Andres Lehtmets M.D. President of the Estonian Psychiatric Association. May 12, 2009 Nicosa

Transcription

1 Updating the guideline for the treatment of opiate dependency in Estonia finding a balance between the expectations of the government, private service providers and pharmaceutical industry. Andres Lehtmets M.D. President of the Estonian Psychiatric Association May 12, 2009 Nicosa

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3 History of the guideline drafting process The first officially approved guidelines for the treatment of drug addiction in Estonia were drafted by a working group supported by the CE Pompidou Group DRSTP in These guidelines were aiming at the drug addiction problem from a more general perspective, although a substantial part was also devoted to the treatment of opiate addiction. At that time the practice in treating opiate addiction was stillscarce and the main focus was on detoxification to achieve full abstinence. The guideline did however also recommend several psychosocial interventions for rehabilitation and relapse prevention. By 2007 the need for an update of guidelines was clear for all the different parties involved in the process of addiction treatment.

4 The role of the government : service provision The first regulations for the use of substitution treatment dateback to They restricted the initiation of substitution treatment to psychiatric hospitals. The availability of such a treatment option was extremely limited; the main focus of the use of opioid agonist drugs was detoxification. The explosive raise in HIV incidence among IDU forced the government to seek for assistance from the Global Fund. Methadone substitution was advocated as a HIV prevention measure. The focus was on availability and low cost. Some local governments (Tallinn in particular) since 2003 gradually started to finance substitution programmes for opiate dependent patients; they were -and still are mainly run by hospitals. The availability of treatment options still remains to be a problem.

5 Private service providers All the service providers in the health care system in Estonia are by legal definition private. The system is however based on a health insurance model; the insurance covers over 94% of the population. The state has adopted a liberal approach to service provision in health care the main interactions are carried out through licensing and financial provisions via the Health Insurance. There are very few service providers in the health care system who specialise on addiction treatment. Persons suffering from long term addiction are often not covered by health insurance and therefore have to find their own means for treatment.

6 The role of the government : control over drug tourism Well established contacts with neighbouring countries (Finland in particular) opened the door for drug tourism users from abroad seeking for prescription drugs (mainly buprenorfine) from local physicians. The government made several attempts to limit prescription trafficking, unfortunately with poor results. One of the examples was the introduction of the restriction, that buprenorphine could only be prescribed after 5 days of treatment in psychiatric hospital andthat prescriptions could be renewed by the same physician who initiated the treatment. Joining the Schengen Border regulations actually managed to provide substantial results in cutting drug tourism.

7 The role of professional organisations In the early 90 is the majority of physicians in Estonia were sceptical of the need to introduce substitution treatment. This was considered as a palliative option in situations of no hope. Estonian Psychiatric Association has been advocating for professional standards in service provision. Remaining focused mainly on the medical side, we have been supportive of psychological and social interventions in drug treatment. We have participated in the drafting of guidelines and providingtraining seminars for our members. Estonian Medical Association has on several occasions criticisedthe involvement of certain physicians in prescription trafficking and the ignorance of the government to introduce more appropriate regulations.

8 The role of the pharmaceutical industry The interests of the pharmaceutical industry are obviously in commercial markets. They however do need to keep up a positive image and are therefore also interested in transparent regulations on the use and prescriptions on substitution medication. Both the regulatory bodies (State Agency of Medicines) and the Health Insurance Fund have strict rules on the reimbursement of medication and one of the preconditions to apply for it is a treatment guideline. The role of pharmaceutical industry should not b underestimated in the training of physicians and medical staff.

9 The main objectives for the development of the new guideline Establish the main criteria for a comprehensive model for substitution treatment of opiate dependent drug users definitions : substitution treatment, detoxification with opiateagonist medication, maintenance treatment, supportive maintenance treatment patient selection criteria for substitution treatment quality criteria for the service provider directly observed medication intake during the first 6 months of treatment psychotherapeutic and psychosocial interventions as a part of the integrative treatment model substitution treatment for adolescents and pregnant women The guideline recommends the establishment of a state programme for addiction treatment

10 The drafting and adoption of the guideline The drafting of the guideline was carried out by a small working group composed by the Estonian Psychiatric Association and supported by the National Health Institute. The guideline was discussed on a seminar of the Psychiatric Association and consulted by the different departments of the Ministry of Social Affairs, The Health Insurance Fund and the State Agency of Medicines. The guideline remains to be a recommendation and has no legal weight; it would however be consulted by officials in decision making process.

11 Devlopments since the adoption of the guideline The government has introduced a new regulation for treatment with buprenorfine : it can only be used under directly observed intake and is no longer available in pharmacies The Global Fund harm reduction programme has been taken over by the state and resources have been allocated for running it The availability of substitution treatment is slowly on the risebut still far from what is needed. There are a few new initiatives i.e. a programme on the substitution treatment for pregnant women is starting in Tallinn

12 National Health Institute assessment of the substitution treatment system (2008) The assessment revealed several shortcomings in the service provision_ There is still no unified concept for the implementation of substitution treatment The supportive health care and socio rehabilitative services are not sufficient There is little cooperation between the centres offering substitution treatment and the rest of the health care and social services The image of substitution treatment among the public and also among the drug users is negative The assessment recommended to focus on training, service descriptions and develop psychosocial supportive services. The crucial issue would be the financing of the services. The goal for the next 3 years would be to achieve 10% involvement of the IDU-s in substitution programmes introduce special programs for pregnant women and amphetamine users improve the availability of substitution programs for adolescents

13 Financing of the drug prevention strategy (including substitution treatment) from the state budget , , , ,00 Eelarve ,00 0,