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In 2005, WHO added methadone and buprenorphine to their Model List of Essential Medicines for opioid dependency treatment. This was the result of numerous studies showing that their use in substitution therapy benefits mental and physical health, improves quality of life and reduces high-risk injection behaviours. These studies were completed in countries with different socioeconomic conditions and different drug treatment systems, and all of them showed methadone/buprenorphine substitution treatment to be safe and effective.
Substitution therapy admittance criteria
Most experts agree that substitution treatment can be prescribed to all patients with opioid dependency under their informed consent and if they don’t have counter-indications (this expert opinion is reflected in WHO-2009 recommendations). Before assigning treatment medical specialists should prove the patient’s opioid dependency (check traces from injections, withdrawal syndrome indications, documents about the history of treatment).
In some countries eligibility criteria additionally include attempts at abstinence-based treatment and that the patient should be at least 18 years of age. However, these requirements serve as barriers to early start of therapy and effective prevention of HIV and Hepatitis, that is why in many countries doctors are allowed to prescribe substitution therapy regardless of drug use duration or treatment attempts.
Most guidelines recommend offering substitution treatment to patients with HIV or chronic Hepatitis B or C irrespective of their duration of use, age or treatment attempts. Pregnant opioid users are eligible for methadone/buprenorphine treatment during the whole period of pregnancy and after childbirth. Substitution treatment with methadone or buprenorphine is in most cases funded by the mandatory medical insurance system.
Forms of substitution treatment. Psychotherapy and social support Previously, depending on the criteria for accessing and receiving treatment, initiatives were differentiated into low- and high-threshold programmes. High-threshold programmes had strict criteria for the patients’ behaviour and dismissed those who broke the set rules. Such programmes were aimed at discontinuing the use of illicit psycho-active substances and providing social and professional rehabilitation to patients. Psychotherapy and social support was a mandatory requirement for these programmes. Low-threshold initiatives were targeted not so much at treatment, but rather at reducing the harms of the clients’ behaviour that can have an impact on the society. These programmes had less strict rules, as the main goal was to reduce criminal behaviours and decrease mortality among patients. Such differentiation in programmes was not too successful, as it required that patients respect all treatment rules and restrictions, which led to high levels of discontinued treatment. Currently most experts agree that substitution treatment should be administered by a multi-disciplinary team of doctors from various backgrounds, nurses, social workers and psychotherapists. The composition of this team, as well as the form and content of the offered treatment should be determined on an individual basis and be informed by the patient’s needs.
In USA, Austria, Germany, Ireland and France substitution treatment is prescribed by general practitioners. Such an approach has certain advantages: patients do not line up together in one treatment facility and have an opportunity to receive qualified treatment of infectious diseases. Drawbacks include poor identification and treatment of associated mental disorders, loose patient control and complicated processes of cooperation with psychosocial services.
Substitution treatment in medical facilities (day inpatient centres or polyclinics) is offered in ex-Soviet countries (Ukraine, Georgia, Belarus, Lithuania) and in Greece, France, Norway, Sweden, Denmark, Italy, the Netherlands, Portugal and Spain. Such treatment modality provides for multidisciplinary approach and is considered to be optimal, though quite expensive. Other shortcomings include remoteness from the patients’ places of living, as such centres are limited in number. Apparently, in the future these centres will be used to provide support for the most ‘problematic’ patients.
‘Mixed’ substitution therapy model is being run in Belgium, France and UK. The patients are divided in almost equal proportions between general practitioners and specialised polyclinics.
The goal of substitution therapy programmes in prisons is reducing the risks of HIV and Hepatitis, which means it’s a purely harm reduction intervention. It is being offered in many European countries (Germany, Switzerland, the Netherlands, Austria, Denmark, France, Luxembourg, Portugal and Spain), although not in every prison where drug users serve their terms.
Earlier on, psychosocial interventions were viewed as mandatory for substitution therapy initiatives, regardless of the client’s wish to be involved in them. Research shows that patients receiving psychosocial support alongside with substitution treatment demonstrated better results than patients on methadone without psychotherapy. Currently there is a lack of common standard of providing psychosocial support to patients in maintenance treatment programmes. Such activities may include psychoeducational sessions, cognitive-behavioural psychotherapy on an individual basis or in groups.
[1] Amato L, Davoli M, A Perucci C, Ferri M, Faggiano F, P Mattick R. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat 2005 Jun;28(4): 321-9
[2] Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence (Review) The Cochrane Library 2005, Issue 2
[3] Connock M., Juarez-Garcia A., Jowett S., Frew E., Liu, Taylor R.J., Fry-Smith A, Day E., Lintzeris N., Roberts T., Burls A., Taylor R.S. Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technology Assessment 2007; Vol 11: number 9
[4] Farre M., Mas A., Torrens M., Moreno V., Cami J. Retention rate and illicit opioid use during methadone maintenance interventions: a meta-analysis. // Drug and Alcohol Dependence. – 2002. - Vol.65. – P. 283–290.
[5] Gibson D.R., Flynn N.M., McCarthy J.J. Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion among injecting drug users. // AIDS. – 1999. – Vol. 13. – P. 1807 –1818.
also: Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, 2009 [In English]
[6] Legal aspects of substitution treatment. An insight into nine EU countries. EMCDDA, 2003
[7] Marsch L. A. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis. // Addiction. – 1998. – Vol. 93, № 4. – P. 515-532.
[8] Spire B, Lucas GM, Carrieri MP. Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST). Int J Drug Policy. 2007 Aug;18(4):262-70.
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