access to pharmacotherapy of opioid dependence 29-30.02

Access to pharmacotherapy of opioid dependence

29-30.02.2008, Riga

Ave Talu

National Institute for Health Development

Estonian Drug Monitoring Centre

e-mail: [email protected]

http://eusk.tai.ee

http://www.tai.ee

2

1. Availability of drug treatment for injecting drug users (IDUs) in Estonia

2. Results of and conclusions drawn from an assessment survey (funded by UNODC) on the quality of methadone maintenance treatment and on the demand for services in Estonia

3. Available data for planning substitution treatment for IDUs and possible activities to be implemented on the framework of UNODC project in Estonia

3

Availability of drug treatment (1)

The majority of health care institutions providing addiction treatment engage in

outpatient care (five of the treatment institutions funded by the NIHD provides only

outpatient care and one outpatient as well as inpatient care).

In 2007 drug treatment was funded from the financial resources of the Global Fund,

HIV/AIDS prevention strategy and of local governments. A person can also seek

treatment, funding it from his own financial means.

According to the HIV/AIDS 2007 prevention strategy and the Global Fund report, the

number of persons undergoing methadone substitution treatment increased over the

years.

Alternative substitution treatment with buprenorphine for IDUs was not funded

According to experts the availability of drug (substitution) treatment for injecting drug

users (IDUs) is insufficient in Estonia (Drew et al, 2008).

4


673 methadone substitution treatment places funded by the Global Fund and HIV/AIDS prevention strategy were filled in six treatment centres in 2007 (National Institute for Health Development, 2008).

A total of 1030 clients received methadone substitution treatment in 2007of whom 35% (357 clients) stopped the treatment.

As for local governments, in 2007 only Tallinn funded the treatment of 104 adult clients in addition to the state funding of methadone substitution treatment.

In 2007 a total of 777 methadone substitution treatment places were funded from various sources (covers 5.6% of IDUs)

5


356,689 euros of state funds were used for the provision of substitution treatment service, which ensured treatment for less than one-tenth (4.9%; N=673) of injecting drug addicts

On the average 346 euros were spent on the substitution treatment of one opiate addict in 2007.

Drug treatment (detoxification and substitution treatment) is very limited in prisons and lacking in detention houses and due to the limited number of treatment places drug addicts under probation supervision have very linited access to drug treatment.

It is known that best substitution treatment results are achieved when treatment is consistent, support services are provided and adequate amounts of medications are used

6


Experts responsible for the drafting of the Development Plan for Drug Treatment found that more emphasis should be laid on referring injecting drug users to treatment and on introducing treatment options

They also found that there is a need to pay attention to the development of an early intervention, addiction diagnostics and referral to treatment system for minors (e.g. innovative options, such as peer-driven intervention for involving IDUs in drug treatment)

Such target groups as amphetamine and opiate injectors, under-age drug addicts, drug addicts under probation supervision, inmates, persons in detention, etc., have limited access to suitable treatment options.

7

Availability of methadone substitution treatment for IDUS in 2007.

1,030673356,6895,580,976Total

1485,88092,000Western Tallinn Central Hospital

1287543,951687,690AS Wismari Haigla

16911752,681824,284OÜ Elulootus

23013072,8161,139,317OÜ Narva Sõltuvusravi Keskus

386274144,4102,259,526OÜ Corrigo

1046936,951578,159OÜ Aasa Kliinik

Number of

clients in a year

(incl. stopped persons)

Filled treat-ment

places a year

Funds allocated

(EUR)

Funds allocated

(EEK)

Health care institution

Source: National Institution for Health Development, Department of the Prevention of Infectious diseases and Drug Addiction, 2007; National HIV/AIDS strategy 2007 report.

8

Characteristics of persons seeking for drug treatment in 2008

(NIHD, Drug Treatment Database 2009)

In 2008 in total 824 of drug treatment case notices were enetred to the Drug

Treatment Database of which 228 were treatment discontinuation notices.

77.5% of persons starting the drug treatment were male, close to 70% were 20-

29 years old, 86% were Russian speaking.

More than half of persons (56%) seeking for drug treatment live in Ida-Viru

County and 36% in Tallinn

96% of persons seeking for drug treatment were IDUs with opioid dependency

56% of clients in treatment injected fentanyl or 3-methylfentanyl (TMF) and 25%

heroin as a main drug.

9

Assessment survey on the quality of methadone substitution treatment

and on the demand of services (NIHD & UNODC, 2009) (1)

The survey was funded from the resources of the XEE/J20 project of the UN

Office on Drugs and Crime (UNODC) “HIV/AIDS Prevention among Injecting

Addicts and in Prisons in Estonia, Latvia and Lithuania 2006-2010”.

The assessment survey includes substitution treatment centres of six service

providers and their 54 clients.

The survey point to various problems in opiate substitution treatment that require

quick solutions.

The findings of this survey are similar to those of a quick assessment of

methadone maintenance treatment conducted in June 2007 on the framework of

UNODC project in Estonia by Dr. E. Subata

Five of the sampled service providers offer only methadone substituton

treatment and one methadone as well as buprenorphine treatment.

10



Different sets of questions were used in order to obtain an overview of the political and

organisational context of opiate maintenance treatment, to assess how satisfied

clients are with the provided treatment service, to study the management of work and

service quality in health care institutions providing maintenance treatment and their

cooperation with other social and health care institutions.

In addition a supplementary questionnaire was composed for opiate-injecting addicts

not undergoing treatment in order to gain information on their attitudes and opinion on

methadone maintenance treatment.

The past years the focus of opiate substitution treatment in Estonia has been rather on

damage reduction or motivational enhancement treatment than on individual

substitution treatment

It could be concluded that substitution treatment is a highly fragmentised field lacking

an integral approach and distribution of responsibility.

11



Uniform understanding of the essence and goals of treatment across service

planners and providers varies considerably.

The lack of support services is a major weakness of substitution treatment; many

refer to the absence of psycho-social additional services and counselling.

Cooperation between service planners and service providers is weak.

The main issues are as follows: weak general concept and management system,

shortcomings in the organisation of work in treatment centres, limited support

services, lack of cooperation with other institutions and the negative image of

methadone maintenance treatment among injecting drug addicts as well as service

providers.

12



The lack of a unified framework and guidelines calls for setting national standards

of substitution treatment, a fixed treatment structure and development trends,

distributing responsibility and for political will to develop the field.

Various parties of the survey offered as one solution the authorisation of new

treatment guidelines for opiate addiction on a higher level so as to avoid their

turning into a document of an advisory nature.

The next step after setting the general framework for opiate addiction treatment is

the enhancement of the organisation of work in treatment centres.

Responses of employees providing methadone maintenance treatment revealed

that first and foremost it is the in-house organisation of work that is problematic.

13


and and on the demand of services (NIHD & UNODC, 2009) (5)

It would be useful to compile specific education plans for various professional

groups and find funding possibilities for organising training events.

Substitution treatment centres could also perform the function of connecting

clients to other services of health and social care institutions.

According to the staff of treatment centres such cooperation between different

institutions could be facilitated by a case manager working for a treatment

centre.

Organising round-table meetings and making mutual cooperation contracts

should contribute to effective cooperation between different institutions

14



Giving take-away methadone doses to clients is quite a common practice in

Estonia.

Regarding take-away doses it is important to note that clients have to

“deserve” such a privilege.

According to clients the period after which they can apply for take-away

methadone varies among treatment centres from three weeks to two years.

The frequency of taking urine samples (used as a check-up mechanism) in

treatment centres remains elusive.

In the current situation it would be practical to further structure the

requirements for take-away methadone and establish a more efficient

system for check-up urine samples.

15



Tests used for identifying opiates in urine have a low-sensitivity for synthetic

opiates, such as fentanyl (Berens at al., 2002; Heit et al, 2004).

The specific ELISA testing procedure needs to be applied to determine the use of

fentanyl – highly widespread in Estonia – among substitution treatment clients.

The hours of work of treatment centres should be carefully considered, taking into

account clients’ preferences, the surroundings, public transport schedules and the

capabilities of centre’s employees.

Some centres in the sample were open from 8.00 to 18.00 providing clients with

quite a large window for obtaining their daily dose. Others were open in the

morning or in the evening, depending on the day of the week.

Client responses reveal a certain degree of discontent with centres' working

hours. Weekends were regarded as especially difficult periods.

16



According to employees’ estimates an average dose ranged 25-80 ml.

This estimate indicates that differences between methadone doses provided in

various centres are relatively large.

Also, the client satisfaction survey backs up this guess: according to the survey a daily

methadone dose remains in the range of 9-205 ml.

A positive change that new treatment guidelines for opiate addiction establish

recommended methadone doses and instructions for administration. The approval of

treatment guidelines on a higher level is required for the development of a unified

standard and common practice.

More than half of clients have friends who do not attend substitution treatment

because they do not believe in it or consider it to be harmful. The unpopularity of

methadone substitution treatment is also manifested in the lack of treatment queues in

most of the centres.

17



The factors currently reducing demand for methadone substitution treatment are the

lack of adequate information and the dubious quality of the treatment.

On the basis of survey results it can be assumed that the rise in the quality of the

treatment experienced firsthand by clients and the distribution of adequate

information via appropriate channels should increase demand for the treatment.

The survey indicates that IDUs regard as the most reliable source of information

fellow addicts and employees of syringe exchange points. Planned approaches

should be conducted through the aforementioned information sources in order to

distribute adequate information and direct addicts to the drug treatment service.

It is vital to improve the image of substitution treatment in the general population in

order to create competition in providing the treatment service and a stronger sense

of self-esteem among the staff.

18



Raising the quality of the substitution treatment service contributes to improving the

reputation of methadone maintenance treatment in the general public and to

increasing its coverage.

One of the positive findings of the survey that a number of clients manifested a

favourable attitude toward substitution treatment and stated that treatment has

brought about positive behavioural changes and improved their psychological

situation.

A number of clients claimed that their health as well as psychological and social

situation has improved thanks to undergoing the treatment. Some respondents say

that they have completely quit substance use and criminal behaviour.

Rise in treatment quality and the development of psycho-social support services in

substitution treatment programmes guarantees better observation of treatment

routine and higher efficiency (McLellan et al, 1993).

19

Characteristics of IDUs in Estonia

Differences in the structure of the local illegal drug market are probably accountable

for variations in injected narcotic substances.

Earlier surveys indicate that injecting drug addicts in Estonia inject primarily

amphetamine and fentanyl (Platt et al, 2006; Uusküla et al, 2008).

Cross-sectional surveys conducted in 2007 among injecting drug users in two

regions (Tallinn (N=350) and Kohtla-Järve (N=350) suggest a similar trend.

According to the risk behaviour survey of injecting drug users conducted by the

National Institute for Health Development in 2006 and 2007 respectively, 53.3% and

48.6% of the drug addicts using the syringe exchange service had injected

amphetamine and 9% and 12%, respectively fentanyl in the last month (Lõhmus et

al., 2007, Lõhmus et al., 2008).

In terms of the regional prevalence of drugs the percentage of injectors was higher

in Tallinn (64%) than in Ida-Viru County (47%).

20

Primary injected drug over the course of the last four weeks among IDUs in

Tallinn and Kohtla-Järve in 2007(NIHD & University of Tartu, 2008)

1.10.4-7.56.7Other

1.40-2.30.6Sudafed

8.95.2-15.69.8Heroin

57.641.7-57.049.5Poppy liquid

12.910.7-22.316.2Amphetamine

1612.3-24.718.2Fentanyl

Studied IDUs in Kohtla-Järve

0.30-1.10,3Sudafed

1.10-1.60.6Heroin

25.723.1-44.133.5Amphetamine

71.153.7-74.464.2Fentanyl

Studied IDUs Tallinn

%95% CI%

SPP**EPP*

* EPP Estimated Population Proportion; **SPP Sample Population Proportion

21

Drug injecting during the last 4 weeks in Tallinn in 2007 (NIHD & University of

Tartu, 2008) (1)


0.60-2.80.9Other

2.30.3-4.01.8Ecstasy

0.30-0.30.1Ephedrine

0.90-4.31.4Sudafed

0.90-6.62.2Cocaine

2.90.2-2.41.2Heroin

0.30-1.30.8Poppy liquid

4638.0-57.347.6amphetamine

79.462.4-81.371.9Fentanyl

Studied IDUs in Tallinn

%

95% confidence interval%

SPPEPP

22

Drug injecting during the last 4 weeks in Kohtla-Järve in 2007 (NIHD &

University of Tartu, 2008) (2)


8.65.1-13.38.9Other

0.30-0.50.2Ecstasy

0.30-0.30.1Ephedrine

1.70-2.70.9Sudafed

24.614.4-25.219.5Heroin

66.249.0-65.157.3Poppy liquid

21.817.6-31.124.2Amphetamine

36.426.8-40.533.4Fentanyl

Studied IDUs in Kohtla-Järve

%

95% confidence

interval%

SPPEPP

23

Male (82%), Russian-speaking (in Tallinn 81% and in Kohta-Järve

92%)

More than 40% of the studied persons in both regions were in the age

group 25-29

Half of studied IDUs had passed no more than 9 grades at school

Close to half of the studied persons had health insurance

Background information on the studied IDUs in Tallinn and Kohtla-Järve in 2007 (NIHD & University of Tartu, 2008)

24

Average age in initiation of injecting drug use (NIHD &

University of Tartu, 2008)

13-3019,813-4019,7Sudafed

15-2821,516-3321,7Cocaine

13-3318,910-3118,6Home-made poppy liquid (MAK)

13-3019,211-4419,3Amphetamine

15-4022,313-4922,5Fentanyl

15-3019,311-4219,8Heroin

RangeAverage age

RangeAverage age

Drug

Kohtla-JärveTallinn

25

Prevalence of HIV, HBV, HCV and latent TB among studied

injecting drug users in 2007 (NIHD & University of Tartu, 2008)

4.40-30.86.4Kohtla-Järve (181 IDUs were tested)

10.12.5-14.07.6Tallinn (208 IDUs were tested)

Latent TB

72.553.3-68.359.5Kohtla-Järve

76.862.7-79.471.4Tallinn

HBV antibody

82.869.1-82.775.9Kohtla-Järve

94.382.2-95.789.8Tallinn

HCV

69.951.1-68.059.4Kohtla-Järve

55.139.2-56.047.5Tallinn

HIV

%95%CI%

SPPEPP

26

Riski behaviour of new vs old IDUs (Uusküla et al., 2008) (1)

The comparison of new and long-time injectors (Uusküla et al, 2008) as based

on cross-sectional surveys on the prevalence of HIV and risk behaviour

conducted in Tallinn in 2004 (Uusküla et al, 2007b) and 2005 (Platt et al, 2006)

demonstrates that new as well as long-time injecting drug users have similarly

risky injecting and sexual behaviour.

The majority of new and long-time injectors included in the 2004 and 2005

surveys were mostly Russian-speaking (in 2004 new injectors 96 % versus

long-time injectors 92%, in 2005 respectively 78% and 89%).

Half of the new as well as long-time injectors studied in the 2005 survey

injected drugs every single day.

New injectors were less probably daily injectors than long-time injectors (21.9%

versus 42.2%).

27

Riski behaviour of new vs old IDUs (Uusküla et al., 2008) (2)

According to the 2004 survey 43% of the new and 30% of the long-time IDUs reported receptive needle sharing during the last 90 days

According to the 2005 survey about one-third of the new and long-time users reported receptive needle sharing during the last 28 days.

Both studies (2004 versus 2005) show that the sexual risk behaviour of new and long-time IDUs (more than 1 sexual partner during the last 12 months) was similarly very risky (the 2004 survey: 45.8% versus 47.9%; the 2005 survey: 55.6% versus 59.6%).

The prevalence of HIV is very high among new and long-time IDUs. 2004. The HIV pevalence among new injectors was 50% in 2004 and 34% in 2005

and among long-time injectors 56% in 2004 and 34% 2005.

28

Drug-related deaths of IDUs (1)

117 IDUs died of fentanyl poisoning in 2005–2006, three of them in prison

(Ojanperä et al, 2008).

91% of the persons who died of fentanyl poisoning were male and their average age was 26.

In most cases the cause of death was incidental poisoning related to using fentanyl or fentanyl in combination with other drugs.

Three death related to 3-methyfentanyl were registered in prison.

29

Drug-related deaths of IDUs (2)

In 2007 in total of 107 IDUs died of fatal accidental poisoning of narcotic drugs and psychotropic substances (Female=7; Male=100). The vaste majority of died IDUs were young people (average age 26).

Results of comprehensive toxicological analysis

3Cocaine

22Opiates

25Methadone

25Amphetamine

49Bensidiazepines

98Fentanyl

30

The size and prevalence of IDU population aged 15–44 years (CRC

method) in 2004 (Uusküla et al 2007)

0,5% (0,4–1,3%)1499 (1013 –3842)Female

0,5% (0,3–1,2%)1344 (787–3334)other Estonia

3,5% (2,0–8,6%)2517 (1474 –6242)Ida-Viru County

4,3% (2,5–10,6%)10 025 (5871–24 866)Harju County

4,3% (2,5–10,6%)12 387 (7 119–30 600)Male

2,4% (1,4–5,9%)13 886 (8 132–34 443)Estonia

The prevalence of IDU population (95%

CI)

Size of IDU population (95% CI)

31

http://eusk.tai.ee

access to pharmacotherapy of opioid dependence 29-30.02

Documents