Standards of treatment and case management in Germany Dr. Ingo Ilja Michels Meeting Addiction Researchers from Germany and The Netherlands Münster, 8 October 2008
Problem : only a small percentage of those who need treatment get treatment Community/general population Drug Use Experience (lifetime user) Current Users Problematic Drug Users* SUD ( Substance Abuse/ and Dependence) Persons in contact with services For treatment and intervention *Problem drug use: i.e social or physical harm
Current Situation
Aims of treatment to assist the patient to remain healthy until, with the appropriate care and support, they can achieve an life free of drugs to reduce the use of illicit and non-prescriped drugs by the individual to deal with the problems related to drug misuse to reduce the dangers associated with drug misuse, particularly the risk of death by overdose and HIV, hepatitis infections from injecting and sharing injecting paraphernalia
Aims of treatment to reduce the duration of episodes of drug misuse to reduce the chances of future relapse to drug misuse to reduce the need for criminal activities in order to finance the drug misuse to improve overall personal, social and family functioning
Idealistic vs. Realistic Change Idealistic Change Realistic Change
Drug Addiction needs a comprehensive answer Drug Abuse Treatment Core Components and Comprehensive Services Housing / Transportation Services Financial Services Family Services Abstinence- Oriented Substance Abuse Counseling Substance Motivational Use & Urine Incentives Monitoring Legal Services Child Care Services Intake Motivational Processing / Interviewing Assessment Treatment Plan Buprenorphine Pharmacotherapy Detox Continuing TELE Care Self-Help (AA, NA) Meetings AIDS / HIV Risk Services Vocational Services Supportive Group and Individual Counseling Clinical & Case Management Educational Services Mental Health Services Medical Services Robert Hubbard 2000
Cessation facilities for hardcore addicts: Substitution treatment with methadone/buprenorphine Heroin-assisted treatment Heroin outpatient clinic in Hanover
Dependent Opioid Use and Treatment Pathways Relapse Abstinence Relapse Prevention Residential (drug-free) Outpatient (drug-free) Psychological counselling Support group Antagonist (e.g. naltrexone) Cessation Withdrawal Management Setting Medication Speed Heroin use Dependence Substitution Treatment Buprenorphine Methadone (LAAM) SR morphine Harm Reduction Education about overdose HIV/HCV risk reduction info
The global response: UN support for good treatment Substitution maintenance treatment is an effective, safe and cost-effective modality for the management of opioid dependence. Repeated rigorous evaluation has demonstrated that such treatment is a valuable and critical component of the effective management of opioid dependence and the prevention of HIV among IDUs. (Source: WHO/UNODC/UNAIDS position paper: Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention)
Key outcomes of maintenance pharmacotherapy programmes Retention in treatment Facilitates reduction/cessation of opioid use Reduces risky behaviours associated with opioid use Enables opportunity to engage in harm reduction measures Mortality and morbidity Psychological, emotional, and physical well-being of patients Social costs associated with illicit drug use Crime Opioids
Effectivness of MMT in Germany Raschke et.al. More than two thirds of the patients had received treatment in inpatient, drug-free TCs, but failed MMT shows considerably higher retention rates than TCs (87% after 1 year, 66% after 3 years, 53% after 5 years and 48% after 7 years) remarkable improvement in the general health HIV seroconversion rates are well below 1% during MMT risk of mortality is drastically reduced reduction in the use of illegal drugs, with increasing length of time in treatment there is also a decline in, or termination of the additional use of other psychotropic substances About 10% of treatment participants become totally abstinent
Final Report 2006 Cost Benefit and Risk Appraisal of Substitution Treatment (COBRA) Institute of Clinical Psychology and Psychotherapy, TU Dresden Overall the study revealed a wealth of findings: (1) The 12-month retention rate is high and similar to that in controlled trials; trials however reveal mostly a considerably shorter duration as the current trial. Retention rates range between 60-80% depending on length of prior maintenance treatment and did not differ significantly between methadone and buprenorphine treated patients. (2) The mortality rate during the 12 month follow-up rate was 1.1% and thus at the lower end of the expected rates. No significant differences between treatments were found. (3) There are indications that buprenorphine treated patients more frequently reached the therapists individual treatment goals and overall a higher proportion of buprenorphine patients seem to have a favourable outcome. This is reflected, for example, in rates of patients that completed the treatment within the observation period successfully (rated as being clean) or who switched from maintenance to drug-free psychosocial treatment settings. (4) Concomitant drug use of opiates (from 19.3% to 15.8%), and other drugs (49% to 46%) decreased overall with some indications of less pronounced concomitant drug use figures for buprenorphine treated patients. (5) The somatic and mental health status as well as the self-reported quality of life improved significantly in both groups.
(6) Among patients in substitution treatment there is substantial proportion of HIV/Aids patients 10-15% and considerably higher proportions of HCV-infected patients. The latter remain largely untreated and not infrequently undetected. The rates of inadequately managed patients are alarming and call for action. (7) Given the exceedingly high rates of infectious diseases with great potential to spread the large proportions of patients having regular unprotected sex and/or needle or equipment sharing is alarming as well. Treatment and management guidelines should emphasize this obviously neglected area of intervention with more rigors. (8) In terms of cost the major cost-driver in substitution treatments are the infectious diseases followed by inpatient hospital stays. (9) It is remarkable, that when controlling for initial severity and other confounders, no consistent differences were found neither by type of maintenance medication nor by type of provider setting. Small primary care-based settings revealed higher retention and lower concomitant drug use and had lower costs with no apparent disadvantage. (7) This latter finding might suggest that incentives to encourage primary care doctors to treat at least a few patients (=small substitution settings) is a way to improve the currently deficient care situation particularly in smaller cities and rural areas.
What are the long-term effects of substitution treatment?
Substitution treatment in Germany 1992-2005 MMT patients in Germany 70000 60000 50000 40000 30000 20000 10000 0 1990 1995 2000 2005 2010 The Baron Edmond de Rothschild Chemical Dependency Institute
Substitution Treatment in Germany: used substances - what role does the substance play? 100 90 80 70 60 50 40 30 20 10 0 2002 2003 2004 2005 Meth Bupr Codeine
Concomitant drug use change by type of medication Methadone (n=1,248) Buprenorphine group (n=367) cocaine *** cocaine cannabis ** cannabis metamphetamine metamphetamine amhetamines * amhetamines benzodizepine benzodizepine methadone *** baseline follow-up methadone baseline follow-up opiates opiates 0 10 20 30 40 50 % with concomitant use 0 10 20 30 40 50 % with concomitant use
自注册后继续在美沙酮门诊就诊之时间 (1998) 以前曾注册次数之百分比 50 40 30 20 14,3 40 20 0 37 24.7 14.7 9.3 1-4 次 5-9 次 10-14 次 >15 次 14,5 14 12 9,9 11,4 18,8 10 5,1 0 首次 <1 年 1-3 年 3-5 年 5-10 年 10- (N=7,669) 15 年 15- >20 年 20 年 47.3% * 美沙酮治疗计划检讨报告 (2000), 附件第 20 页, 香港特区政府保安局禁毒处 30
Drug free cessation help: 5000 places in therapeutic communities and specialised cinics What do we know about the effects? A therapeutic community in a village near of Berlin
Self Help-Groups of Ex-drug addicts what is the role in treatment? Self help-group of drug addicts in substitution treatment Activities against HIV- and Hepatitis
Ecology of Recovery The Science of Recovery and Recovery Capital (Bill White 2006) Recovery is the process through which severe and persistens Alcohol and Drug Problems are resolved in tandem with the development of physical, emotional, ontological (spirituality, life meaning), relational, and occupational health) Recovery is more than the absence of symptoms; it is the achievement of a state of complete physical, mental and social wellbeing (WHO) Overall recovery process involves both push factors (pain) and pull factors (hope) Recovery processes range from full recovery (complete cessation) and partial recovery (reduced frequency of usage) to enriched recovery (profound changes with enhanced personal functioning) and sudden transformation, even without professional support
Recovery Capital (Bill White 2006) Creating physical and social environments conducive to recovery enhance long-term recovery outcomes Participation in recovery support groups can play a significant role Combination of addiction treatment with recovery mutual aid groups (i.e. AA, NA etc.) is more predictive of longterm recovery than either activity alone sustainable livelihoods (vocation & employment) are a crucial element to support continued progress of resolving AOD problems Integration with the community is essential for success
Action Plan Drugs and Addiction, Implementation Please feel free to contact me for questions or comments: ingo.michels@bmg.bund.de Many Thanks for your attention!