Delivery Systems for Substance Abuse Treatment: Integration with Primary Care, Mental Health, and Social Services September 5-7, 2005 Istanbul, Turkey

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Delivery Systems for Substance Abuse
Treatment Integration with Primary Care, Mental
Health, and Social ServicesSeptember 5-7,
2005Istanbul, Turkey Overview of the
International Experience on SMT Implementation

• Andrej Kastelic
• Center for Treatment of Drug Addiction
• Ljubljana, Slovenia, European Union
• email andrej.kastelic_at_guest.arnes.si

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IDU as of all reported HIV/AIDS Cases NOTE
of AIDS cases in countries not reporting
HIV Sources EuroHIV national reports
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Introduction of substitution treatment in the EU
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Estimated coverage of substitution treatment
amongst problem drug users (EMCDDA, 2001)
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MMT and buprenorfine in CEE/NIS, 2002
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Drug Abuse Treatment Toolkit

• Investing in Drug Abuse Treatment
• A Disscussion Paper for Policy Makers
• UNITED NATIONS, Office on Drugs and Crime
• New York, 2003

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Drug Abuse Treatment Toolkit

• Contemporary Drug Abuse Treatment
• A Review of the Evidence Base
• UNITED NATIONS
• New York, 2002

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EuroMethwork, 2003Training manual Information
for Policy Makers (E.Buning, A.Verster)
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WHO/UNODC/UNAIDS Position Paper

• Substitution maintenance therapy in the
  management of opioid dependence and HIV/AIDS
  prevention

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EuroMethwork Methadone Guidelines
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Network of Centres for Prevention and Treatment
of Drug Addiction
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NETWORK OF CENTERS FOR THE PREVENTION AND
TREATMENT OF DRUG ADDICTION

• prevention
• individual, group and family therapy
• counseling service for addicts, relatives and
  trainers
• community health services
• substitution programs
• preparation for hospital treatment
• rehabilitation and social reintegration
• consultations for health, social, education
  services and police
• cooperation with NGOs, TCs, self-help groups
• education, research, publishing the magazine
  Addiction

• Services provided by Centers for the Prevention
  and Treatment of Drug Addiction

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STAFF

• general medicine or social medicine specialist
• psychiatrist
• psychologist
• college-graduate nurse
• social worker (?)
• laboratory technician
• administrative worker
• volunteers

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STATE OF THE ART

• Health council at the Ministry of Health in 1994
  discussed the medical aspects of the treatment of
  drug addicts and adopted a set of recommendations
  for doctors concerning the treatment of drug
  addiction.
• The symposium on methadone in 1994 adopted
  Guidelines on Clinical Management.
• Updating Guidelines in March 2000.
• Euromethwork Methadone guidelines (in Slovene)

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Organization of Medical Care

• Important principles
• Accessible and comprehensive services
• Appropriate organization, linkage and integration
  of services
• Link with harm reduction/HIV prevention
  programmes to facilitate engagement and retention
• Social education, drug treatment and adherence
  support services are more important to optimize
  medical care
• Co-location or close proximity of services will
  enhance outcomes
• Continuity and consistency are more important
  aspects of successful care delivery
• Staff and services need to be user-friendly,
  non-judgmental, and knowledgeable about IDU,
  HIV/AIDS and related clinical issues
• Go where the patients are

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Models of Comprehensive Care

• Take advantage of all potential interfaces
  between IDUs and the health care system
• street outreach
• correctional institutions
• social service agencies
• emergency departments
• acute care hospitals
• primary care sites
• drug treatment programmes

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Contd

• Outreach/special population models
• mobile outreach units
• community-based storefronts
• peer engagement and adherence support programs
• needle-exchange/harm-reduction-based medical care
  and referral services
• correctional facilities, including within
  prisons/jails and post-release programs

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Prevention of the Use of Illicit Drugsand
Dealing with Consumers of Illicit Drugs Act (Of.
Gazzette, 98/99)

• This Act sets out the measures for preventing the
  use of illicit drugs and for dealing with
  consumers of illicit drugs.
• Treatment of consumers of illicit drugs shall be
  carried out in the form of hospital and
  outpatient clinic treatment programmes approved
  by the Health Council.
• For the implementation of outpatient clinic
  activity for the prevention and treatment of
  addiction, centres for the prevention and
  treatment of addiction to illicit drugs shall be
  organised on the primary level as part of the
  public health service network.
• For the implementation of hospital and specialist
  outpatient clinic treatment, the Government of
  the Republic of Slovenia shall establish a public
  health institution the Centre for Treatment of
  Illicit Drugs Addicts.
• Hospital treatment shall be deemed to be hospital
  detoxification, psychosocio-therapeutic
  treatment, extended treatment, and health
  rehabilitation.

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International Conferences
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Slovene Conferences
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SEEA Conferences
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Vanguard
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CPTDA Nova Gorica/Koper
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CPTDA Piran/Ljubljana
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CPTDA Nova Gorica/ Ljubljana
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Methadone dispenser
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Methadone Guidelines in Slovenia
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Number of patients (Dec.31,2004)

• Inclusion criteria
• opiate dependence
• failed in outpatient detoxification
• informed consent
• age over 16 years
• residence in the region where a drug prevention
  and treatment center is located
• family doctor
• health insurance

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Budget for Centres for the Prevention and
Treatment of Drug Addiction (in SIT)
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FINDINGS OF THE METHADONE TREATMENT PROGRAM IN
THE REPUBLIC OF SLOVENIA

• Research conducted in Centres for the Prevention
  and Treatment of Drug Addiction in May 2000
• Compared data to 1995
• and 1997, 2000, 2003
• Prepared by
• Tatja Kostnapfel Rihtar
• Andrej Kastelic

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Usefulness of methadone maintenance program
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COSTS FOR SUBSTITUTION MEDICINES
SR MORFIN 10 SR MORFIN 10 SR MORFIN 10
metadonmet M E T A D O 85 N S U B U 15 T E X 15
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REASONS FOR CHOOSING BUPRENORPHINE

• Acceptable for drug users and communities
• Long acting
• Low level of physical dependance
• Low level of withdrawal
• Less toxic than methadone (accidental swallowing)
• Less interactions with other drugs
• Less euphoric and less sedating
• Stabilizing disphoria, not really antidepressive
• Blocks the effects of other opioids
• Easy to transfer to other medication
• Major compliance for double-diagnosis patients

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ONE FITS ALL

• Certainly not
• Both are save drugs, but
• Who wants to be more awake does better on
  buprenorphine
• Who needs more sedation does better on methadone
• Who wants to detox does mostly better on
  buprenorphine
• Who wants to be more active/sexually active /
  creative is better on bup
• Who must be treated with IfN/Riba or Haart is
  better on bup
• Who is stabile on a maintenance-therapy should
  not change medicament
• Data suggest better outcome in pregnancy/breast-fe
  eding for bup
• Depression, insomnia occur on both therapies, bup
  shows clear advantages for bup
• A lot of research to be done, but excellent first
  impression of buprenorphine

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Slow release morphine

• Better side effect profile than methadone
• Excellent results
• Safe in pregnancy (?)
• Easy to use (once daily)
• Additional consumptionof other drugs is low (BDZ,
  opioids)
• Better concentration
• Better drive
• No major mood disturbances
• No weight gain

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ST pathways
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Needle exchange/Outreach programmes/Injecting
rooms

• Day-centres (drop in)
• Night-centres (sleep in)
• Hot lines
• OD prevention

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Stigma Ljubljana
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Project STIGMA - ten years of development, Evita
Leskovšek NUMBER OF ISSUED AND RETURNED SYRINGES
ON STIGMA BY YEAR
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Needle exchange program in SVIT, Koper
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Night centre Areal in Ljubljana
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Ustanova Odsev se sliši The Sound of Reflection
FoundationZaloška 29, Ljubljana, SLOVENIA
www.ustanova-odsevseslisi.si
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Ustanova Odsev se sliši The Sound of Reflection
FoundationZaloška 29, Ljubljana, SLOVENIA
www.ustanova-odsevseslisi.si
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Publications
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Publications
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Recidivism among substance abusing prisoners

• Between 70 and 98 of those who have been
  imprisoned for drug-related crimes and not
  treated during the course of their incarceration
  relapsed within the year following release.

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cont.

• Harm reduction lowers the threshold so that
  people who are unsure of that to do about their
  drug and alchohol use can have access to
  treatment.

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• Doing more of what has not worked repression
  (prohibition) is not the answer.
• We have a lot of scientific data and experiences
  that treatment and/or harm reduction work.

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Violating human rights

• Drug laws and policies that help spread disease
• Drug laws and policies that deprive users of
  their human rights
• By denying them access to some forms of treatment
  (substitution)
• By imprisoning them in high-risk prison
  environments that increase the risk of spread of
  disease
• By denying access to syringe exchange programs
• By denying honest education about safer drug use
  practices

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Countries that provide methadone in prisons
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Source UIKS, Annual Report 2004
MMT 2000 2001 2002 2003 2004
jail 49 121 88 142 142
prison 123 226 134 192 238
Together 172 347 222 334 380
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• Prison health is public health.

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Barriers to Harm Reduction in Prisons

• Zero-tolerance/abstinence based approaches even
  more entrenched
• Seen as admission of failure
• Discrimination against prisoners
• Criminal laws and punishment
• Lack of legal framework
• Staff safety concerns/perception of danger

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General Instructions

• 1. The health services for individuals in prisons
  or correction houses should be equivalent to
  those provided outside the correctional system.
• a. The professional independence of
  counsellors and therapists is very important.
• 2. Close cooperation between the professionals
• in prisons and regional network of centers
  for
• prevention and treatment of drug addiction
• must be established.
• 3. Addicted individuals must have the option for
  treatment upon their entry into the prison system
  (i.e. harm-reduction programs, substitution
  treatment, detoxification, drug-free treatment,
  etc).
• a. They must have the option to be treated in
  community programmes.

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Prison Syringe ExchangeModels of Distribution
hand-to-hand
Harm Reduction Kit Soto de Real Prison, Madrid
Photographs by Rick Lines
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Prison Syringe ExchangeModels of Distribution
machines
Anonymous Syringe Dispensing Machines
Lichtenberg Prison Berlin
Saxerriet Prison Switzerland
Photographs by Rick Lines
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Total cases of AIDS
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Total cases of HIV
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Case Studies Booklet (Central and Eastern
Europe and the Central Asian States)

• UNDCP Meeting on Lessons Learned on the
  Prevention of the Transmission of HIV/AIDS among
  IDUs in Central and Eastern Europe and Central
  Asian Republics
• Minsk, July 2000

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CPTDA Sarajevo
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Nyswander-Dole Marie Award(AMTA Conference,
St.Luis, October 2001 National Roleston Award
2002(HR Conference, Ljubljana, March 2002) The
EUROPAD Awards 2002-"Chimera d'Argento(EUROPAD
Conference, Oslo, May 2002)
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Center for Treatment of Drug Addiction, LJUBLJANA
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Program of the Center for Treatment of Drug
Addiction

• Outpatient clinic
• Detoxification unit
• Day center
• Intensive treatment unit
• Adolescent program
• Crisis intervention
• Training, research, coordination
• Center of excellence

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• South Eastern Europe-Adriatric network
• www.seea.net

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• VANGURD 2006
• Belgrade, May 17-20, 2006
• VANGUARD SPORT
• LJUBLJANA, May 23-26, 2007

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• Our lives begin to end the day we become silent
  about things that matter.
• Dr. Martin Luther King, Jr.

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Thank you for attention.