Treatment of problem opioid use
Data gathered by the EMCDDA’s treatment demand indicator can be used to describe the characteristics of a substantial subgroup of drug users entering treatment and, more specifically, those who have entered specialised drug treatment services during the year.
Clients entering outpatient treatment for primary opioid use are on average 34 years old, with female clients and those entering treatment for the first time being on average younger (1). Almost all countries report an increase in the mean age of their opioid clients since 2003. The overall male to female ratio among outpatient opioid clients is 3.5:1, though females make up a higher proportion in northern countries (e.g. Sweden, Finland) and a lower proportion in southern countries (e.g. Greece, Spain, Italy) (2).
Opioid users entering treatment have higher rates of unemployment, lower levels of educational attainment and higher levels of psychiatric disorders than clients reporting other primary drugs (3). Almost all opioid users entering treatment report initiation before the age of 30 and about half before the age of 20. An average time lag of about ten years is reported between first use of opioids and first contact with drug treatment (4).
Treatment provision and coverage
Treatment for opioid users is mostly conducted in outpatient settings, which can include specialist centres, general practitioners’ surgeries and low-threshold facilities (see 'Responding to drug problems — an overview'). In a few countries, inpatient centres are a major component of the drug treatment system, notably in Bulgaria, Greece, Latvia, Poland, Romania, Finland and Sweden (5). The range of options available in Europe for the treatment of opioid dependence is broad and increasingly differentiated, though it varies geographically in terms of accessibility and coverage. Drug-free and substitution treatment for opioid use are available in all EU Member States, Croatia and Norway. In Turkey, the use of substitution treatment is currently under study.
Drug-free treatment is a therapeutic approach that generally requires individuals to abstain from all substances, including substitution medication. Patients participate in daily activities and receive intensive psychological support. While drug-free treatment can take place in both outpatient and inpatient settings, the types most commonly reported by Member States are residential programmes that apply therapeutic community principles or the Minnesota model. France and the Czech Republic are currently performing outcome evaluations of their therapeutic communities, with results expected in 2010. Under the French action plan, the availability of this treatment modality is to be expanded in the future. Therapeutic communities are the largest type of drug treatment in Poland. However, for economic reasons and because of changing patient profiles, the duration of treatment programmes is reported to be gradually shortening. Finally, Croatia and Portugal have recently developed guidelines for therapeutic communities.
Substitution treatment, generally integrated with psychosocial care, is typically provided at specialised outpatient centres. Thirteen countries report that it is also provided by general practitioners, usually under shared-care arrangements with specialised treatment centres. General practitioners can achieve better results than specialised centres in terms of retention in treatment, abstinence rates and co-consumption of other drugs. This was found in a 12-month naturalistic study of 2 694 clients in substitution treatment in Germany (Wittchen et al., 2008). Other studies have shown that the implementation of substitution treatment in primary care settings is not only feasible, but can also be cost-effective (Gossop et al., 2003; Hutchinson et al., 2000).
The total number of opioid users receiving substitution treatment in the European Union, Croatia and Norway is still growing, with an estimated 670 000 clients in 2008, up from 650 000 in 2007 (6) and about half a million in 2003. Client numbers showed some increase in several central and eastern European countries, but the countries that joined the European Union after 2004 continue to make up only about 2 % of the total number of opioid substitution clients in the European Union (7).
A comparison of the number of substitution treatment clients in the European Union with the estimated number of problem opioid users suggests a treatment coverage rate of about 50 %. However, coverage varies considerably between countries, with rates below 40 % reported by seven of the 14 countries for which estimates of the number of problem opioid users are available, and four of these countries reporting less than 10 % coverage (see 'Figure 11: Estimated proportion of problem opioid users undergoing substitution treatment'). Nevertheless, it can be estimated that two out of three problem opioid users in the European Union live in countries where substitution treatment coverage is high (8).
Most substitution clients in Europe receive methadone (70–75 %), but the number of countries where it is the only available substance is decreasing. High-dosage buprenorphine is now available in all but four EU Member States (Bulgaria, Spain, Hungary, Poland), and is used in 20–25 % of all substitution treatments provided in Europe and in more than 50 % in the Czech Republic, France, Cyprus, Latvia, Sweden and Croatia. In France, where buprenorphine has always predominated, methadone is now prescribed to a growing proportion of substitution clients. The buprenorphine–naloxone combination, which was approved by the European Medicines Agency in 2006, has been introduced in 14 countries. Other options, which represent a small percentage of all substitution treatments, include slow-release morphine (Bulgaria, Austria, Slovenia), codeine (Germany, Cyprus, Austria) and diacetylmorphine (heroin). Heroin prescription has now become an established treatment option in Denmark, Germany and the Netherlands; it also exists in Spain and the United Kingdom, and pilot projects are under preparation in Belgium and Luxembourg.
Access to treatment
Regulations about provision and dispensing of opioid substitution treatment are key to its accessibility. Legal frameworks may allow all general practitioners (Belgium, Czech Republic, Denmark, Germany, France, Italy, Cyprus, Netherlands, Portugal, United Kingdom, Croatia) or those who have been specifically trained or accredited (Germany, Ireland, Luxembourg, Austria, Slovenia, Norway) to prescribe one or more substitution substance. In other countries (Bulgaria, Estonia, Greece, Spain, Lithuania, Hungary, Poland, Romania, Slovakia, Finland, Sweden), only specialist treatment centres can provide substitution treatment.
In most European countries, substitution medication can be dispensed by general practitioners, pharmacies or mobile outreach units. This is, however, not the case in Bulgaria, Estonia, Greece, Lithuania, Poland and Slovakia, where only specialist treatment centres can dispense the medication. High-dosage buprenorphine can be dispensed by all general practitioners in the Czech Republic, or any pharmacy in Latvia. In Romania, Hungary and Finland, pharmacies are only entitled to dispense the combination buprenorphine–naloxone. It is reported that as this medication is only recently available and expensive in Hungary and Romania, only small numbers of clients receive it in these two countries.
Information on the cost of opioid substitution medication for clients has recently been collected. Among the 26 reporting countries, 17 indicated that the medication (in most cases methadone) is free of charge unless treatment is sought from private providers. In Belgium and Luxembourg, the client has to pay part of the medication costs only when it is prescribed by a general practitioner. In the Czech Republic, Latvia, Portugal, Hungary and Finland, treatment with methadone is free of charge, but buprenorphine or the combination buprenorphine–naloxone have to be paid for in full or partially by the client. In Latvia, for example, the monthly cost for a daily 8 mg dose of buprenorphine is about EUR 250. Methadone is generally cheaper than other substitution medications with similar effectiveness, such as buprenorphine (WHO, 2009), which partly explains why many national health insurances provide full reimbursement for methadone in preference to other substitution medications. Generic versions of high-dosage buprenorphine, which are cheaper, are available since 2006 in France, where they are prescribed to approximately 30 000 clients (30 % of all buprenorphine clients).
Information on costs, provision of substitution treatment and dispensing of substitution medicines show regional differences in Europe. Countries in the north and in the east of Europe often apply a more focused and higher-threshold access model, whereas many countries in the west of Europe implement a multi-site and low-threshold access model. These differences may reflect different models of care, with priority given in some countries to the goal of abstinence and to psychosocial approaches, and in others to the stabilisation and retention of clients and to harm reduction approaches.
Treatment effectiveness and quality
Opioid substitution treatment, combined with psychosocial interventions, was found to be the most effective treatment option for opioid users. In comparison with detoxification or no treatment at all, methadone or high-dosage buprenorphine treatments show significantly better outcomes regarding drug use, criminal activity, risk behaviours and HIV-transmission, overdoses and overall mortality, as well as better rates of retention in treatment (WHO, 2009).
The outcomes of opioid withdrawal are generally low in the long term (Mattick et al., 2009), but it may help patients, if it is their informed choice to undergo this type of treatment. In inpatient or outpatient settings, detoxification is achieved through diminishing doses of methadone or buprenorphine (as preferred treatments), or alpha-2 agonists. Accelerated withdrawal techniques that use opioid antagonists in combination with heavy sedation are not recommended because of safety concerns (Gowing et al., 2010). After opioid withdrawal, patients who are motivated to remain abstinent from opioid use should be advised to consider naltrexone to prevent relapse.
The combination of buprenorphine and naloxone (marketed as Suboxone) was created to prevent the injection of buprenorphine. Nevertheless, its effectiveness in preventing intravenous use of buprenorphine is not yet clear (Bruce et al., 2009; Simojoki et al., 2008).
(3) See also 'Responding to drug problems — an overview'.
(5) See Table TDI-24 in the 2010 statistical bulletin.
(6) See Table HSR-3 in the 2010 statistical bulletin.
(7) See Table HSR-2 in the 2010 statistical bulletin.
(8) These estimates should be considered with caution as there is still a lack of precision in the data sets.
Bruce, R.D., Govindasamy, S., Sylla, L., Kamarulzaman, A. and Altice, F.L. (2009), ‘Lack of reduction in buprenorphine injection after introduction of co-formulated buprenorphine/naloxone to the Malaysian market’, American Journal of Drug and Alcohol Abuse 35, pp. 68–72.
Gossop, M., Stewart, D., Browne, N. and Marsden, J. (2003), ‘Methadone treatment for opiate dependent patients in general practice and specialist clinic settings: outcomes at 2-year follow-up’, Journal of Substance Abuse Treatment 24, pp. 313–21.
Gowing, L., Ali, R. and White, J.M. (2010), ‘Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal’, Cochrane Database of Systematic Reviews, Issue 1.
Hutchinson, S.J., Taylor, A., Gruer, L., Barr, C., Mills, C. et al. (2000), ‘One-year follow-up of opiate injectors treated with oral methadone in a GP-centred programme’, Addiction 95, pp. 1055–68.
Mattick, R.P., Breen, C., Kimber, J. and Davoli, M. (2009), ‘Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence’, Cochrane Database of Systematic Reviews, Issue 3.
Simojoki, K., Vorma, H. and Alho, H. (2008), ‘A retrospective evaluation of patients switched from buprenorphine (Subutex) to the buprenorphine/naloxone combination (Suboxone)’, Substance Abuse Treatment Prevention and Policy 17, 3:16 (available online).
WHO (2009), Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence, World Health Organization, Geneva.
Wittchen, H.U., Apelt, S.M., Soyka, M., Gastpar, M., Backmund, M. et al. (2008), ‘Feasibility and outcome of substitution treatment of heroin-dependent patients in specialized substitution centers and primary care facilities in Germany: A naturalistic study in 2694 patients’, Drug and Alcohol Dependence 95, pp. 245–57.