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1 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Heroin assisted treatment in Switzerland – the picture now
We talk – they die
October 8th, 2019
Marc Vogel, MD, MScPH University of Basel Psychiatric Clinics & Psychiatric Services Thurgovia
2 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
What is Swiss HAT and why is it working?
https://medium.com/@brought_on/the-elephant-sized-assumption-1f8c4d7153b5
3 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
A rational and evidence-based choice?
Opioid agonists used in OAT
EDR, 2018
4 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
› ...be long-acting
› ...have a slow onset of effect
› ...reduce craving and withdrawal
› ...block the effects of street opioids
› ...retain patients in treatment
› ...reduce illicit substance use
› ...have few adverse effects
› ... reach all patients
› ...minimize potential risks with acceptable effectivity
› ... be unattractive on the black market
› ...be cost-effective
The perfect agonist for OAT should...
Von Georg Mittenecker - http://kamelopedia.mormo.org/index.php/Datei:Wollmilchsau.jpg, CC BY-SA 2.5,
5 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Beginning of the 70s in Switzerland
› Inpatient detoxification is only available treatment
› Largely missing follow-up concepts or treatments
› Alarming increase in number of heroin users despite of increased inpatient treatment slots
Increasing heroin use
[Source: picturesandperspectives.blogspot.com]
6 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
› Beginning of the 70s: first OAT (methadone)
› 1975: revision of the federal narcotics law: sanctions for use of illicit substances, licensing for doctors engaged in OAT
› Entry criteria: several failed withdrawal attempts and residential treatments
› Patients needed to be employed
› Opioid agonist: methadone, but also dihydro- codeine and sporadically buprenorphine
› OAT only offered to chosen, highly disciplined patients,«Privilege»
› Take Home dosages very high threshold
› Methadone dispensal in the morning before work (06:15 AM)
› Tapered dosing with abstinence as treatment goal
› From the beginning a comprehensive programme of psychosocial care and medical treatment
An example of how not to do it
First Steps of OAT in Switzerland
7 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
What are the main barriers from the perspective of opioid users?
Conditions of treatment entry that were hardest to meet*
Conditions of remaining in treatment that had most impact on daily life*
Having dose supervised every day 33% Having dose supervised every day
24%
Having to attend all appointments
28% Having to attend all appointments
22%
Having to completely stop all illegal drug use
26% Long-term aim of drug-free state 20%
Project Access CH, 2012 *Only the top 3 most frequently given answers are shown
8 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
1980s/1990s
Open drug scenes / «Needleparc»
9 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Swiss overdose deaths
52
84 85
102 88
107 109
144 133
120
136
196 205
248
280
405
0
50
100
150
200
250
300
350
400
450
1975 1980 1985 1990 1995 2000 2005 2010 2015
10 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Newly diagnosed HIV-infections in Switzerland
BAG, 2009
Heterosexual contact
Homosexual contact
IDU
Other
Incidence & prevalence of high risk opioid use in Switzerland
Nordt, Vogel & Herdener, in preparation
12 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Four-pillar-Strategy 1991
Pre
ve
nti
on
Th
era
py
Ha
rm R
ed
uc
tio
n
Law
En
forc
em
en
t
13 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
› needle exchange programs and drug consumption rooms (safe injection facilities, contact points)
› low threshold offers: social support, shelters, free meals, day structuring activities etc.
› supported employment (even on hourly basis), tailored reintegration
› access to methadone on less restrictive conditions for all heroin dependent persons seeking treatment
low threshold OAT with methadone
Harm Reduction measures broadly introduced in 1991
14 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
An example of how it can be done
› Opioid dependence is the only precondition, treatment is initiated on the day the patient first presents – no waiting list!
› Covered by health insurance (which is mandatory in CH)
› Optimal dose is determined clinically and individually together with the patient
› Ongoing substance use is not sanctioned
› Long-term treatment possible - no termination date, no mandatory dose reductions, abstinence is not a mandatory treatment goal!
› Comprehensive coverage and availability
o Specialized institutions
o Private practices and pharmacies
› Continuation of OAT in case of hospitalization, detention or imprisonment
› Take-home for the large majority of patients
Low threshold OAT
15 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
«We continually see a clinically relevant portion of opioid dependent patients not responding sufficiently to
adequately performed methadone treatment.»
[Advisory Council on the Misuse of Drugs, 1993]
About 20% of patients need a mode of application with rapid onset of effect, i.e. „flash-accepting treatment“
Oral OAT does not reach all patients
16 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
› Start of a national cohort study (PROVE) in 1994
› Federal ordinance concerning the medical prescription of heroin
› Drug registration, approval and listing (Diaphin®)
› Health insurance: definitive inclusion in the Narcotics Law
› expansion of outpatient clinics offering heroin assisted treatment
› Closure of open drug scenes;
› since its introduction several referendums on HAT were held, all in favour
Heroin Assisted Treatment (HAT)
17 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
› minimal age of 18
› documented opioid dependence of minimal 2 years
› documented health and/or social deficits
› at least 2 previous treatments that failed (not defined further)
Evidence-based?
No - chosen for pragmatic reasons, nevertheless these criteria are being used similarly in other countries
Entry Criteria for HAT
18 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
› available for injection (IV, IM) as IR and SR tablets, for inhalation (only NL)
› Diversification of diacetylmorphine (injectable DAM, IR tablets, SR tablets) allowing combinations and easier transition to lower risk routes of administration
› Tmax 2 min - 4.3 h, T½ (morphine) 2-4 h
› No fixed doses, no maximum doses, clinical and individual dose finding
› (injectable) DAM with more side-effects than oral methadone: available only in specialized centers
› Dispensing varies from once every three days to 5 times daily (2 times daily in Basel, open 3 hours each in the morning and afternoon)
› more effective than methadone in reducing illicit opioid use
Diacetylmorphine (DAM) in HAT
19 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
The simple fact is that it works…
Conclusion scientific report PROVE*):
Enrolment of patients not responding to conventional OAT
Safety of patients and staff was proven
The use of non-prescribed substances was reduced significantly
Health status was significantly improved
Homelessness was significantly reduced
Most spectacular was the reduction of criminal activities
Cost-effective
The results have since been confirmed by various studies in Germany, NL, UK, Canada, Spain, Belgium...
Heroin assisted treatment
[Uchtenhagen, 1997]
*) Prove: national cohort study: Projekt zur Verschreibung von Opioiden, starting 1994
70% 10%
Dramatic Decline of criminal activities
source: ISGF, HeGeBe-Monitoring, 2005
29. April 2015
Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
| 20
delinquency at beginning of treatment delinquency after 18 month in treatment
21 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
„Overall the introduction of heroin assisted treatment constitutes one of the
most effective approved individual projects in the field of crime prevention.“
Prof. iur. Martin Killias Professor of Criminal Law, University of Lausanne
Evaluation of HAT effects on delinquency
[source: Schmid O, Müller T. Heroin - von der Droge zum Medikament; Pabst Science Publishers 2008]
22 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
IV DAM vs. oral Methadone
23 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
1200 HAT patients in 23 treatment centers
MMT- and HAT-centers in CH
24 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
› (Fairly) low-threshold, „flash-accepting treatment“
› Physician prescribes DAM, but does not need to be in-house for dispensing times; nurses can reduce dose when they see fit
› HAT is mostly continued in case of inpatient treatment (somatic or psychiatric)
› Heroin assisted treatment: interdisciplinary (nurses, physicians, social workers, psychologists), social support, psychotherapy, medication
› Patients inject IV (in peripheral veins, rarely the groin, never the neck) or IM
› Take home of DAM tablets for stable patients for 2 days
› Dispensing of reserve medication (alternative oral agonist) to prevent withdrawal symptoms in case of missed DAM dispensings
› Individualized treatment where patients can choose to return tablets in order to inject
› Dose finding is a mutual process with (mostly) the patient deciding
› Overdoses are very rare (Basel: 7 years, 4 ambulances, 1 naloxone)
› Police/security is neither involved nor necessary
The Swiss HAT
25 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Nasal application of liquid DAM
› Significant proportion of opioid users use nasally or chase the dragon
› For this group, there is currently no option available with rapid onset of effect (apart from the Netherlands...)
› Alternative for patients in treatment with injectable opioids that
› Can no longer inject safely in peripheral veins (aging population!)
› Can no longer inject due to somatic problems such as COPD (aging population!)
› Inject IM (similar PK)
› Want to change to less harmful route of administration
› Patients that take tablets but are in need of more rapid onset of effect
› Pilot study planned
IV DAM doesn‘t reach all patients neither
26 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Age distribution of HAT patients in Basel
Age (years)
< 20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 >= 60
Pro
po
rtio
n o
f p
atie
nts
(%
)
0
10
20
30
40
Year 2001 n=130
Year 2010 n=156
Year 2019 n=151
www.focus12.co.uk
Mean age 48.6 yrs, Median age 49.8 yrs, Range 26-68 yrs
27 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Benzodiazepines in OAT in Basel
n=193 Met/Mor/Bup
DAM p Overall n
Lifetime use of BZD
96 (85%) 68 (85%) .993 164 (85%)
Prolonged use of BZD*) (> 2 months)
61 (54%) 29 (37%) .018 90 (47%)
Current use 76 (67%) 41 (51%) .025 117 (61%)
Former users 25(25%) 27(40%) .039 52(31%)
28 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Diazepam (Valium) 79 (88%)
Flunitrazepam (Rohypnol) 13 (14%)
Midazolam (Dormicum) 10 (11%)
Oxazepam (Seresta) 3 (3%)
Other 4 (5%)
Short- and medium-acting 4 (5%)
Long-acting 63 (75%)
Both 17 (20%)
BZDs used by prolonged users in OAT
n= 90 [Vogel et al., 2013]
29 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
HAT/OAT 65 (72%)
Other prescription 17 (19%)
Black market 41 (46%)
Other 3 (3%)
Total receiving prescription 75 (84%)
Source of BZDs in prolonged users
n= 90 [Vogel et al., 2013]
30 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Motives for BZD use
31 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
One size does not fit all – diversification of opioid agonists
Nordt, C., Vogel, M., Dey, M., Moldovanyi, A., Beck, T., Berthel, T., … Herdener, M. (2018). One size does not fit all -evolution of opioid agonist treatments in a naturalistic setting over 23 years. Addiction
32 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Zurich 1992-2015
› BUP: younger than methadone patients, more often male, higher social integration
› SROM: younger than methadone patients, more often male
› Diacetylmorphine: most homogenous group compared to other opioids, older, more injecting experience, lower social integration
Are there differences between patients in OAT on different agonists?
Injection experience
Duration of opioid dependence
Social integration (index)
Age
Nordt, C., Vogel, M., Dey, M., Moldovanyi, A., Beck, T., Berthel, T., … Herdener, M. (2018). One size does not fit all -evolution of opioid agonist treatments in a naturalistic setting over 23 years. Addiction.
33 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
OAT coverage
CH
EDR, 2019
34 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
52
84 85
102 88
107 109
144 133
120
136
196 205
248
280
405 419
353
399
361
312
241
210
181
205 197
167
194 182
211
193
152 143
171
137 125 121 126
134 132
0
50
100
150
200
250
300
350
400
450
1975 1980 1985 1990 1995 2000 2005 2010 2015
52
84 85
102 88
107 109
144 133
120
136
196 205
248
280
405
0
50
100
150
200
250
300
350
400
450
1975 1980 1985 1990 1995 2000 2005 2010 2015
Swiss overdose deaths
35 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
Other
IDU
Homosexual contact
Heterosexual contact
Newly diagnosed HIV-infections in Switzerland
BAG, 2009
Incidence & prevalence of high risk opioid use in Switzerland
Nordt, Vogel & Herdener, in preparation
37 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |
https://www.researchgate.net/profile/Marc_Vogel
Thank you for your attention