Treatment of problem opioid use
Provision and coverage
Both drug-free and substitution treatment for opioid users are available in all EU Member States, Croatia, Turkey and Norway. In most countries, treatment is conducted in outpatient settings, which can include specialised centres, general practitioners' surgeries and low-threshold facilities. In a few countries, specialist inpatient centres play an important role in the treatment of opioid dependence (1). A small number of countries offer heroin-assisted treatment for a selected group of chronic heroin users.
For opioid users, drug-free treatment is generally preceded by a detoxification programme, which provides them with pharmaceutical assistance to manage the physical withdrawal symptoms. This therapeutic approach generally requires individuals to abstain from all substances, including substitution medication. Patients participate in daily activities and receive intensive psychological support. While treatment can take place in both outpatient and inpatient settings, the types most commonly reported are residential (or rehabilitation) programmes, many of which apply therapeutic community principles or the Minnesota model.
Substitution treatment, generally integrated with psychosocial care, is typically provided at specialist outpatient centres. Fourteen countries report that it is also provided by general practitioners, usually under shared-care arrangements with specialist treatment centres. The total number of opioid users receiving substitution treatment in the European Union, Croatia and Norway is estimated at 700 000 (690 000 for EU Member States) in 2009, up from 650 000 in 2007, and about half a million in 2003 (2). The vast majority of substitution treatments continue to be provided in the 15 pre-2004 EU Member States (about 95 % of the total), and numbers in these countries continued to increase between 2003 and 2009 (Figure 14). Among these countries, the highest increases were observed in Finland with a three-fold increase, and Austria and Greece where treatment numbers doubled.
In the 12 countries that joined the EU more recently, the number of substitution clients nearly tripled between 2003 and 2009, from 6 400 to 18 000. Relative to the index year 2003, a steep increase can be noted in 2005-2007, but from this date onwards there has been little further increase. Proportionally, the expansion of substitution treatment in these countries over the six-year period was highest in Estonia (16-fold from 60 to over 1 000 clients, though still reaching only 5 % of opioid injectors) and Bulgaria (eight-fold), while there was a three-fold increase in Latvia. The smallest increases were reported from Slovakia and Hungary, and client numbers in Romania remained practically unchanged. Increased provision of substitution treatment might be linked to several factors, including: responding to high levels of injecting drug use and related HIV-transmission; alignment with the EU drugs strategy; and the funding of pilot projects by international organisations, such as the Global Fund and UNODC.
A comparison of the number of clients in substitution treatment with the estimated number of problem opioid users suggests varying coverage levels in Europe. Of the 16 countries for which reliable estimates of the number of problem opioid users are available, nine report a number of substitution treatments corresponding to 40 % or more of the target population. Eight of those countries are pre-2004 EU Member States, and the remaining high-coverage country is Malta. Coverage reaches 32 % in the Czech Republic and Hungary. Of the five countries with coverage levels below 30 %, four are newer Member States. The exception in this group is Greece, with an estimated coverage of 23 % (3).
Countries in central and eastern Europe report efforts to improve access, quality and provision of substitution treatment. In 2010, clinical guidelines for the treatment of opioid dependence with methadone and buprenorphine were issued in Lithuania. Geographical availability of substitution treatment in Latvia is expanding, with new treatment providers outside of the capital Riga. Regulations for the financing of opioid substitution treatment under national health insurance have been adopted in the Czech Republic. Lack of funding for substitution treatment is, however, reported as limiting the geographical coverage in Poland and reducing significantly the number of treatment slots available among the main providers of substitution treatment in Bulgaria, which are non-publicly funded organisation.
Overall, it is estimated that about half of the European Union's problem opioid users have access to substitution treatment, a level that is comparable to those reported for Australia and the United States, though higher than that reported for Canada. China reports much lower levels, while Russia, despite having the highest estimated number of problem opioid users, has not introduced this type of treatment (see 'Table 11').
|Problem opioid users||Clients in opioid substitution treatment|
(1) Since few countries report the retail price and the purity of heroin hydrochloride (‘white’), the data are not presented here. They can be consulted in Tables PPP-2 and PPP-6 in the 2011 statistical bulletin.
|European Union and Norway||1 300 000||695 000|
|Australia||90 000||43 000|
|Canada||80 000||22 000|
|China||2 500 000||242 000|
|Russia||1 600 000||0|
|USA||1 200 000||660 000|
In Europe, methadone is the most commonly prescribed substitution medication, received by up to three-quarters of clients. Buprenorphine is prescribed to up to a quarter of European substitution clients, and is the principal substitution drug in the Czech Republic, France, Cyprus, Finland, Sweden and Croatia (4). The combination buprenorphine-naloxone is available in 15 countries. Treatments with slow-release oral morphine (see below), codeine (Germany, Cyprus) and diacetylmorphine (5) (Belgium, Denmark, Germany, Spain, Netherlands, United Kingdom) represent a small proportion of all treatments.
In addition to the more commonly used substitution medications, slow-release oral morphine, which was originally licensed to treat pain in cancer patients, is currently provided as an alternative drug for substitution treatment for opioid dependence in Bulgaria, Austria, Slovenia and Slovakia. A recent review (Jegu et al., 2011) of 13 studies concluded that levels of retention in treatment appeared sufficiently high with this substance (80.6 % to 95 %), and no different from those reported for methadone. Most studies showed that quality of life, withdrawal symptoms, craving and illicit drug consumption improved with morphine, but there was no comparison with other substitution drugs. More information might be provided by a forthcoming Cochrane systematic review.
Opioid treatment: effectiveness and outcomes
Opioid substitution treatment, combined with psychosocial interventions, is considered to be the most effective treatment option for opioid dependence. In comparison with detoxification or no treatment at all, both methadone and high dosage buprenorphine treatments show better rates of retention in treatment and significantly better outcomes for drug use, criminal activity, risk behaviours and HIV-transmission, overdoses and overall mortality (WHO, 2009).
A number of recent studies focus on medication that may complement substitution treatment. Two systematic reviews have explored whether antidepressants reduced drop-out among methadone or buprenorphine patients, but did not find evidence of effectiveness (Pani et al., 2010; Stein et al., 2010). Another study showed that a single additional methadone dose could help reduce craving-induced mood problems among stabilised methadone patients (Strasser et al., 2010).
The opioid receptor antagonist naltrexone is used to prevent relapse to opioid use. In a small-scale trial, naltrexone implants were found to be more effective than oral naltrexone in reducing both craving and relapse (Hulse et al., 2010). A study among released prisoners showed that naltrexone implants provided similar reductions in heroin and benzodiazepines use as methadone (Lobmaier et al., 2010). Buprenorphine implants, developed to overcome problems of non-compliance and to prevent treatment diversion, have also been tested in the United States against placebo implants. A preliminary study showed a minor difference regarding abstinence in favour of the active implants (Ling et al., 2010), and the next step will be to compare these implants against other treatments (O'Connor, 2010). In Europe, a Finnish study is testing whether providing suboxone in an electronic device that registers use improves compliance and limits the diversion of take-home drugs.
Treatment outcome research documents some encouraging results. The Drug Treatment Outcome Research Study used a 12-month window to assess treatment outcomes of 1 796 drug users recruited from 342 agencies (6) across England (Jones, A., et al., 2009). Among heroin users involved in the baseline interviews, 44 % had stopped using at first follow-up and 49 % at second follow-up, and there were also consistent reductions for all of the other major substances assessed.
(1) See Table TDI-24 in the 2011 statistical bulletin.
(2) See Table HSR-3 in the 2011 statistical bulletin.
(3) See Figure HSR-1 in the 2011 statistical bulletin.
(4) See Table HSR-3 in the 2011 statistical bulletin.
(5) See the box 'Heroin-assisted treatment' on this page.
(6) Community-based treatment (mainly oral methadone maintenance) and residential treatment.
Hulse, G.K., Ngo, H.T. and Tait, R.J. (2010), 'Risk factors for craving and relapse in heroin users treated with oral or implant naltrexone', Biological Psychiatry 68(3), pp. 296-302.
Jegu, J., Gallini, A., Soler, P., Montastruc, J.L. and Lapeyre-Mestre, M. (2011), 'Slow-release oral morphine for opioid maintenance treatment: a systematic review', British Journal of Clinical Pharmacology 71(6), pp. 832-43.
Jones, A., Donmall, M., Millar, T., Moody, A., Weston, S., Anderson, T., Gittins, M., Abeywardana, V. and D'Souza, J. (2009), The Drug Treatment Outcomes Research Study (DTORS): Final outcomes report, Home Office, London.
Ling, W., Casadonte, P., Bigelow, G., Kampman, K.M., Patkar, A. et al. (2010), 'Buprenorphine implants for treatment of opioid dependence: a randomized controlled trial', JAMA 304(14), pp. 1 576-83.
Lobmaier, P.P., Kunoe, N., Gossop, M., Katevoll, T. and Waal, H. (2010), 'Naltrexone implants compared to methadone: outcomes six months after prison release', European Addiction Research 16(3), pp. 139-45.
O'Connor, P.G. (2010), 'Advances in the treatment of opioid dependence: continued progress and ongoing challenges', JAMA 304(14), pp. 1 612-4.
Pani, P.P., Vacca, R., Trogu, E., Amato, L. and Davoli, M. (2010), 'Pharmacological treatment for depression during opioid agonist treatment for opioid dependence', Cochrane Database of Systematic Reviews, Issue 9, p. CD008373.
Stein, M.D., Herman, D.S., Kettavong, M., Cioe, P.A., Friedmann, P.D. et al. (2010), 'Antidepressant treatment does not improve buprenorphine retention among opioid-dependent persons', Journal of Substance Abuse Treatment 39(2), pp. 157-66.
Strasser, J., Wiesbeck, G.A., Meier, N., Stohler, R. and Dursteler-Macfarland, K.M. (2010), 'Effects of a single 50 % extra dose of methadone on heroin craving and mood in lower- versus higher-dose methadone patients', Journal of Clinical Psychopharmacology 30(4), pp. 450-4.
WHO (2009), Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence, World Health Organization, Geneva.