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National Guidelines for Substitution Treatment of
Opiate Addiction in the Czech Republic
Petr PopovApolinar – Addiction Treatment Centre
General Faculty Hospital PragueCzech Republic
Substitution Treatment Standard
(Order of the Czech Ministry of Health; part 6/2000, part 4/2001)
• drug dependence diagnostic criteria (ICD - 10)
• substitution treatment definition• substances for substitution treatment• substitution treatment typology• indications, contra-indications• therapy (dosage, non-pharmacological components, assessment)
F11.2, F11.3(ICD – 10)
F11.22 : „At present abstain in clinical controlled maintenance
or substitute treatment“(e.g.. methadone; nicotine)
„abstinence-oriented treatment“
Substitution Treatment Definition
(Substitution Treatment Standard, Czech Ministry of Health )
•Standard treatment (therapy)•time unlimited (open-end)
therapy (maintenance therapy)•harm reduction
Personal Requirements
• Diagnosis and indication made by psychiatrist or adictologist
• Substitution treatment performed in specialised centre (with the exception of minimal substitution treatment)
• External supervision for facilities is required
Substitution Treatment of Opiate Addiction in the Czech
Republic - legal substances
1. methadone (HCl)2. buprenorphine (HCl)
(Order of the Czech Ministry of Health; part 6/2000, part 4/2001)
Substitution Treatment of Opiate Addiction in the Czech
Republic
methadone (pharmacopoeia substance)
(Order of the Czech Ministry of Health part 6/2000, part 4/2001)
Substitution Treatment of Opiate Addiction in the Czech
Republic
buprenorphine Subutex®
(tbl. subl. 0,4mg, 2mg, 8mg)Temgesic®
(tbl. subl. 0,2mg, inj.0,3mg)
(Order of the Czech Ministry of Health part 6/2000, part 4/2001)
Buprenorphine in Substitution Therapy
general purpose: • short-term treatment - detox (heroin,
methadone)
• „half-life“ treatment - stabilization• long-term treatment – maintenance
(event. undated/time-unlimited maintenance)
Substitution Treatment of Opiate Addiction in the Czech
Republic - treatment typology
1. Complete substitution treatment
2. Basic substitution treatment
3. Minimal substitution treatment
1. Complete substitution treatment
Administration (provision under control, expense, and/or prescribing) of substitution substance and services, provided within institution:
- treatment of somatic and psychic disorders - detoxification - group psychotherapy - individual psychotherapy - family therapy - counselling - health-risk education etc. (see your copy)
2. Basic substitution treatment
Administration (provision under control and/or prescribing) of substitution substance plus services, provided within institution (dtto)
3. Minimal substitution treatment
(in health institutions with other specializations) Administration (provision under control and/or
prescribing) of substitution substance • short-term - acute states of patients coming from different types of
substitution treatment - planned diagnostics or treatment of patients from
different types of substitution treatment - travels (work, holiday)
• long-term (maintenance) - psychiatric ambulatory - GP´s
Methadone treatment indications
• heavy and long-term dependency on high doses of opioid substances
• repetitive unsuccessful abstinence-oriented treatment
Supporting factors :– Positive experience with substitution treatment – HIV+
– pregnancy
Methadone treatment contra-indications
• possibility and suitability of abstinence-oriented treatment
• prevalence of non-opioid dependence• absence of physical dependence• age under 16• serious hepatic disorders (hepatic
failing)• acute/chronic alcohol intoxication
Buprenorphine treatment indications
opioid type dependence (daily dosage equivalent max. 60mg
methadone)
Buprenorphine treatment contra-indications
• prevalence of non-opioid dependence • age under 15• serious hepatic disorders (hepatic
failure)• IMAO therapy, incl.14 days after
termination• acute/chronic alcohol intoxication
Relative contra-indications of substitution
treatment• alcohol addiction• disability to stop psychoactive
substances intake in despite of adequate dose of substitution substance
• forthcoming imprisonment
Outlook
• Corrections and changes of Standards is continuous– based on practical experiences – according to changes of the system
(e.g. accreditations)– with regard to the future
(involvement of the GPs)
Still interested?Still some time?
What about the recent numbers?
Clients of substitution centres in the Czech republic
Institute of Health Information - ÚZIS (10.3.2003)
382 clients(V/2000 - III/2003: 1268/886)
Clients of substitution centres in the Czech
republic (ÚZIS, 10.3.2003)
methadoneactive: 319
intake (V/2000 - III/2003): 1140terminated (V/2000 - III/2003) 821
Clients of substitution centres in Czech republic
(ÚZIS, 10.3.2003)
buprenorphineactive: 63
admission (V/2000 - III/2003): 128termination (V/2000 - III/2003) 65
Reasons for treatment termination
1. other centre2. different treatment3. breaking rules4. imprisonment5. death6. other
115
228
591
5385
1 2 3 4 5 6
Substitution centres in the Czech republic
1. Apolinář – VFN Praha 22. AT ordinace Hradec Králové3. AT ordinace Mělník4. FN Olomouc5. Masarykova nemocnice Ústí n.
Labem6. DPS Elysium Brno7. DROP IN o.p.s. Praha 18. DROP IN o.p.s. Praha 49. FN Ostrava - Poruba
(Zdroj: MPK, 2001)
Substitution centres in the Czech republic
Centre Number of clients
VFN – Apolinář, Praha 2 56
DROP-IN o.p.s., Praha 4 (1) 101
Masarykova nemocnice Ústí n/L
146
DPS Elysium Brno 51
OAT Hradec Králové 13
OAT Mělník 7
OAT Olomouc 4
FN s poliklinikou Ostrava 4
Substitution treatment- problem drug users in Czech
republic
Prevalence of problem heroin and other opioid users in the Czech
republic (2000):12.000 – 18.000 (PAD, 2001)
Methadone maintenance in CR (2000):190 clients (< 2%)
actual (2003): 2,5 – 6%