- period treatment? Is no treatment better than a short- period treatment? in treatmentout of treatment 2.67 x 1000 19.26 x 1000 out of treatment 7.7 x 1000 1 month A B

19 Is no treatment better than a short- period treatment? Is no treatment better than a short- period treatment? Excess of mortality attributable to being in a short-term treatment in a 2-month period 5.52 deaths x 10000 episodes

20 Summary of results High heterogeneity in treatment offer Apparent PTCs preference towards abstinence oriented therapies (70% of patients at their first visit) Methadone Maintenance offered on avearage at lower doses than those known to be effective (40 mg/day) a range of specialist drug treatments are protective, substantially reducing the risk of drug related overdose during treatment the risk of death is substantially higher in the month after treatment discharge or drop out; leading to an excess of 6 deaths per 10,000 treatment episodes lasting less than one month

21 What to change if designing a new Vedette study Necessisity to simplify information collected on treatment Is there a better way to collect information on treatment? 18 months of follow-up. Is it a too short period? 100 deaths after 18 months, 189 after 30 months. Do we have to plan longer studies to evaluate treatments correctly? Tretaments already ongoing at the start of the study are difficult to be analyzed. Who to enroll? How many?

22 Strenght points of the Vedette study Valuable information about effectiveness of treatments for drug-dependance on more than one outcome An insight of treatment demand and offer Mortality follow-up. Easy to be updated It provides the unique possibility of studying the occurance of outcomes in the real world where: Patients are not randomized Treatments are not optimal Resources are limited

23 Results from A STYSTEMATIC REVIEW OF the OBSERVATIONAL STUDIES ON TREATMENT OF OPIOID DEPENDENCE

24

25 What do you need to implement a study similar to Vedette? 1 Ministry 2 coordination centres 10 researchers 13 regions 119 treatment services + di 1000 health operators + di 15000 clients and A strong collaboration among the coordination centres and the services It contributed to spread the aweraness of the importance of evidence based practice, and of quantitative evaluation of treatments

26 CONCLUSION The Vedette study is still ongoing: Imputing missing treatment to use all the deaths registered at the last vital status ascertainment Continuing the analysis of the effect of short- period treatments Updating the follow-up of mortality Designing a nested case-control study to better understand the determinants of overdose mortality Ongoing follow-up on treatments on a sub-cohort (one region).......................

27 CONCLUSION Do you think it would be valuable feasible to replicate the Vedette study in other European countries?


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