1. Module 1 General introduction to substitution treatment

2. What is opiate dependence? Opiate consumption versus addiction Dependence is a complex condition: –Metabolic, biological, psychosocial aspects –Chronic relapsing Varying prevalence across countries

3. Neurobiology of opiate dependence Craving is a symptom of a deficiency in the function of the natural opiate-like substances in the brain The brain adapts to repeated exposure of narcotic drugs and becomes pharmacologically dependent For some people, this adaptation becomes fixed From this perspective, substitution treatment is a replacement therapy when taken in adequate doses compensating for the impairment in function of the natural opiate receptor system

4. Is there a cure for opiate dependence? Different forms of treatment: residential, drug-free, outpatient, psychosocial, medically assisted Substitution treatment has proven to be the most effective form of treatment for the majority of people with an opiate dependence

5. Prevalence of problem drug use in the EU per 100.000 population, aged 16-65 (EMCDDA, 2002) Germany Netherlands Austria Denmark Finland France Ireland Spain Norway Italy Luxembourg Portugal UK 200 - 300 (0.2 – 0.3%) 400 - 600 (0.4 – 0.6%) 600 - 900 (0.6- 0.9%)

6. HIV prevalence amongst IDU in the EU (EMCDDA, 2002) * (local data between brackets) Austria0 – 4.9 Belgium0.5 (5.9)* Denmark(0 – 3.4) Finland(0 – 7.9) France15.9 – 19.3 Greece0.0 – 2.2 Ireland 3.5 – 8.7 Italy15.8 (2.3 – 32.8) Luxemburg3.6 The Netherlands(0.5 – 25.9) Portugal(9.2 - 48) Spain33.5 Sweden2.6 UK: England and Wales 0.3 – 2.9 UK: Scotland0.6

7. Substitution treatment Use of safe medication: Agonist Acts in a similar way as opiates Longer half-life Alleviates withdrawal symptoms Long-term treatment Maintenance versus detoxification

8. Agonist Substitution treatment Acts in similar way as opiates Stimulates opiate reception Alleviates craving for opiates Does not produce a rush Can produce physical dependence Methadone, LAAM, morphine, heroin Blocking or aversion treatment Blocks the action of opiates Blocks opiate reception Does not produce a rush Does not produce physical dependence Naltrexone, naloxone (emergency OD) Antagonist

9. Heroin use and methadone dose

10. The aims of substitution treatment To reduce risk behaviour Injecting use of illegal drug use To improve physical and social well-being Improve participation in medical care Give health education Deal with social problems To reduce criminal activity

11. Methadone Synthetic opiate Introduced in the sixties in the USA Half a million people worldwide In Europe, 90% of opiate substitution treatment with methadone

12. Increase in the numbers of drug users (times 100) receiving methadone in the 15 EU member states (1993-2000) Source: EMCDDA 2000

13. Other opiate substitution medication Buprenorphine LAAM Diamorphine Slow-release morphine

14. Country1 st availability of methadone Introduction of other substitute medications Austria1987Buprenorphine (1997) slow-release morphine (1997) Belgium1994Dihydrocodeine Denmark1970Buprenorphine (1998) Finland1974Buprenorphine (1997) France1995Buprenorphine (1996) Germany Greece Ireland 1992 1993 1992 Dihydrocodeine (1985), heroin (2002), Buprenorphine (2000) - Italy1975Buprenorphine (1999) Luxemburg The Netherlands Portugal 1989 1968 1977 Dihydrocodeine (1994), Mephenon (1989) Heroine (1997) Buprenorphine (2000) Spain Sweden UK 1983 1967 1968 Heroin (2002) Buprenorphine (2000) Buprenorphine (1999), Heroin (1926) History of substitution treatment in the EU EMCDDA 2002

15. Extent of treatment

16. Types of treatment 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

17. The balance between methadone maintenance and detoxification treatment in EU in 2000 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:EMCDDA 2000 (estimates)

18. Types of programme Low threshold programmes »Easy to enter »Harm reduction oriented »Primary goal improve quality of life and alleviate withdrawal symptoms »Offer a wide range of treatment options High threshold programmes »Selective intake criteria »Abstinence oriented »No flexible treatment options »Compulsory counselling and psychotherapy »Urine controls and inflexible discharge policy

19. Organisation of substitution treatment (EMCCDA, 2002) General practitioner’s: Austria, Belgium, France (buprenorphine), Germany, Ireland, Luxembourg, UK, Denmark Specialised centres: Denmark, France (methadone), Italy, the Netherlands, Portugal, Spain Specialised centres, limited number: Finland, Greece, Sweden, Norway

20. Conclusion Opiate dependence is a complex and often chronic condition It is prevalent across Europe Substitution treatment valuable form of treatment Various forms and types of treatment programmes (detoxification-maintenance), medications, etc across the EU.