Substitution therapy in Poland, lessons learned from history, advances in treatment of dependence and prevention of HIV

Bogusław Habrat

Institute of Psychiatry and Neurology, Warsaw. Poland

Beijing, June 2006

Poland

•      Country in a Middle Europe

•      Borders with: Germany, Czech Republic, Slovakia, Ukraine, Belarussia, Lithuania, Kaliningrad Enclave (Russia)

•      Over 38 mln citizens

•      Since 80’s – great political, economical, social and cultural transitions

Heroin use history

•      Up to 60s – casual opiate dependence among medical staff member

•      Since 60s – influence of „hippies ideology”, borders were closed, discovering „kompot” – cheap product from poppies containing heroin, morphine, other alcaloids and being very unpure microbiologically and chemically

History of heroin use (cont.)

•      60s-70s – neglecting problems but many restrictions concerning psychoactive medications

•      Late 70s-80s – begining of discussion on drug problems solving, supporting non-public health services for drug addicts treatment (based on therapeutic communities principles, Synanon-like programs)

History of heroin use (cont.)

•      80s-90s – legal acts for counteracting against drug use, National Programs Against Drugs, developing treatment and prevention programs

•      1992 – permission for 1st experimental, time limited up to 7-months methadone program (IPN-Warsaw)

•      1993 – very strong patients’ and their familes’ pressure for program continuation

Circumstances of introducing first substitution program in Poland
Medical professionals

•      Observations of ineffectivity of detoxification

•      Low knowledge about nature of addiction

•      Wide opinion about high efectiveness of drug-free oriented, demedecalized programs

•      Research - Low effectivity of drug-free oriented programs

•      Many patients didn’t accept drug-free programs

•      Etical opposition to „Western experiments”

 

Circumstances of introducing first substitution program in Poland
Public opinion

•      Low acceptance of heroin addicts („self caused disorder”, dirty, agressive, dangerous)

•      Fear of AIDS – proposals of rejecting patients to closed, out-of-city located centers, „exporting to isolated island” etc.

•      Competition to public money („why old diabetics, paying money for health insurance should cover (partailly) treatment, but young unenployed people with caused by themself disorders will be treated free of charge”)

 

Circumstances of introducing first substitution program in Poland
Politicians

•      Fear of politicians to undertake nonpopular, expansive decision in a situation of a lack of money in just reformed public medical services

•      Preferring voices of milion pensionares over small number non-voting drug adicts

•      Suspiciousness to international organisation promoting substitution therapy („what is their real aim”, fear of expansion of Western culture)

•      Lack of law regulation permitted ST  

Activity for introducing ST

•      Lobbying among medical university communities (discussions, asking for support)

•      Asking for permission for EXPERIMENTAL program that don’t need special regulations

•      Organization of conferences, symposiums, lectures, inviting distinguish foreign persons

•      Press conferences, media, initiating public discussion

•      During discussion with politicians thanks for their (often non-existing) support in introducing modern, effective solving of medical and social problems caused by drugs

Activity for introducing ST

•      Supporting argues by citation of prestigious international organisations positions (UN and their agendas including WHO, Council of Europe)

•      Cooperation with international NGO in staff training

•      Involving to international cooperation people being against ST

•      Involving drug-free oriented staff for cooperation

Experimental program as a gate to wider project

•      Experimental programs don’t need so many administrative permissions

•      Status of scientist is higher as „obvious practitioners”

•      Experimental programs resulte evidence (for effectivity)

•      Opened programs self-defende (local communitee can see clear difference)

•      Presentation of results make able to be present in many conferences, symposium, discussions and have better argues

% of continuing treatment in drug free and methadone maintenance progarms

Physical health before and after one year participation in MMP

The use of psychoactive substances by methadone patients before and after one year participation in MMP

AUDIT scores before and after one year participation in MMP

Change of cigaretts brand for containing less nicotine (mg/cig.)

Quality of Life (SF-36) before and after one year participation in MMP

 

Results of ST promotion

•      Permission by low for ST (1996)

•      Slowly, but systematic increase of ST centers and slots

•      Increasing acceptance for ST among drug users, their families, professionals, politicians and public opinion

•      Stable position in treatment alternatives (law, handbooks, standards, algorithms

•      Moving level of dicussion from „if” to „how”, „how many”, „for whom”, „when”

i.v. drug use as a source of HIV infection in 1994 in PL

Heroine use and treatment programs

•      Early 90s – „AIDS panic”, majority of HIV infected patients were I.V. drug users

•      1994-95 – next two programs in Warsaw (one for AIDS patients only)

•      1994/5 – program in small city Starachowice for all 18 HIV-negative heroin users (different experiences with small community reactions)

Opiate use and maintenance programs

•      1996 – Act against drugs permitted substitution therapy

•      1999 – Executive act for methadone treatment (high threshold)

•      90s – discussion between professionalists and in media on substitution treatment

•      90s – „good will but not decission” undertaken by officials

Finansing as a source of troubles and successes in PL

•      Bad experiences when medical services were financed from a central budget

•      „Golden era” of methadone programs when medical organization and financing were on community level (centers in: Zgorzelec, Chorzów, Lublin/Puławy, Szczecin, Kraków, Poznań)

•      Many problems when all public medical services begun to be financed by local insurance companies

•      Need of stable financing sources. Receiving money for first 1-2 years from outsources make a presure for continuation by local sources, is risky but in PL - successfull 

Current status of opiate addiction in Poland

•      Estimated number of opiate addicts is between 35.000-40.000

•      Yearly on 5.000-7.000 of them have contact with addiction medicine services

•      High mortality (because of overdosing, mainly) and morbidity

•      In detoxification unit in major cities about half of patients are dependent from non i.v. opiates („brown suger”), they are different from former i.v. „kompot” users

Current treatment of opiate dependence in Poland

•      Avoilability of addiction medicine is improved but still unadequete

•      Waiting lists in detoxification units

•      Waiting list in rehabilitation centers

•      Small number of effective outpatients programs

•      There more than 12 methadone programs for over 700 patients. It means that MMP is avoilable for ca 2% of opiate dependent patients.

Legal regulations

•      Act for counteracting of drug use 1996: „substitution therapy is one from the forms of opioid dependence treatment”

•      Executive act concerning substitution therapy detaily described inclusion criteria, reasons of exlusion, minimum quantity of psychotherapy, frequency of urine testing, central registering etc.

Legal regulations, guidelinesses

•      Permission for MMP can be given by vojvoda (governors) but customary contens of programs were reviewed and opinioned by Institute of Psychiatry and Neurology. Currently new regulations (2004) moved decision to lower level and opinion is given by comission on National Bureau for Counteracting Drug Problems.

•      Executive acts (1999, 2004)

•      Euromethwork broschure is widely avoilable.

Program description –
inclusion criteria

•      Opioid dependence

•      Age >18 years

•      >3 years of dependence history

•      min. 3 unsucessfull trials of treatment in the past

•      Possibility non-respecting of that „if exist important medical indications”

Program description – assessment procedure

•      Routine physical and psychiatric investigation using ICD-10 criteria

•      HIV when patients agree for that, HBV or HCV – when are clinical indications

 

 

Treatment planning

•      All patients are putting into structured treatment: beginning from hospitalization for change opiates to metahdone and dose fixing.

•      Common program for rehabilitation with individualized differences dependent from needs and possibilities (phusical treatment, individual psychotherapy, social support)

Treatment components

•      1. Methadone distribution

•      2. Treatment of mental and physical illnesses

•      3. Obligatory participations in min. 2 hours/week group psychotherapy

•      4. Access to individual psychotherapy

•      5. Some elements of family therapy/education

•      6. Social support

Dosages

•      Individual dosages dependent from patients’ needs

•      Mean dosage – ca 80mg/day

•      No maximum limit

•      Dosages over 150mg very rare

Supervision of methadone intake

•      All dosages of methadone solution must be consumed in a presence og qualified methadone staff

•      Although low doesn’t permit that, ca 20% of patients can deliver methadone to home for 3-4 days

 

 

Urine controls

•      Executive act obligated staff to test urine no less frequently as 1 time/month

•      In practice beginners or patients suspected for substance use have more frequent urine control

•      Used test are focused on substances often abused

Restriction and sanctions

•      Discharge from the program CAN be made when:

–   3 following urine tests are positive

–  there is non-complience (absence in program for more than two days, aggression, dealing of drugs, being intoxicated with alcohol on area of hospital)

Staff and training of staff

•      Head of program must be a psychiatrist having min. 3 months experience in addiction medicine

•      If psychiatrist is not a head of programme, a head of program should be a medical specialist having min. 2 years of experiences with addiction medicine. Psychiatrist must be employed.

•      Other staff: psychotherapists, trained nurses (min. two of both professions for 50 patients

•      All professional staff should be after training in Institute of Psychiatry or adequate foreign training

Funding of program

•      All programs should be financed by insurance companies only

•      Permission cannot be given when stable financial support is not warranted

•      There is not a possibility to receive money from patients or from other sources for basic program

Annual statistics

•      There is not regular statistics about methadone treatment

•      Institute of Psychiatry and Neurology regularly publish scintific papers, between others on retaining in program, discharges, reasons of discharges etc.

Links to other agencies and services

•      Access to basic specialistic services: internists, surgeons, obstetrics and gynecologists, infectious diseases clinics must be warranted

•      Collaboration with social care services are mostly good although their possibilities are not high (lack of job offers, hostels etc.)

Patient documentation

•      At intake: full routine physical and psychiatric examinations documented in routine patients’ records; serological examination for syphilis, chest X-ray examination for tbc are obligatory; offer of HIV serology id given to all patients but can be made after patients agreement, only; HBV and HCV are made in cases of suspected infection (high costs); obligatory general urine examination, blood morphology, hepatic enzymes are routine test; in suspection of comorbid physical disorders – adequate examinations should be made (CT, MRI)

 

Patients documentation

•      During treatment: controlling of methadone distribution is extremely restricted. Many forms must be completed, signed etc. All medical, psychological and social interventions are noted. Adverse evants are noted, in case of serious adverse evants special Comission must be informed.

•      .

Similarities and differences to other programs

•      Programs in Warsaw and Łodź will be typical substitutional programs.

•      One Warsaw program is adressed to AIDS patients only, program in Chorzów – to HIV or AIDS patients

•      Small program in Starachowice is quite different, because works in a small community and contain all heroin dependent

Current problems and obstacles to programme implementation

 

•      The main problem is with stability and adequacy of prpgram financing

HIV-preventive guidelines and regulations in drug treatment services

Act concerning infectious disease (modyfying by adding HIV and AIDS as the main dangers for public health)

National Programme for HIV Prevention and Care for People Living with HIV/AIDS for period 1999-2003 www.aids.gov.pl/arch/933

European Guidelines for teh Clinical Management and Treatment of HIV Infected Adults in Europe (the EACS Euroguidelines Group 2002)

 

Available HIV/hepatitis prevention intervention and procedures

•      All basic diagnostic tests can be made. There is a possibility to turn patients to AIDS centre for more sophisticated tests and consultation. There can be a problem with financing of expansive tests.

•      Syringe/needle exchange don’t concern MMP patients

•      Condoms are available but are not very popular in that population (independently of medical advices)

•      Good access to infectious disease counselling

•      Outreach activities are not made by IPN but by other institutions

•      HIV/AIDS informations are available

•      Hepatitis B vaccination are avoilable in other institutions, but are made rerely because of high rate of infections

Prevalence of HIV seropositivity, AIDS, hepatitis B and C

•      Since 1985 – 7.826 infections of HIV

•      2001 – 560 new cases of HIV+

•      Since 1985 – 1.237 cases of AIDS (608 died)

HIV+ among i.v. drug users

Yearly morbidity of hepatitis B

Hepatitis type B and C

•      Big campaign against hepatitis type B

–   all newborns were vaccinated – govern.

–   free vaccination for risk groups- govern,

–   possibility of paid vaccination for others

•      Although drug addicts are risk group, majority of them are infected

•      In major cities up to 100% methadone patients are HCV infected! (negative selection). In small „closed” communities all drug addicts are HBV, HCV and HIV negative

Available guidelines and regulation for the management of clients with infectious disease

•      European Guideliness for the Clinical Management and Treatment of HIV Infected Adults in Europe (The EACS Euroguidelines Group 2002)

Available medication and medical care

•      In Poland all infected patients can access to free antiretroviral program. There can be some limitations (long distance to AIDS centers, medical counterindications.

•      Access to hepatitis treatment with interferon is very limited (high cost, high treshold including criteria)

Link to special services for the management of infectious diseases

•      In Warsaw there is no problem so with acces to couselling as to prolonged treatment

Similarities and differences to client management for infectious diseases in other services

•      The best access have patients in program located and orgnized by infectious disease sector (Warsaw, Chorzów)

•      Programs in small cities have more problems

Current problems and obstacles...

•      High cost of antiretoviral and interferon therapy

Research resources

•      Research staff – three psychiatrists with M.D., Ph.D after many training in Poland and abroad, having certificate of therapist of addictions; 1 psychologist – certificated therapists of addictions, all are lecteurer on trainings organized by IPN.

 

Research experience

•      Members of program staff are authors of 250 papers in English and Polish, mainly in the field of dependences, MMP especially.

•      Currently in IPN is provided fifth scientific program on subjective needs and expectancies of detoxification patients, formerly, QoL before and after 1 year of MMP, physical status after MMP, analysis of reteining in program, pharmacokinetics of heroine