CHAPTER 3. PHARMACOLOGICAL TREATMENT

Transcription

1 CHAPTER 3. PHARMACOLOGICAL TREATMENT 3.1 Pharmaclgical treatment f alchl and drug use disrders Rbert Ali The brad cntext f treatment Treatment f substance use disrders wrks and is cst-effective (Cartwright, 2000; Simens et al., 2002). Fr instance, Gerstein & Harwd (1994) examined the effects f treatment, the csts f prviding treatment and the ecnmic value f treatment in the United States. They fund that the cst f prviding the treatment was apprximately US$ 209 millin, while the benefits sciety received during and after treatment were wrth apprximately US$ 1.5 billin. A number f studies in ther cuntries have cnfirmed that treatment wrks and that there is a net return n investment t the cmmunity (e.g. Simpsn & Sells, 1982; Hubbard et al., 1997; Gssp, Marsden & Stewart, 1998). O Brien and McLellan (1996) cmpared drug dependence with adult nset diabetes, hypertensin and asthma. Fr example, asthma is als a chrnic relapsing cnditin with multiple etilgies, including a genetic cmpnent, persnality and envirnment. Asthma, like substance use disrders, invlves chice in the develpment f the cnditin (e.g. smking) and requires significant behaviur changes. Cntinuing care acrss a persn s lifespan is necessary. Relapse rates fr asthma are in the rder f These features are similar t drug dependence, yet n ne argues abut the benefit f prviding treatment fr asthma. The treatment f substance use disrders is as successful as the treatment f these medical cnditins. Gvernance can be described as the institutins, prcesses, plicies and laws affecting the way peple direct, cntrl and administer treatment. Gvernance is an imprtant cmpnent f the safety and quality f health care as pr treatment utcmes are ften the result f failures f the health care system. Withut prper gvernance systems, treatment services becme vulnerable t abuse. Simpsn (2000) fund that interactins between individual needs, mtivatin factrs, scial pressures and aspects f the treatment prgramme itself influence individuals t enter and remain in treatment. Drawing n research abut hw clients becme engaged in treatment, Simpsn (2000) cnceptualized treatment as phases f utreach, inductin, engagement, treatment and aftercare. The gals f treatment include reducing r stpping drug use, imprving physical and emtinal health, imprving scial functining and relatinships, and making meaningful cntributins t the cmmunity, such as emplyment. Maintenance f behaviur change requires substantial time and emtinal cmmitment. Relapse preventin and managing cravings are central behaviur change requirements. In additin, individuals may need t learn t deal with emtins differently, acquire new r altered scial skills, manage time effectively, and deal with interpersnal cnflict in an 57

2 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders assertive manner. Financial management, emplyment skills and educatinal pprtunities are als imprtant cmpnents f establishing a drug-free and prductive life. Withdrawal treatment The primary gal f withdrawal treatment (als called detxificatin) is neuradaptatin reversal. Drug withdrawal treatment can be prvided in a variety f settings acute hspital, cmmunity residential unit, r as an utpatient service. The essential factrs in effective withdrawal are a supprtive envirnment and supprtive cunseling, prvisin f apprpriate symptm management (usually pharmactherapy), and develpment f a plan fr further treatment after withdrawal (neuradaptatin) has been cmpleted. It is imprtant t nte that withdrawal management is nt a treatment in and f itself, and des nt result in the substantial behaviural changes required fr an individual t maintain a drug-free lifestyle. It is, hwever, the first step in attaining abstinence. A meta-analysis f studies f pharmaclgical therapies fr alchl withdrawal (May- Smith, 1997) suggested that benzdiazepines are effective in reducing withdrawal severity, incidence f delirium and seizures with a greater margin f safety and lwer abuse ptential cmpared t ther therapies. A mre recent systematic review (Hlbrk et al., 1999) f randmized cntrlled trials reached a similar cnclusin. Mst research int piid agnists has fcused n their use in maintenance treatment. Hwever, the Cchrane review f piid withdrawal cmpared 22 studies invlving 1736 participants (Gwing, Ali & White, 2009). The majr cmparisns were between buprenrphine, methadne and clnidine r lfexidine. Severity f withdrawal was similar fr withdrawal managed with either buprenrphine r methadne, but withdrawal symptms may reslve mre quickly with buprenrphine. Methadne is cheaper than buprenrphine and its administratin in withdrawal management has n risk f precipitated withdrawal. Relative t clnidine r lfexidine, buprenrphine culd be mre effective in amelirating withdrawal symptms, and patients treated with buprenrphine r methadne are mre likely t cmplete withdrawal treatment. At the same time there is n significant difference in the incidence f adverse effects, but drp-ut due t adverse effects may be mre likely with clnidine. 58 Opiid agnist pharmactherapy (OAP) There are three main medicatins fr the treatment f herin dependence, namely methadne, buprenrphine and naltrexne. Methadne and buprenrphine wrk by eliminating withdrawal symptms, reducing r eliminating cravings and blcking euphric effects frm any additinal herin use. These three mechanisms are imprtant and an adequate dse is required fr these effects t ccur. This dse may exceed the dse requirement just t eliminate withdrawal. The lnger a persn is in treatment, the greater the gains and benefits that accrue frm piid agnist pharmactherapy. Methadne treatment has repeatedly been fund t reduce substantially and, in many cases, cmpletely eliminate herin use. It als prtects against HIV/AIDS and reduces HIV risktaking behaviur. There are als benefits f reducing the risk f death frm herin verdse death as well as f criminal behaviur. Opiid agnist pharmactherapy treatment has been fund in Cchrane reviews t be mre effective than n treatment in terms f reducing herin use, imprisnment and retentin in treatment. It has als been fund t be mre effective than detxificatin r utpatient drug treatment cunselling in terms f reducing herin use, criminal behaviur

3 Pharmaclgical treatment and risky sexual behaviur. Finally, piid agnist pharmactherapy has been fund t be mre effective in terms f retentin in treatment than therapeutic cmmunities, utpatient drug-free treatment and naltrexne treatment. WHO cnducted a study in China, Indnesia, Iran, Lithuania, Pland, Thailand and Ukraine which fund that treatment utcmes in terms f retentin, drug use, HIV risk, health, criminal behaviur and emplyment were cmparable t thse fund in studies cnducted in Australia, the United Kingdm and the United States (Lawrinsn et al., 2008). Opiid agnist pharmactherapy has cnsistently been fund t reduce injecting drug use in terms f bth the prprtin f participants wh cntinue injecting and the frequency f injecting fr thse wh cntinue t inject. The interactin between these tw cmpnents is imprtant in terms f HIV risk-taking behaviur. Several studies have als shwn lwer rates f HIV sercnversin r f acquiring HIV when in treatment. HIV-infected drug users are mre likely t take up treatment fr their HIV and are als mre likely t adhere t that HIV treatment when n piid agnist pharmactherapy. Health care csts and HIV-related medical cmplicatins are als significantly lwer. Training needs fr piid agnist pharmactherapy Until recently piid agnist pharmactherapy was largely restricted t specialist, clinicbased prgrammes that were heavily regulated and marginalized frm mainstream health services. Changes in understanding the rle f piid agnist pharmactherapy prgrammes, alng with a shift twards a public health mdel f interventin, has seen the develpment in sme cuntries f cmmunity-based prgrammes that are incrprated in ther health and welfare services. Further expansin f piid agnist pharmactherapy prgrammes t meet unmet demand brings with it the need t train the wrkfrce in the use f this pharmactherapy. This requires the develpment f clinical guidelines and prcedures specifically tailred t cmmunity-based prgrammes. It als requires specialist services t prvide clinical cnsultancy and treatment back-up fr mre cmplex clients. Any training prgramme in piid agnist pharmactherapy will need t address attitudes and knwledge as well as skills. Training shuld cmbine didactic teaching, interactive learning, clinical case scenaris, assessment rle plays and the pprtunity fr feedback and discussin. The use f learning bjectives and cmpetency-based training mdels is als required (Allsp et al., 1997). The assessment prcedure can be used t determine whether the medical practitiner meets the learning bjectives and can be authrized t prescribe. The assessment prcedure will als assist practitiners in identifying their wn training needs as well as prviding the cmmunity and patients with cnfidence in the standards f treatment. Duratin and cmprehensiveness f treatment Duratin f treatment is imprtant. Lnger length f treatment has been demnstrated t be assciated with imprved utcmes (e.g. Magura et al., 1999; Ball & Rss, 1991; Kang & De Len, 1993). In additin, impsing arbitrary time limits n treatment des nt enhance treatment utcmes (Ward, Mattick & Hall, 1998). A meta-analysis f treatment utcmes has cnfirmed the relatinship between length f treatment and treatment utcmes (Brewer et al., 1998). 59

4 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 3.2 Plicy framewrk and guidelines fr the pharmaclgical treatment f substance use disrders (Figures ) Backgrund Plicy dcuments and guidelines n the pharmaclgical treatment f substance use disrders may assist in regulating the cntext in which pharmaclgical treatment is prvided, thus ensuring the ptimal availability and use f different medicines in the treatment f substance use disrders. A plicy framewrk is ften needed t guide the regulatin f medicines which have the ptential fr abuse, a number f which are useful fr the treatment f substance use disrders including piids and benzdiazepines. Nminated fcal pints were asked abut the presence f plicy dcuments n the pharmaclgical treatment f substance use disrders, and were requested t indicate whether guidelines n the pharmaclgical treatment f these disrders exist in their cuntries. Salient findings Plicy dcuments n pharmaclgical treatment Plicy dcuments n the pharmaclgical treatment f substance use disrders were reprted by 40.2% f cuntries. The regin reprting the highest prprtin f plicy dcuments n the pharmaclgical treatment f substance use disrders was Eurpe (70.4%). There is sme variatin accrding t cuntry incme grup. The lwest prprtin f cuntries reprting plicy dcument was in the lwer middle-incme cuntries (22.5%). In 73.5% f high-incme cuntries, plicy dcuments were reprted. Guidelines n pharmaclgical treatment Guidelines n the pharmaclgical treatment f substance use disrders were reprted by apprximately half f the surveyed cuntries (51.8%). The Eurpean and Western Pacific regins reprted having the highest prprtins f cuntries with pharmaclgical guidelines fr substance use disrders (76.8% and 71.4% respectively). The lwest prprtin f cuntries with pharmaclgical guidelines was reprted frm the African Regin (21.). There is an effect f cuntry incme level n the presence f guidelines regulating pharmaclgical treatment f substance use disrders between lw-incme/lwer middle-incme cuntries (31.7% and 37.5% respectively) and higher middle-incme/ high-incme cuntries (69.2% and 79.4% respectively). 60

5 Pharmaclgical treatment Ntes and cmments Plicy dcuments and guidelines n the pharmaclgical treatment f substance use disrders appear t be absent in a significant prprtin f surveyed cuntries, especially in lw-incme and middle-incme cuntries. This may reflect the difficulties that lwer-incme cuntries have in develping such plicies, r the perceived lack f need fr such plicies. This in turn may affect the capacity t regulate the use f medicines with abuse ptential, such as benzdiazepines and piids. Guidelines fr the pharmaclgical treatment f substance use disrders are cmmn in high-incme and upper middle-incme cuntries, but much less s in lw-incme and lwer middle-incme cuntries. Again, this may reflect the difficulties that lwincme and lwer middle-incme cuntries have in develping guidelines, r the lack f pririty given t such guidelines. This may affect the capacity t ensure that the mst cst-effective medicines are used. 61

6 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 70.4% 42.9% 40.2% 35.7% 30. n= % 18.6% Americas Africa Wrld Western Pacifi c Suth-East Asia Eurpe FIGURE 3.1 PROPORTION OF COUNTRIES WITH POLICY DOCUMENTS ON THE PHARMACOLOGICAL TREATMENT OF SUBSTANCE USE DISORDERS, BY REGION, % Eastern Mediterranean 40.7% n= % 22.5% High Higher-middle Lwer-middle Lw FIGURE 3.2 PROPORTION OF COUNTRIES WITH POLICY DOCUMENTS ON THE PHARMACOLOGICAL TREATMENT OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, % 71.4% % 21. Wrld Western Pacifi c Suth-East Asia Eurpe FIGURE 3.3 PROPORTION OF COUNTRIES WITH GUIDELINES ON THE PHARMACOLOGICAL TREATMENT OF SUBSTANCE USE DISORDERS, BY REGION, 2008 n= % Americas Africa 69.2% Eastern Mediterranean n= % 31.7% High Higher-middle Lwer-middle Lw FIGURE 3.4 PROPORTION OF COUNTRIES WITH GUIDELINES ON THE PHARMACOLOGICAL TREATMENT OF SUBSTANCE USE DISORDERS, BY INCOME GROUP,

7 Pharmaclgical treatment 3.3 Availability f therapeutic drugs fr alchl and drug use disrders (Figures ) Backgrund Nminated fcal pints were asked abut the use f different medicatins fr the treatment f alchl withdrawal in their cuntries. Fcal pints were requested t indicate the availability f piid agnist pharmactherapy fr the treatment f piid dependence such as the availability f methadne, buprenrphine and buprenrphine/nalxne. On the treatment f piid dependence, cuntries were asked which piid agnists wuld be used fr the treatment f piid withdrawal and which fr the maintenance f piid dependence. WHO recmmends the use f benzdiazepines fr the management f alchl withdrawal. The Organizatin recmmends methadne fr the treatment f piid dependence as it is mre cst-effective than buprenrphine, but als recmmends that bth methadne and buprenrphine shuld be available, if pssible, and that the syrup/slutin frmulatins f methadne shuld be used since it is easier t supervise their dispensing effectively. WHO des nt have recmmendatins n the use f buprenrphine/nalxne as it was nt cnsidered in the mst recent WHO guidelines n the treatment f piid dependence. Salient findings Pharmaclgical treatment f alchl withdrawal In 90.9% f cuntries, benzdiazepines were reprted t be used fr the management f alchl withdrawal. Chlrprmazine and new antipsychtics were identified fr the management f alchl withdrawal in 55.9% and 49.2% f cuntries respectively. The use f chlrprmazine in cuntries appears t decrease with increasing cuntry incme. The use f acamprsate fr the management f alchl withdrawal was reprted t be highest amng cuntries in the high-incme grup (41.9%), cmpared t cuntries in the lwer incme grups (lw-incme = 5.3%). Pharmaclgical treatment f piid dependence Fr the treatment f piid dependence, availability f methadne was reprted by 41.6% f cuntries that respnded t this questin in the survey, buprenrphine by 27.7%, and buprenrphine/nalxne by 20.8% f cuntries in the survey. The highest prprtin f cuntries reprting availability f methadne (88.6%), buprenrphine (59.1%) and buprenrphine/nalxne (50.) was in Eurpe. Africa was the regin reprting the lwest prprtin f cuntries having methadne and buprenrphine (9.3%). N cuntry in the Eastern Mediterranean Regin reprted having buprenrphine/nalxne frmulatin. 63

8 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders There is an effect f incme level n the availability f piid agnists fr the treatment f piid dependence acrss different incme grups f cuntries. This incme effect is strngest fr methadne. The prprtin f cuntries using methadne increases acrss different incme grups f cuntries (i.e. 12.2% f lw-incme cuntries reprted methadne, cmpared t 88.6% f high-incme cuntries). Pharmaclgical treatment f piid withdrawal and maintenance f piid dependence Apprximately a third f cuntries reprted using methadne fr detxificatin and maintenance f piid dependence. Fr maintenance f piid dependence, methadne slutin/syrup seems t be used mre ften than methadne tablets. Fr piid withdrawal and maintenance, buprenrphine was reprted t be used by apprximately 25% f cuntries. Ntes and cmments The situatin with availability f medicatins may change ver a relatively shrt time. This, as well as the number f cuntries frm which the relevant infrmatin was cllected in the survey, shuld be taken int cnsideratin when interpreting the data presented. The reprted use f medicatins ther than benzdiazepines fr alchl withdrawal suggests that there is cnsiderable variatin in practice in the management f alchl withdrawal. The high rate f use f chlrprmazine is a cncern since chlrprmazine is specifically nt recmmended by WHO as it may increase the risk f seizures during alchl withdrawal. The fact that alchl and drug medicatin is available in cuntries des nt imply there is infrmatin n the cverage f the ppulatin in need f pharmaclgical treatment. As described in chapter 2, cverage f piid-dependent persns with agnist maintenance appears t be lw. Availability f piid agnist pharmactherapy fr the treatment f piid dependence appears t be lw, especially in lw-incme and lwer middle-incme cuntries. The use f buprenrphine and buprenrphine/nalxne is effectively limited t high-incme cuntries and apprximately 1 f lwer-incme cuntries. This is cnsistent with its higher cst. Methadne is mre available in lwer middle-incme and upper middle-incme cuntries, presumably due t a greater sensitivity t cst in these cuntries. The reprted use by tw cuntries f buprenrphine patches fr piid agnist maintenance is ntewrthy. While 42% f cuntries reprt the availability f methadne, nly 31% reprt the availability f the methadne syrup frmulatin. The remaining 15 cuntries are presumably using methadne tablets fr piid agnist maintenance treatment. It is difficult t supervise the dispensing f methadne in tablet frm. Take-hme dses are als easily sld r injected, which can result in prblems, including diversin t the street market. 64

9 Pharmaclgical treatment FIGURE 3.5 MEDICATIONS USED IN COUNTRIES FOR THE MANAGEMENT OF ALCOHOL WITHDRAWAL, BY INCOME GROUP, % 55.9% 49.2% Benzdiazepine Acamprsate Gabapentin Tiagabine Flumazenil infusin Nitrus xide Alchl infusin/reductin Chlrprmazine New antipsychtics Percentage f cuntries n= % % % WORLD 8.2% 82.1% 79.5% 92.1% 51.4% 55.6% 48.6% Percentage f cuntries 5.3% 8.1% 2.7% 2.6% 5.4% Percentage f cuntries 11.8% 20.6% % 14.3% LOW LOWER MIDDLE 93.5% % 45.2% 41.9% 28.6% Percentage f cuntries 13.6% 13.6% 4.5% 4.5% Percentage f cuntries 14.3% 10.7% 7.1% 3.6% 7.1% HIGHER MIDDLE HIGH 65

10 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Methadne Buprenrphine Buprenrphine/nalxne 88.6% 59.1% % Percentage f cuntries 9.3% 9.3% % 10.5% 5.3% 21.4% 14.3% % % 21.4% % 20.8% Wrld FIGURE 3.6 AVAILABILITY IN COUNTRIES OF OPIOID AGONIST PHARMACOTHERAPY FOR THE TREATMENT OF OPIOID DEPENDENCE, BY REGION, 2008 Western Pacifi c n=144 Eurpe Suth-East Asia Eastern Mediterranean 88.6% Africa Americas 74.3% 62.9% 50. Percentage f cuntries % 12.2% 12.5% 7.3% % 10.7% FIGURE 3.7 AVAILABILITY IN COUNTRIES OF OPIOID AGONIST PHARMACOTHERAPY FOR THE TREATMENT OF OPIOID DEPENDENCE, BY INCOME GROUP, 2008 n=144 High Higher-middle Lw Lwer-middle Percentage f cuntries n= % 23.1% 14.3% 1.4% Methadne Buprenrphine Buprenrphine/nalxne Buprenrphine patches FIGURE 3.8 OPIOID AGONISTS USED IN COUNTRIES FOR THE TREATMENT OF OPIOID WITHDRAWAL, 2008 Percentage f cuntries n= % 24.5% 15.6% % Methadne slutin/syrup Methadne tablets Buprenrphine Buprenrphine/nalxne Buprenrphine patches FIGURE 3.9 OPIOID AGONISTS USED IN COUNTRIES FOR THE MAINTENANCE TREATMENT OF OPIOID DEPENDENCE, 2008 WORLD WORLD 66

11 Pharmaclgical treatment 3.4 Administratin f piid agnist pharmactherapy (Figures ) Backgrund Nminated fcal pints were requested t indicate the duratin f piid agnist treatment, and were asked whether such treatment wuld be prvided in a timelimited r an pen-ended manner. WHO recmmends pen-ended treatment. Questins were asked n the frmulatin f methadne which is used fr the treatment f piid dependence. Fcal pints were requested t indicate whether methadne wuld generally be prvided in tablet frm r in syrup/slutin. WHO recmmends the use f the syrup/slutin frmulatins as they are easier t supervise when being dispensed and, when diluted, they are nt easily diverted t the black market fr injectin. Fcal pints were asked abut the use f inpatient facilities fr the cmmencement f methadne, buprenrphine and buprenrphine/nalxne, and were asked specifically whether treatment wuld nrmally be started as an utpatient r as an inpatient in their cuntries. WHO recmmends that utpatient cmmencement shuld mainly be used. The fllwing figures (Figs ) apply t cuntries in which piid agnist treatment is available. Salient findings Duratin f piid agnist treatment Treatment with piid agnist pharmactherapy was reprted t be pen-ended in the majrity f cuntries, with 74.1% f cuntries reprting n time-limit fr piid agnist pharmactherapy. Acrss different incme grups, the lwer middle-incme grup f cuntries seems t have the highest prprtin f cuntries with a timelimited piid agnist treatment apprach (45.5%). Frmulatin f methadne Over 55% f cuntries in the survey (cuntries having piid agnist pharmactherapy available) reprted using methadne syrup/slutin fr the treatment f piid dependence. Apprximately 25% f cuntries reprted using methadne tablets nly, while anther 2 f cuntries reprted using bth ral slutin and tablets. Inpatient facilities fr the cmmencement f piid agnists Opiid agnist pharmactherapy such as treatment with methadne, buprenrphine, and buprenrphine/nalxne is cmmenced n an utpatient basis in apprximately 6 f cuntries in the survey. Apprximately 2 f cuntries reprted cmmencing treatment with methadne, buprenrphine and buprenrphine/nalxne as an inpatient. An additinal 2 f cuntries reprted cmmencement f piid agnist pharmactherapy n bth an inpatient and utpatient basis. 67

12 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Cmpared t high-incme cuntries in which utpatient treatment with piid agnists seems t be cmmn, there is a tendency fr fewer cuntries in the lw-incme and lwer middle-incme grups t cmmence treatment with methadne and with buprenrphine/nalxne n an utpatient basis. Ntes and cmments Availability f piid agnist pharmactherapy such as treatment with methadne, buprenrphine r buprenrphine/nalxne appears t be limited, especially in lwerincme grups f cuntries. Thus the verall number f cuntries in the respective grups are lw. Outpatient treatment fr piid agnist pharmactherapy appears t be a cmmn treatment apprach in high-incme cuntries. Outpatient treatment fr the pharmaclgical treatment f piid dependence might be less expensive fr cuntries, and may imprve the capacity f inpatient services t deal with mre cmplicated patients. As mentined in sectin 3.3, the use f methadne tablets fr piid agnist maintenance treatment can result in difficulties in the capacity t effectively supervise the dispensing f methadne. The data in this sectin indicate that sme cuntries have bth tablet and slutin frmulatins f methadne available and use bth frmulatins in the treatment f piid dependence. 68

13 Pharmaclgical treatment 82.1% % 71.4% 54.5% Percentage f cuntries 28.6% 45.5% Lw [n=7] 25. Lwer-middle [n=11] 17.9% High [n=28] Higher-middle [n=12] 25.9% Wrld [n=58] Time-limited Open-ended FIGURE 3.10 DURATION OF OPIOID AGONIST TREATMENT IN COUNTRIES, BY INCOME GROUP, 2008 Percentage f cuntries Wrld [n=57] High [n=30] Higher-middle [n=13] Lwer-middle [n=10] Lw [n=4] Tablets nly Bth ral slutin and tablets Syrup/slutin nly FIGURE 3.11 FORMULATION OF METHADONE USED IN COUNTRIES FOR THE TREATMENT OF OPIOID DEPENDENCE, BY INCOME GROUP, 2008 Outpatient Bth inpatient and utpatient Inpatient 8 Percentage f cuntries Wrld [n=59] High [n=30] Higher-middle [n=14] Lwer-middle [n=10] Lw [n=5] FIGURE 3.12 USE IN COUNTRIES OF INPATIENT FACILITIES FOR THE COMMENCEMENT OF METHADONE TREATMENT, BY INCOME GROUP, Percentage f cuntries FIGURE 3.13 USE IN COUNTRIES OF INPATIENT FACILITIES FOR THE COMMENCEMENT OF BUPRENORPHINE TREATMENT, BY INCOME GROUP, 2008 Percentage f cuntries FIGURE 3.14 USE IN COUNTRIES OF INPATIENT FACILITIES FOR THE COMMENCEMENT OF BUPRENORPHINE/ NALOXONE TREATMENT, BY INCOME GROUP, 2008 Wrld [n=36] High [n=23] Higher-middle [n=4] Lwer-middle [n=5] Lw [n=4] Wrld [n=29] High [n=22] Higher-middle [n=3] Lwer-middle [n=2] Lw [n=2] 69

14 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 3.5 Supervisin and prescriptin requirements fr piid agnist pharmactherapy (Figures ) Backgrund Nminated fcal pints were asked whether supervisin f piid agnist pharmactherapy such as pharmaclgical treatment with methadne, buprenrphine, and buprenrphine/nalxne was required in their cuntries. WHO guidelines recmmend that the administratin f bth methadne and buprenrphine shuld be directly supervised, at least early in treatment, t reduce misuse and diversin t the illicit market. Fcal pints were requested t indicate whether the level f supervisin f methadne, buprenrphine and buprenrphine/nalxne wuld be individually determined by the treating dctr, r whether it was determined by a universally applied standard. WHO guidelines recmmend that the level f supervisin be individually determined. Fcal pints were asked abut the minimum training requirements fr health care staff respnsible fr the prescriptin f piid agnists, and what kind f health care staff in their cuntries wuld have the authrity t prescribe methadne, buprenrphine r buprenrphine/nalxne. Salient Findings Supervisin f piid agnist pharmactherapy Supervisin f methadne fr the treatment f piid dependence was required by 85.4% f cuntries in the survey. In 60.6% f cuntries buprenrphine supervisin was required, and in 71.4% f cuntries buprenrphine/nalxne supervisin was required. There seems t be n effect f cuntry incme level n the supervisin requirements f piid agnist pharmactherapy. Apprximately three quarters f cuntries in the survey (74.1% fr methadne, 74.3% fr buprenrphine, 69. fr buprenrphine/nalxne) reprted that the level f supervisin with the respective piid agnists wuld be individually determined by the treating dctr. Cmpared t high-incme cuntries, a higher prprtin f cuntries in the lwincme and lwer middle-incme grups reprted that the level f methadne and buprenrphine supervisin wuld be individually determined by the treating dctr. 70

15 Pharmaclgical treatment Training requirements fr health care staff fr the prescriptin f piid agnists Almst every cuntry in the survey reprted that dctrs require sme additinal training t prescribe methadne (98.2%), buprenrphine (97.4%) and buprenrphine/ nalxne (96.4%). In apprximately ne third f cuntries surveyed, methadne, buprenrphine and buprenrphine/nalxne may be prescribed by any dctr, withut additinal training. In apprximately 1 f cuntries surveyed, it was reprted that nn-dctrs are given the authrity t prescribe piid agnists. The prprtin f cuntries in which nn-dctrs may prescribe methadne, buprenrphine and buprenrphine/nalxne seems t be highest in the lw-incme grup. Ntes and cmments Mst cuntries have been shwn t use a supervised system f delivering methadne and buprenrphine, despite the increased cst that this entails. It is wrth nting that the prprtin f cuntries requiring supervisin f buprenrphine/nalxne is nt markedly different frm the prprtin f thse requiring supervisin f methadne r buprenprhine. In apprximately 3 f cuntries in the survey, the level f methadne, buprenrphine r buprenrphine/nalxne supervisin is nt individually determined by the treating dctr. The questin n additinal training requirements demnstrates that in mst cuntries the rutine training f medical staff is nt cnsidered sufficient fr the treatment f piid dependence with methadne r buprenrphine. The fact that mre than 2 f cuntries which use methadne allw prescriptin by any dctr withut special training implies that it is pssible t integrate methadne and buprenrphine int primary care services. Sme fcal pints in the survey reprted that nn-dctrs may prescribe piid agnist pharmactherapy. This has happened in bth high-incme and lw-incme cuntries. 71

16 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Required Nt required 85.4% 77.8% 75. Percentage f cuntries % 14.6% FIGURE 3.15 SUPERVISION OF METHADONE TREATMENT IN COUNTRIES, BY INCOME GROUP, 2008 Wrld [n=48] High [n=27] 75. Higher-middle [n=11] Lwer-middle [n=6] Lw [n=4] 66.7% 59.1% 60.6% % 39.4% 33.3% Percentage f cuntries 25. FIGURE 3.16 SUPERVISION OF BUPRENORPHINE TREATMENT IN COUNTRIES, BY INCOME GROUP, 2008 High [n=22] Wrld [n=33] Lw [n=4] Higher-middle [n=3] Lwer-middle [n=4] 66.7% 71.4% % 28.6% Percentage f cuntries FIGURE 3.17 SUPERVISION OF BUPRENORPHINE/NALOXONE TREATMENT IN COUNTRIES BY INCOME GROUP, 2008 High [n=21] Wrld [n=28] Lw [n=2] Higher-middle [n=3] Lwer-middle [n=2] 72

17 Pharmaclgical treatment % 74.1% 58.3% FIGURE 3.18 PROPORTION OF COUNTRIES IN WHICH THE LEVEL OF METHADONE SUPERVISION IS INDIVIDUALLY DETERMINED BY THE TREATING DOCTOR, BY INCOME GROUP, 2008 Wrld [n=54] High [n=28] Higher-middle [n=12] Lwer-middle [n=10] Lw [n=4] % 69.6% 66.7% Wrld [n=35] High [n=23] Higher-middle [n=3] Lwer-middle [n=4] Lw [n=5] FIGURE 3.19 PROPORTION OF COUNTRIES IN WHICH THE LEVEL OF BUPRENORPHINE SUPERVISION IS INDIVIDUALLY DETERMINED BY THE TREATING DOCTOR, BY INCOME GROUP, % 66.7% 72.7% 69. Wrld [n=29] High [n=22] Higher-middle [n=3] Lwer-middle [n=1] Lw [n=3] FIGURE 3.20 PROPORTION OF COUNTRIES IN WHICH THE LEVEL OF BUPRENORPHINE/NALOXONE SUPERVISION IS INDIVIDUALLY DETERMINED BY THE TREATING DOCTOR, BY INCOME GROUP,

18 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Any dctr Dctr with special training Nn-dctr 96.7% 98.2% 36.7% 28.6% Percentage f cuntries 22.2% % % FIGURE 3.21 AUTHORITY OF HEALTH PROFESSIONALS IN COUNTRIES TO PRESCRIBE METHADONE, BY INCOME GROUP, 2008 Higher-middle [n=12] Lwer-middle [n=9] Lw [n=5] High [n=30] Wrld [n=56] 95.7% 97.4% % 31.6% 95.2% 96.4% Percentage f cuntries Lwer-middle [n=5] Higher-middle [n=5] 9.1% High [n=23] 8.1% Wrld [n=38] FIGURE 3.22 AUTHORITY OF HEALTH PROFESSIONALS IN COUNTRIES TO PRESCRIBE BUPRENORPHINE, BY INCOME GROUP, 2008 Lw [n=5] 50. Percentage f cuntries 33.3% 28.6% 25.9% 9.5% 11.1% FIGURE 3.23 AUTHORITY OF HEALTH PROFESSIONALS IN COUNTRIES TO PRESCRIBE BUPRENORPHINE/ NALOXONE, BY INCOME GROUP, 2008 High [n=21] Wrld [n=28] Higher-middle [n=3] Lwer-middle [n=2] Lw [n=2] 74