Opioid substitution therapy

Opioid users currently represent 80–90% of the registered drug users seeking medical care. In most of the former USSR countries drug dependency treatment is government-funded. It includes inpatient and outpatient care facilities, data collection and administrative function. Most centres focus their treatment efforts on total abstinence. Some centres also have harm reduction programmes, including syringe exchange and methadone substitution therapy. Over the last several years, HIV infection has been on the rise among injecting drug users in Eastern Europe and Centrala Asia.
 
According to some estimates, over 3.7 million injecting drug users live in Central and Eastern Europe and Central Asia, most of whom are opioid users (UN Reference Group on HIV Prevention among IDUs, 2008). The data show a high incidence of HIV and Hepatitis C among injecting drug users. In most of the countries in this region parenteral transmission of HIV is the most common, representing 50–85% of registered cases (UNAIDS 2008; IHRD 2008). Prevention efforts reach few IDUs, with less than 10% coverage in most countires, and as low as 2% in some (for example, in Russia).

Access to substitution treatment programmes in selected countries in Central and Eastern Europe and Central Asia (source: EMCDDA, IHRD)

In all the countries where opioid substitution therapy was introduced, programme effectiveness evaluations were completed or are now underway. The most detailed study was in Lithuania and Ukraine under the WHO Collaborative Study. The study proved the effectiveness of OST programmes in reducing the frequency of injecting drug use, reducing crime among drug users, reducing risky injecting behaviors, and improving overall health.

The primary achievements of OST programmes have been obtaining government funding (Lithuania and Georgia), an opioid substitution therapy programme launch in a prison system (Kyrgyzstan), and interactions with AIDS treatment programmes (antiretroviral therapy adherence support). There have been few reported incidents of methadone appearing on the black market.

The primary challenges encountered during the introduction and rollout of OST involved complications in the paperwork required for methadone procurement and importation. Other problems encountered during OST programme implementation were poor levels of awareness among specialists and the general public at program start time, and negative reactions on the part of some law-enforcement authorities. There is a real shortage of Russian-language literature about opioid substitution therapy.

Patient eligibility requirements
Country and patient criteria

Belarus   
- at least 18 years of age
- diagnosed opioid dependency
- regular injected opioid use for more than two years
- two or more unsuccessful attempts at abstinence-based treatment
- HIV-positive or diagnosed with AIDS

Ukraine   
- drug dependence for at least three years
- at least two unsuccessful treatment attempts during the last year
- HIV-positive, needs TB treatment, pregnant, Hepatitis B or C positive, septic illnesses, cancer

Lithuania   
- anyone with opioid dependence, regardless of duration
- minors 15 years of age and older may be treated with buprenorphine; to be admitted, a minor’s medical history must show attempts at abstinence-based treatment

Georgia   
- at least 21 years of age
- at least one attempt at treatment
- total opioid use for three years with at least one year injecting drug use
- people living with HIV are given priority (admitted free of charge, no waiting lists)

Kyrgyzstan   
- opioid dependence for at least two years
- two or more unsuccessful attempts of abstinence-based treatment
- HIV-positive, Hepatitis B and C positive, pregnant, gravely ill are admitted even if they don’t meet the above eligibility criteria

Uzbekistan   
- at least 18 years of age 
- two years of opioid dependency
- history of failed treatment attempts
- pregnancy
- HIV-positive people have a priority

References:

[1] Aizberg O. Opioid Substitution Therapy in Selected Countries of Eastern Europe and Central Asia. EHRN, 2008

[In English] [In Russian]

[2] Ali R., Chiamwongpae S., Isfandari S., Jirammakoon S., Mardiati R., Murauskiene L., Newcombe D., Subata E., Poznyak V., Uchtenhagen A. The WHO Collaborative Study on Substitution Therapy of Opioid Dependence and HIV/AIDS. World Health Organization, 2005. 16 pp.

[3] Habrat B. Difficulties encountered in Central and Eastern European countries
in accepting methadone substitution. - P. 107 – 119. // Development and improvement of substitution programmes. Seminar, Strasbourg, October 2001

[4] European Monitoring Centre for Drugs and Drug Addiction. Country overview: Ukraine

[In English]

[5] European Monitoring Centre for Drugs and Drug Addiction  Country overview: Lithuania    

[In English]

[6] European Monitoring Centre for Drugs and Drug Addiction. Country overview: Georgia.

[In English]

[7] Lawrinson P., Ali R., Buavirat A., Chiamwongpaet S., Dvoryak S., Habrat B., Jie S., Mardiati R., Mokri A., Moskalewicz J., Newcombe D., Poznyak V., Subata E., Uchtenhagen A., Utami D.S., Vial R., Zhao C. Key findings from theWHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS. Addiction, 103, 1484–1492

[8] Ukraine Healthcare Policy Research Institute, OST Resource Centre.

http://www.uiphp.org.ua/resourcenter.htm

[9] Dvoryak S.V., Shtengelov V.V. Obstacles in the implementation of maintenance substitution therapy in Ukraine. Mental Health Magazine, 2007, № 2 (15), pp. 41–48.