1994 VOL 5 NO 4
Copyright© IJDP Ltd.
METHADONE IN EUROPE
Ernst Buning looks at the diversity of methadone provision across the European region.
Within the European Region, the provision of methadone ranges from country to country. Some countries such as the United Kingdom, Switzerland and the Netherlands have a long history of prescribing methadone. Others such as Spain, Germany and Belgium are in the middle of a process of developing and extending the provision of methadone. In some countries, such as France and Norway, the provision of methadone is still limited to a (very) small number of clients or forbidden (Greece).
DIFFERENCES IN APPROACH
Methadone provision is not the same In quality, style or quantity of methadone prescribed. A brief look at a number of programmes will illustrate this.
Wirral, Merseyside, UK
In April 1991 the Wirral Drug Service was established to provide a prescribing service primarily to prevent the spread of HIV. The service is primary health care based and led by a general practitioner rather than a consultant psychiatrist. The service is currently prescribing to 800 people. In addition, during 1992 a GP Liaison Scheme was established to encourage more GPs to take responsibility for prescribing methadone. Four hundred people are currrently receiving prescriptions under this scheme.
Seventy-seven per cent of clients receive oral methadone mixture. About 15% receive injectable methadone and a small number receive methadone reefers or tablets. These clients were inherited from another service in the Region and there are no plans to extend the prescription of smokables. The averge daily dose is 75 milligrams. Dose levels are determined in a number of ways including the dose the client is currently using, assessment by the worker and the doctor, urinalysis and tolerance testing. Eligibility for injectable methadone is an option within a range of treatment goals following comprehensive assessment. The decision about the length of treatment is usually determined by the client, keyworker and doctor within the context of an overall treatment plan.
The methadone programme in this Danish reglon is small: they have 100 patients. A clinic serves 30 clients and general practitioners have another 70 patients on methadone. The general practitioners refer their clients to the clinic where the staffdoes the counselling, social welfare and psychiatry for all the 100 patients. Regulations of the National Health Board stipulate that the provision of methadone is only allowed if there is some form of social assistance. In principle, there is no methadone handed out unless a professional sees to it that the person takes the methadone. They have to drink it on the spot. Onl clients who are working can have a special take hom arrangement; all the other clients have to come 36 days a year. The dosages used are between 40 and 10 mg/day, with an average of 55 mg. Denmark has th highest prescribing rate per head of population in th European Region.
In Barcelona, there are 10 outpatient programmes specialising in drug addiction treatment. About 1200 patients are in methadone maintenance programmes Methadone is dispensed in the centres, not through general practitioners. The general idea is that methadone should be available for all the patients who want it. The high rate of HIV infection (65-70 % of the clients are seropositive) is the main reason fo this objective. To attract most heroin addicts, the) work with low-threshold methadone maintenance programmes. Once in contact, it is possible to refel them to more structured and restrictive methadonf programmes. The dosages used are high, with an aver age of about 80 mg/day. In the programmes, the staffis confronted with a lot of organic pathology. General practitioners in these centres address those problems.
Amsterdam, The Netherlands
About 1200 drug users receive methadone from the Amsterdam Drug Department of the GG&GD (Health Department) and another 1000 drug users receive methadone prescriptions from their own general practitioners. The drug department has been operating for 15 years and works without a waiting list. This means that someone who comes for help receives it the same day or, in cases of doubt regarding his or her addiction, within 24 hours.Todate, AIDS is an important focus, because many patients are infected with HIV (about 30% of the injectors).
The staff of the drug department operate as a sort of 'medical advocate' between the patients and the hospitals. They motivate clients to use clinic medical care. The drug department has an arrangement with the methadone-prescribing general practitioners that they can always refer their patients to the drug depart ment whenever they become problematic. At the moment, about 30 people receive injectable opiates. This is a group of drug users who have been addicted for 10, 15 or 20 years. There are plans for the provision of non-injectable palfium for drug users with a long history of smoking heroin (chasing the dragon)
In France, only 75 people receive methadone. The system of care is supported by the State, which means that the methadone programme depends on the Min-istry of Health, i.e. the Ministry has to give its authorisation to open programmes. At the moment there is help to those who cannot detoxify and support drug addicts with AIDS problems. Recently, the Minister of Health announced that by the end of 1994, 1000 methadone slots will be available in France.
Methadone prescription started about five years ago. Because of the large number of drug users it was felt that sharing the care with general practitioners was the best option for the team of the Community Drug Problem Service in Edinburgh. Training for GPs was organised which paid special attention to the negative attitudes of general practitioners regarding methadone. They offered to advise them and to coun-sel drug users. So, the team and the general practition-ers shared the care. The case-load of a GP could vary between l O and 100. However, it is very exceptional to have 100 drug users on the list and where it happens they are big health centres.
The services are sectorised, so that each key work-er works with a limited number of GPs. They work very closely with GPs and discuss cases with them. About 1200 drug users are being treated in this way. Many ofthem have been on methadone maintenance for over three years.
The picture in some countries is, however, not quite so promising. In some European Region cities there are great problems. In Belgium doctors were sent to jail for prescribing methadone. The basis for sentencing these doctors was the Belgian narcotic law which had a special paragraph about 'abusive prescription'. The Belgium Medical Association considered methadone prescription as abusive, therefore agreeing with the law and leaving the doctors exposed.
In Greece, an architect has been sentenced to 8 years' imprisonment for the possession of 800 tablets of methadone. The architect claims that he had the methadone for his own personal use to treat his addiction to heroin. Methadone cannot be prescribed in Greece.
In Germany, where methadone programmes have recently been set up, methadone treatment in the form of harm reduction is still discouraged. The so-called 'Verschreibungs Verordnung' says that every methadone patient should show up every day and receive hisorher methadoneunder controlofthe doc-tor. This makes the treatment very expensive. Since February 1993, the law has been changed so that peo-ple who have been in treatment for over a year can get a weekend dose with permission from the Ministry. The German 'Bundesarztekammer', the central body of the medical profession, is a very conservative body and there is an absence of a public health tradition.
In Spain, there are considerable differences between the Regions. Before 1990, only two Regions had consolidated methadone programme. Reasons for not developing methadone programmes vatied. A major point was the emphasis that was put,.in the 1980s, on establishing a network of drug-free treatrrent. Furthermore, there was no clear harm-reduction policy until 1990. Public order and control issues predominated over clinical arguments. The ideological resistance towards substitution programmes was enormous. This was seen in various groups, NGOs, professional groups and politicians too. To date, an opposition from neighbourhoods and politicians is still seen. The centres of methadone usually concentrate man clients and dealers around them, which provokes the NIMBY reaction, 'not in my back yard'.
In Italy, the 1991 law on possession made methadone programmes more difficult to operate when a decree stipulated that minimum and sufficient doses be used Take-home doses for clients in methadone pro grammeswere already prohibited.Theclimate in Ital has changed, especially during 1994, since the recen changes in the law on possession. New guidelines of: more scientific nature have recently been publishev (Ministero della Sanita, 1994).
Methadone can now be given orally at the clinic (Servizio Tossicodipendenza [SERT] ) but can also be prescribed by general practitioners in conjunction with SERT. The guidelines on dosage and duration have also been modified and they recommend higher doses on a maintenance basis if appropriate.
In Scotland, general practitioners were educated through a series of letters, meetings and bi-monthly newsletters. By invitingGPs tomeetings, theyeducat-ed each other. As so many GPs in Lothian prescribe now, they no longer fear that, if they start prescribing, all the drug users will come to them. So, the load has been spread between the drug service and the GPs.
In Belgium, a group of doctors fought for changing the narcotic law and the regulations of the Belgium Med-ical Association. They were successful in doing so. To date, doctors can prescribe methadone without hindrance.
In Spain, the narcotic law, which was very restrictive and bureaucratic, was changed, making it easier to prescribe methadone to drug addicts. As many Spanish professionals had some reluctance towards methadone, material was provided to them to increase their knowledge about methadone programmes, but also to try to change their attitudes. Handbooks with protocols and information aimed at nurses, general practitioners, forensic medicine and chemists were edited. At a Spanish methadone conference, policy makers and care providers met people who were experienced at setting up methadone programmes. They could show the other people how to manage a programme and how to overcome the problems.
METHADONE AND AIDS
In his book AIDS and Drug Addiction in the European Community, Treatment and Mistreatment, Marc Reisinger included presentations from each EC coun-try. He looked at the relationship between the avail-ability of methadone and the number of drug users who are registered as AIDS patients. Reisinger ( 1993 ) concludes that:
Most of the countries who have limited methadone treatment, have a serious problem in terms of AIDS among intravenous drug users, while those who had well developed programs for such treatment have succeeded in keeping the spread of AIDS among drug users under control. Despite this, the supply of methadone is inferior to the demand almost everywhere in Europe. This might be seen one day as an unpardonable error of judgement which will cost the lives of hundreds of thousands of persons and wreak havoc on the health care budgets of several European countries.
Research from Germany, presented data at the 1992 Berlin Aids Conference (Bornemann et al., 1993); 109 seronegative methadone users were fol-lowed during a period of almost two years. Only one person was infected in this period. As the seropreva-lence in that region is 10-20%, the chance of HIV infection is reasonably high when sharing needles. Bornemann concludes from his dataa that there is a clear link between methadone and HIV prevention.
Data were also presented from a 1993 research pro-ject in Switzerland which compared two groups ( Broers et al.,1994) . One group received methadone, the other did not. The groups were compared regard-ing theircompliance to the medical treatmentofHIV-related complaints. The methadone group did much better; their treatment compliance was much higher. Broers emphasised the important role of methadone in facilitating the medical treatment of HlV-infected drug users.
METHADONE AND CRIMINALITY
Evidence from both a strict methadone programme in Uppsala, and a more relaxed 'low-threshold' methadone programme in Barcelona show the effect of methadone in reducing criminality. Correct dosages (somewhere between 50 and 100 mg/ day) may be the key in reducing criminality.
A study conducted in Germany was based on year Iy records of substituted addicts and their treating physicians (Lang and Zenker,1994). The first survey was conducted by the end of 1991 and the second was finished in the spring of 1993. So, the medical and social status before the beginning of methadone treat-ment at the end of 1991 and at the end of 1992 could be outlined. About 70% (n = 198) of all methadone patients in Bremen participated in the first survey. The year's longitudinal sample contains 131 addicts
Marked changes were expected regarding the socio-economic situation, patterns of drug use and a dimin-ishment of the urge to finance drugs. This hypothesis has been confirmed impressively.
Before the beginning of methadone treatment, one-third of the women were dealing drugs, 20% were involved in prostitution and 8% committed larceny.
Among men, delinquent behaviour was the main source of income for 50% (40% dealing and 10% larceny) . The first survey revealed that criminal activ-ities were no longer the main source of income for both sexes: only 2% of all females and 5 % of all males were still primarily living off illegal earnings. The data of the second survey further confirm this outcome.
Based on this research, the researchers believe that methadone treatment can be one way to break the vicious circle of drug use and criminality.
Christian Hertzog from Basel, Switzerland, describes the use of methadone in prisons to prevent the further spread of AIDS (Hertzog et al., 1993).
Most of the drug addicts in Swiss prisons have a long history of drug use. The seroprevalence ranges from 35% to 40%. As drugs are used in prisons and needles are shared, prisons can be a place for further spreading HIV in the drug-using community. The city of Basel runs two prisons with approximately 200 places. The prisoners detained are either in custody for a few days or weeks or in prisons for a 'short' sentence of less than a year. In January 1991, methadone substitution was introduced for drug-addicted prisoners who were already on methadone when entering the prison. When the methadone programme started, urine checks showed that all sorts of legal and illegal drugs were used before and during detention. During their stay in prison, those prisoners on methadone drastically reduced their use of illegal drugs.
It can be concluded that because of the variety in the provision of methadone in Europe, standardisation is lacking and heroin addicts are still denied proper treatment in many regions/countries. On the other hand, the many modalities of methadone provision in Europe allow for tentative conclusions regarding
'what sort of methadone regime works for which clients in which specific setting'.
In particular, the role of general practitioners in a number of European countries seems worthwhile mentioning. The client can receive his or her prescription in a non-stigmatising environment, pick up the methadone at the local pharmacy and have maximum control over time, place and exact dose of intake. This clearly reinforces the autonomy of clients and their perspectives for resocialisation. However, it should be mentioned that some drug users lead a life of such chaos that a more structured setting is necessary.
Therefore a combination of low thresholds programmes, structured 'American' programmes and methadone-prescribing general practitioners seems to give a guarantee for offering a tailor Made treatment to drug users.
The author would like to thank the following people for their help in supplying information for this article:
Nils Andersen, Hilleroed, Denmark; Andrew Bennett, Merseyside, UK; Reinhard Bornemann, Bielefeld, Germany; Maria Bravo, Madrid, Spain; Giel van Brussel, Amsterdam, The Netherlands; Barbara Broers, Geneva, Switzerland; Anne Coppel, Paris, France; Judy Greenwood, Edinburgh, UK; Kleanthis Grivas, Athens, Greece; Leif Gronbladh, Uppsala, Sweden; Christian Herzog, Basel, Switzerland; Peter Lang, Bremen, Germany; Annie Mino, Geneva, Switzerland; Marc Reisinger, Brussels, Belgium; Gerrit van Santen, Amsterdam, The Netherlands; AlessandroTagliamonte, Siena, Italy; Marta Torrens, Barcelona, Spain; Didier Touzeau, Paris, France. Ernst Buning, Co-ordinator, Euro-Methwork, room 510, GG&GD Amsterdam, Nieuwe Achtergracht 100, 1018 WT Amsterdam . The Netherlands.
Bornemann, R.T., Kuehlkamp, 1., Bschor, V., May, F. and f Burkhard ( 1993 ) . Prevention of HIV infection in IVDU ~through methadone substitution treatment: results of a prospective study. Presentation at IXth International Conference on AIDS, Berlin, June 1993.
Broers, B., Morabia, A. and Hirschel, B. ( 1994) . A cohort study of drug users compliance with zidovudine. Archives of Internal Medicine, in press.
Hertzog, C., Fasnacht, M., Stohler, R., Ladewig, D. and Jacob, O. ( 1993 ) . Methadone substitution as an AlDS-preventive measure in the prison environment. Presentation at the European Symposium on Drug Addiction and AIDS, Sienna, October 1993.
Lang, P. and Zenker, C. ( 1994) . Methadone treatment of drug addicts in Bremen: research results. Sucht, 4/1994. Ministero della Sanita ( 1994). Linee-guida per il trattamento della dipendenza da opiacei con farmaci sostitutivi, - 11 0/11/D/F1 0/2505 , 30 Sept, Rome.
Reisinger, M. ( 1993 ) . AIDS and Drug Addiction in the European Community, Treatment and Mistreatment. Brussels.
Euro-Methwork is a forum of methadone providers in the European Region and aims at:
stimulating the exchange of expertise
serving as a resource centre
organising workshops, conferences, etc.
serving as a advocacy group to help each other in 'selling' the concept of methadone provision.
Euro-Methwork was launched in March 1993.