CROATIA. Venija Cerovecki, MD, GP. University of Zagreb School of Medicine Department for Family Medicine

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1 CROATIA Experiences and issues in the management of drug, health and social co-morbidities among clients in opioid substitution treatment (OST) with GPs Venija Cerovecki, MD, GP University of Zagreb School of Medicine Department for Family Medicine

2 Croatian facts Population Heroin addicts 6251* New cases 667* *Croatian National Institute of Public Health, Annual Report 2009.

3 Health Care System in Croatia 3 levels Primary Secondary Tertiary

4 Primary Health Care in Croatia general practitioners paediatricians gynaecologists dental care occupational medicine emergency medical care medical care for school children public nurse

5 General Practice in Croatia about 2350 doctors work as GPs gate-keepers comprehensive care patients list were introduced into PHC average number of patients on GPs lists about 1700 free choice of GPs have been existing 88 % of the population registered in general practice

6 General Practice in Croatia GPs are individual contractors with National Institute for Health Insurance 84 % are individual contractors integrated into the public sector 16 % GPs work as salaried doctors within the Health Centers GPs are paid by capitation (differentiated by age) and fee for services

7 Health Insurance in Croatia national health insurance all Croatian citizens are insured and have free access to health care system some participations for drugs and diagnostic procedures-symbolic private insurance funds- for better comfort

8 Hystorical background of Croatian opioid substitution treatment model tradition of social psychiatry and alcoholism treatment (Hudolin) tradition of social medicine in general practice ( Štampar)

9 Croatian story: methadone start in 1991 avaliable in PHC supervised by special units buprenorphine start in in 2004 avaliable in PHC supervised by special units methadone and buphrenorphine are free of charge

10 Health policy background of OST in Croatia easy acces to health insurance opioid-dependent patient if not insured will get insurance because of his/her disease OST free of charge every person in Croatia has own doctor GPs - gate keepers

11 Croatian model achievement Availability : more than 50% GPs (1200) have clients in OST Professional quality: GPs get specialised support and education from experts

12 Why opioid substitution treatment in GP setting? opioid dependence is a cronic recurrent condition associated with severe health and social consequences opioid dependence is a problem daily encountered in GP setting opioid-dependent patients are chronic patients

13 Croatian model of opioid substitution treatment decentralised, community-based model treatment approach to opioid dependence on the same way as any other chronic disease close collaboration with Centres for Outpatient Treatment of Addiction shared care model

14 Croatian model of opioid substitution treatment - GP s role GP prescribes all medication GP daily controls opioid-dependent patient health status GP plans additional diagnostic and therapeutic interventions GP has complex approach to opioid dependence treatment prepare take home doses

15 Advantages of the treatment of OD in GP setting Croatian experiences GP is available to all persons in Croatia comprehensive - holistic care better insight in overall health status better individual health risk management better diagnostic and treatment monitoring monitoring all prescription offered to opioiddependent patients day-by-day contact contact with family destigmatisation and degetoisation

16 Disadvantages of the treatment of OD in GP setting Croatian experiences part of GPs do not follow national guidelines education of GP s and nurses leaking of methadone and gray market inadequate payment of GP s lost of epidemiological data

17 Croatian model of opioid substitution treatment - Centre s role clinical assessment recommendation for methadone and buprenorphine treatment periodical treatment evaluation urin testing psychosocial approach collecting epidemiological data psychiatrists, MD, social workers, nurses

18 Prescribing and dispensing regimen -methadone and buprenorphine- recommendation from Centre prescribing by GP supervised consumption in GP s office (the rule in the beginning of treatment) take home dose prepared by nurses

19 Comorbidity Croatian National Institute of Public Health Annual Report ICD-10 Code Opiate abuse No Opiate abuse % F60 - F F30 F F40 F F F20 F F90 F Z F00 F F50 F F70 F Others No of diagnosis

20 Cause of death Croatian National Institute of Public Health Annual Report Cause Nr. % Heroin overdose Other opiates Cocaine overdose Methadone overdose Other illnesses Accidents Others Total

21 Outcomes and indicators Age at which the first heroin encounter took place 20.3 years Age at which therapy was first started years Length of involvement into drug-addicted community prior to therapy 10.2 years HIV infection 0,5 %* HBV poz. 10.5%* HCV poz. 42,3%* *Croatian National Institute of Public Health, Annual Report for 2009.

22 Croatian suggestion: more than one medicament OST avaliable in GP setting and PHC the same prescription and distribution policy for all medicaments individual approach in treatment planning investigate addiction population needs investigate public resource capacity costs (clients and public costs) historical reasons

23 Take home messages from Croatia opioid dependence is not different than any other chronic disease opioid-dependent patients are not different than other patients opioid agonists are not different than other medicaments opioid-dependent patients need families and family physicians (GPs) too