1. Special patient groups Module 5

2. Introduction Worldwide, the majority of people in substitute treatment are men between 25-40 Even they do not form a homogeneous group In addition, there are groups with specific needs And specific settings

3. Women Often women with severe dependence do not menstruate. It is important that they understand that this does not necessarily mean that they do not ovulate

4. Pregnant women ST improves outcome regarding pregnancy, childbirth and infant development: Better overall general health of women Better (access to) antenatal care Physiological changes (accelerated metabolism) in third trimester requires higher dosage Detoxification not to be encouraged Breast-feeding encouraged (when HIV- negative) Psycho-social care recommended

5. Parents with young children Needs of children are paramount Care of children to be included in treatment plan Case management

6. Young people ST not recommended under 16, because they do not fit the general criteria of: Long-term dependence Significant tolerance Level of problematic use Buprenorphine more indicated Sometimes need for parental consent

7. People with HIV/AIDS ST can: Reduce risk behaviours which could further damage the immune system Reduce stress Improve general health Retention in treatment can allow for early diagnosis and HIV treatment Liaison with specialist care Interaction of medications

8. People with hepatitis Vaccination for hepatitis B for all patients without antibodies Hepatitis C prevalent and serious Dose of substitute drug may need to be reviewed (liver function) Specialised referral Health education regarding risk behaviour

9. People with mental health problems 30% of patients have mental health problems, including anxiety and depression 25% risk of self harm and suicide 10% severe mental disorders requiring collaboration with mental health specialists Note age- or HIV-related dementia

10. Multiple drug users Assess use of all substances Open relationship and discussion Risk reduction: Increase dose and possibly other medication Frequency of collection Supervised consumption Realistic treatment goals Suspension?

11. Quick metabolisers Some patient demonstrate longer or shorter half life times They require significantly lower or higher dosages Most can be treated relying on clinical factors Testing blood levels can be helpful Various drugs or conditions can alter substitute drug metabolism

12. Minority ethnic groups Barriers to treatment, education and prevention: lack of cultural sensitivity distrust of confidentiality communication problems - language lack of awareness of services stigma failure to target minority ethnic drug users

13. People in prison Treatment should be available to start and/or continue in order to improve health reduce risk behaviour reduce relapse upon release Need to continue afterwards when returned to the community

14. People in hospital Recognise dependence Assessment Liaison with drug treatment Continue treatment (no detoxification)

15. People who travel Continuity of care Make people think about referral standard letter Communication between prescribers Who is responsible, the regular doctor or the one who takes over? Collaboration between cities and countries www.home.muenster.net/-indro/ www.euromethwork.org

16. People with chronic pain A complex, difficult-to-treat condition Can persist following prolonged tissue or nerve injury Opiates and opioid based medications like morphine and methadone are used to relieve patients with chronic pain The guiding principles: to maintain methadone treatment to use short-acting narcotics administered at higher doses as often as necessary, preferably on a fixed schedule supplemental analgesic medication, except that opiate antagonists must be avoided.

17. The aging patient Patients in maintenance treatment are getting older Geriatric illnesses such as cardiac and pulmonary complaints and other signs of aging (menopause) should be taken into consideration

18. Quick metabolisers Some patient demonstrate longer or shorter half life times They require significantly lower or higher dosages Most can be treated relying on clinical factors Testing blood levels can be helpful Various drugs or conditions can alter substitute drug metabolism

19. Conclusions Different patients have different needs Assessment of needs Addressing them Liaison with specialist services