Guidance on Medical Treatment of Drug Abusers in Substitution Treatment for Opioid Dependency Pompidou Treatment Platform, Cyprus, May 2009 Helle Petersen Senior Medical Officer National Board of Health Denmark
Agenda A national strategy for improving quality and safety in the medical treatment of drug addiction in Denmark 1. Overview: Epidemiology, history & legal framework 2. 2008: Guidance 3. 2009: Quality Improvement Proces
Epidemiology - Denmark 5 mio inhabitants 27.000 drug abusers 20.000 opioids (+BZ, cocaine, alcohol etc) 7.000 cannabis 13.500 in addiction treatment programs 6.300 opioid substitution treatment 90 % methadone 10 % buprenorphine
Denmark infrastructure 5 Regions: Hospitals Psychiatry General Practitioners 98 municipalities: Medical and social treatment for drug addiction Social care
Organization of medical treatment of opioid addiction in Denmark The municipality is responsible for providing social & medical treatment for drug addiction Only doctors in the municipality and in the criminal system can prescribe long- term opioid substitution treatment No specialist qualifications in addiction medicine
Short History of Substitution Therapy in DK 1970 Methadone only used in short detox-programs 1980 Methadone maintenance therapy runned by General Practitioners 1996 13 counties take over, first full-time employed doctors in addiction treatment programs 2007 Structure reform, 98 municipalities take over 2007 Buprenorphine first-line drug 2008 Guidance on Medical Treatment of Drug Abusers in Substitution Therapy for Opioid Dependence 2009 Implementation of a national quality assurance system
Structural Characteristics Treatment for drug addiction placed in the social system Distinction between the social and the medical treatment of drug abuse Regulation by different laws (Health Act & Social Act) and different Ministries The medical treatment plan is part of the social action plan No specialization in addiction medicine Limited research tradition in addiction medicine in DK No coordination between alcohol- and drug abuse treatment Lack of medical ressources and recruitment Limited tradition for documentation in the social treatment
Needs for Quality Improvement (QI) in Opioid Maintenance Treatment Quality assurance systems appears in health care sector (Hospitals, General Practise) in the late 1990ties Danish Society of Addiction Medicine: Several conferences and study trip to the Netherlands (reform, Resultaten Score-program) 2004 Governmental decision & funding of QI of Methadone Treatment 2008 Guidance on Medical Treatment of Drug Abusers in Substitution Treatment for Opioid Dependence 2009 Quality Assurance of Medical Treatment of Drug Abusers in Substitution Treatment for Opioid Dependence
Guidance on Medical Treatment of Drug Abusers in Substitution Treatment for Opioid Dependence, July 2008 Overall purpose: Reduction of drug-related morbidity and mortality Law based Specifies the care and conscientiousness that must be exercised by doctors providing drug users with medical treatment The process: Project manager: full time for 2½ year Expert panels (addiction field, family medicine, psychiatry, infection medicine, gynaecology, lab-medicine etc.) Reference group: Ministries of Health and Social Affairs, Local Government Denmark, Prison and Probation Service, Centre for Alcohol and Drug Resarch, Danish Society of Addiction Medicine Duration 2005-2007 Costs: 3 mio DDK (0.4 mio )
Target group for the guidance Medical doctors providing treatment for opioid dependent individuals municipal treatment systems for drug abuse general practitioners the Prison and Probation Service All other doctors providing treatment for drug addicts hospitals (ex. emergency wards, psychiatric hospitals, departments for infectious medicine, gyn&obstetrics) Administrators in municipalities & local treatment systems
Standards for quality in medical services in drug addiction treatment Organization, law, responsibilities Diagnosis of drug abuse Somatic comorbidity (e.g. bacterial infections, TB, COLD ) Viral infections (hiv, hepatitis A,B,C) Psychiatric comorbidity Opioid pharmacotherapy Multiple substance abuse Urine analysis Prevention of pregnancy Pregnancy in opioid addiction
Method Practitioners handbook 1. Projectleader Professionel knowledge & experience Formulation of clinical relevant problems/topics Comprehensive study search Draft for each standard/chapter 2. Approval of each standard/chapter by relevant expert group 3. Final approval by reference group (decicion/policy makers) 4. Public hearing (users org., professionals, adminstr.)
What are new standards? Diagnosis and medical treatment of drug abuse Buprenorphine, first-line Methadone, second-line (2009: inj. heroin) Diagnosis of drugrelated somatic and mental problems and referral to relevant treatment Follow-up, case management, in cooperation with GPs and hospitals Regular medical examinination e.g. by admission and once a year Rutine serological screening for hiv and hepatitis Systematic vaccination (Hepatitis A+B) All women offers referral to rutine gynecological tjeck up by admission (smear, cervical dysplasi) and ad hoc Advise about STD & contraceptives
Quality assurance system from 2009 Primary goals: To estimate compliance to the law based guidance Assurance of consistent and acceptable quality of the most significant medical core services Systematic measurement of structure, proces and performance of medical treatment facilities in municipalities Identifying lack in quality Basis for continuing quality development of the medical services in the treatment of drug addiction Contribute to the organisational planning of treatment in the municipality Monitorering medical services in the municipal drug addiction treatment system
Methodes for the quality assurance system Definition of 20 clinical useful indicators for core medical services in relation to standards defined in the guidance Expert panel IT-monitoring system with central database Municipalities collect data for medical treatment at all addiction treatment programs Municipalities will get access to data Feedback from National Board of Health Report anually Summary data permitting comparisons over time across the country between municipalities within a municipality
Indicators All doctors must once a year collect data for all new patients on services delivered in relation to medical examination screening for mental disorders medical treatment plan serological screening (hepatitis, hiv) vaccination (hep A+B) prescription of buprenorphin for new in treatment ECG at methadon dose > 120 mg prescription of benzodiazepine > 4 weeks treatment for alcohol addiction anticonception counseling Standard questionnaire in all medical files
Municipalities & economy Municipalities collect data from the questionnaires in the medical files at all treatment programs and report data (as pro rata share of all new patients) to a central database in the National Board of Health Price of the system: 10 mio Dkr (1,35 mio Euro) a year to the municipalities ¼ mio Dkr (34.000 Euro) a year to the National Board of Health to management, evaluation, feedback
Contacts hpe@sst.dk www.sst.dk Link: Guidance on Medical Treatment of Drug Abusers in Substitution Treatment for Opioid Dependency http://www.sst.dk/publ/publ2008/eft/substitbehl_en/ Guide_Substtreatm_Drugabuse.pdf