Oral Substitution Treatment in Austria – the role of GPs · Oral Substitution Treatment in...

EMCDDA 22.9.2010 1

Oral Substitution

Treatment in Austria

– the role of GPs

Oral Substitution

Treatment in Austria

– the role of GPs

Hans HaltmayerMedical Director

Outpatient Clinic Ganslwirt

Hans HaltmayerMedical Director

Outpatient Clinic Ganslwirt

EMCDDA 22.9.2010 2

Epidemiology of „problematic drug use“ including opiates in Austria

Epidemiology of „problematic drug use“ including opiates in Austria

GÖG/ÖBIG; Annual Report 2008

22.200 – 33.400 P.

EMCDDA 22.9.2010 3

LowerAustria

Styria

Carinthia

SalzburgTyrolVor-

arlberg

Burgen-land

ViennaUpperAustria

EastTyrol

1987 first administrative regulation

concerning medication assisted treatment of

opioid dependence; substitution classified as

regular medical practice

19871987 first administrative regulation first administrative regulation

concerning medication assisted treatment of concerning medication assisted treatment of

opioidopioid dependence; substitution classified as dependence; substitution classified as

regular medical practiceregular medical practice

Every region developed

different approaches

Every region developed

different approaches

EMCDDA 22.9.2010 4

Diversified use of opioids in OSTDiversified use of opioids in OST

The austrian model had been special

• because of the availability of different opioids.

� the Austrian substitution act covered the prescriptionof different opioids (Methadone and others)

• regulary prescription of oral slow-release Morphine(OSRM) enabled since 1997

• Majority of opioid prescriptions are placed in pharmacies

• all of this under a common set of rules and regulations

� This „Common sense“ changed with the accusationsagainst the OSRM started 2003 and ended with theamandment of the substitution act in 3/2007.

The austrian model had been special

• because of the availability of different opioids.

� the Austrian substitution act covered the prescriptionof different opioids (Methadone and others)

• regulary prescription of oral slow-release Morphine(OSRM) enabled since 1997

• Majority of opioid prescriptions are placed in pharmacies

• all of this under a common set of rules and regulations

� This „Common sense“ changed with the accusationsagainst the OSRM started 2003 and ended with theamandment of the substitution act in 3/2007.

EMCDDA 22.9.2010 5

The new regulation covered… since 3/2007The new regulation covered… since 3/2007

• A new buerocratic procedure for maintenance

prescription as a barrier by some practitioners

• Postgraduate curriculum (40h) for all physicions

as a requirement for maintenance prescription.

• particulary strict control of take-home

regulations.

• methadone and buprenorphine defined as

substances of „first choice“

• A new buerocratic procedure for maintenance

prescription as a barrier by some practitioners

• Postgraduate curriculum (40h) for all physicions

as a requirement for maintenance prescription.

• particulary strict control of take-home

regulations.

• methadone and buprenorphine defined as

substances of „first choice“

EMCDDA 22.9.2010 6

OST in Austria …Role of GPs

OST in Austria …Role of GPs

Roughly three different systems:

A.) GPs are licensed to initiate OST (Vienna, Tyrol, Lower

Austria).

� rapid access to treatment, good coverage rate, no waiting list

B.) Initiating OST only by specialised centres (Upper Austria,

Carinthia):

� bottleneck, waiting lists, no gain of experience by GPs, long

distances to go for treatment

C.) Initiating OST only by specialised centres and specialised GPS

(Styria):

� similar situation to B.)

Roughly three different systems:

A.) GPs are licensed to initiate OST (Vienna, Tyrol, Lower

Austria).

� rapid access to treatment, good coverage rate, no waiting list

B.) Initiating OST only by specialised centres (Upper Austria,

Carinthia):

� bottleneck, waiting lists, no gain of experience by GPs, long

distances to go for treatment

C.) Initiating OST only by specialised centres and specialised GPS

(Styria):

� similar situation to B.)

EMCDDA 22.9.2010 7

LowerAustria

Styria

Carinthia

SalzburgTyrolVor-

arlberg

Burgen-land

ViennaUpperAustria

EastTyrol

Regions with a lack of GPs licensed for OST

and therefore with a lack of access to treatment

Regions with a lack of GPs licensed for OST

and therefore with a lack of access to treatment

Opioid Substitution Treatment in Austria

…role of GPs

Opioid Substitution Treatment in Austria

…role of GPsred – poor attendance

green – strong part

yellow – in between

EMCDDA 22.9.2010 8

Amendment of the substitution act

…12/2009

Amendment of the substitution act

…12/2009

Two different licenses

A.) License to start treatment and even change

dosage and medication:

� 40h basic education, 20h online learning, 12h

quality circle/education in the following 3 years.

B.) License only for maintain OST:

� 4h quality circle/education per year

Two different licenses

A.) License to start treatment and even change

dosage and medication:

� 40h basic education, 20h online learning, 12h

quality circle/education in the following 3 years.

B.) License only for maintain OST:

� 4h quality circle/education per year

EMCDDA 22.9.2010 9

Opioid Substitution Treatment in Austria…No of clients

Opioid Substitution Treatment in Austria…No of clients

Coverage: roughly 1/3 of „problematic opiat users“ (~ 30.000 P)Coverage: roughly 1/3 of „problematic opiat users“ (~ 30.000 P)

New treatment

Ongoing

treatment

GÖG/ÖBIG; Annual Report 2009

EMCDDA 22.9.2010 10

0

1.000

2.000

3.000

4.000

5.000

6.000

7.000

8.000

Anzahl 2 .9 50 2 .9 4 0 3 .2 70 3 .54 3 3 .774 3 .84 0 4 .2 34 4 .3 78 4 .6 70 5.13 4 5.551 5.784 6 .20 0 6 .169 6 .6 46 6 .70 5 6 .8 32 6 .78 8 6 .8 50 7.176 6 .815

Mai.0 0 No v.00 Mai.01 Nov.0 1 Mai.0 2 No v.02 Mai.0 3 No v.0 3 Mai.0 4 No v.0 4 Mai.0 5 No v.0 5 Mai.0 6 No v.06 Mai.0 7 No v.0 7 Mai.0 8 No v.08 Mai.0 9 No v.09 Jun.10

6.815

Source: Health Authority of Vienna; MA15, Juni 2010

7.1767.176

Opioid Substitution Treatment in Vienna

….No of patients: May 00 – June 10


….No of patients: May 00 – June 10

EMCDDA 22.9.2010 11


...prescribed drugs: May 00 – June 10


...prescribed drugs: May 00 – June 10

0

1.000

2.000

3.000

4.000

5.000

Met ha don 1.905 1.783 1.787 1.876 1.878 1.641 1.538 1.431 1.360 1.476 1.416 1.336 1.411 1.417 1.298 1.307 1.348 1.166 1.202 1.246

Morphine 1.006 1.093 1.170 1.269 1.385 1.617 2.061 2.253 2.473 3.093 3.347 3.657 3.639 3.862 3.900 4.060 3.970 4.042 4.297 4.540

Bupre norphin 278 374 485 547 592 687 689 911 956 1.146 1.078 1.312 1.462 1.353 1.328 1.229 1.315 1.574

S uboxone 45 100 126 168 175

Mai.00 Nov.00 Ma i.01 Nov.01 Ma i.02 Nov.02 Ma i.03 Nov.03 Mai.04 Mai.05 Nov.05 Ma i.06 Nov.06 Ma i.07 Nov.07 Mai.08 Nov.08 Mai.09 Nov.09 J une10

Methadone (16,5%)

Suboxone (2,3%)

Buprenorphine (18,4%)

Morphine (59,0%)


EMCDDA 22.9.2010 12

Oral slow-release Morphine ...Evidence ?Oral slow-release Morphine ...Evidence ?Fischer G et al. Oral Morphine-sulphate in the Treatment of Opiate Dependent Patients. Alcoholism 1996; 32(1): 35-

43

Fischer G et al. Oral slow release morphine in pregnant opioid addicts. Addiction 1999; 94: 231-239

Mitchell TB et al. Comparative pharmacodynamics and pharmacokinetics of methadone and oral slow-release formaintenance treatment of opioid dependence. Drug and Alcohol Dependendce 2003; 72: 85-94

Mitchell TB et al. Slow-release oral morphine versus methadone: a crossover comparison of patient outcomes and acceptability as maintenance pharmacotherapies for opioid dependence. Addiction 2004; 99: 940-945(6)

Kraigher D et al. Use of slow-release oral morphine for the treatment of opioid dependence. Eur Addict Res 2005; 11:145-151

Eder H et al. Comparative study of the effectiveness of slow-release morphine and methadone for opioid maintenance therapy. Addiction 2005; 100:1101-1109

Woody GE. New horizons: sustained release morphine as agonist treatment. Addiction 2005; 100(12): 1758-1759

Vasiliev et al. Safety and Efficay of Oral Slow Release Morphine for Mainenance Treatment in Heroin Addicts. A 6-Month Open Noncomparative Study; Eur Addict Res 2006; 12:53-60

Kastelic A et al. Slow-release oral morphine for mainenance treatment of Opioid addicts intolerant to methadone or with inadequate withdrawal suppression. Addiction 2008; 103: 1837-1846

Winkelbauer B et al. Quality of life in patients receiving opioid maintanance therapy. A comparative study of slow-release morphine versus methadone treatment. Eur Addict Res 2008; 14: 99-105

Resinger E et al. Befindlichkeit von Opiatabhängigen unter Substitutionsbehandlung mit Morphin retard im Vergleich zu Methadon: Ergebnisse einer klinischen Pilot-Studie. Wiener Zeitschrift für Suchtforschung 2008; 31: 19-27

Madlung-Kratzer E et al. A double-blind, randomized, parallel group study to compare the efficacy, safety and tolerability of slow-release oral morphine versus methadone in opioid-dependent in-patients willing to undergo detoxification. Addiction 2009; 104: 1549-1557

Bärwert A et al. Substanzabhängigkeit vom Opioidtyp – Behandlung mit oralen retardierten Morphinen. Opiod Dependence – Treatment with Oral Slow Release Morphine. Suchttherapie 2010; 11: 121-128

There is evidenc, but more studies are required!There is evidenc, but more studies are required!

EMCDDA 22.9.2010 13

0

1.000

2.000

3.000

4.000

5.000

6.000

7.000

D rug f a c i li t y 5 8 5 5 3 0 4 8 0 3 8 8 6 2 0 6 7 3 9 0 3 1. 18 8 1. 6 4 7 1. 10 3 1. 0 7 9 1. 13 1 1.0 4 2

P s y c hia t ris t 6 3 7 6 2 3 6 0 6 6 3 3 6 2 1 6 9 4 7 3 8 7 3 5 8 6 0 6 2 4 6 0 7 7 0 3 7 7 6

Ge ne ra l P ra c t i t io ne r 2 .0 4 0 2 . 7 10 3 .0 3 9 3 .2 13 4 . 2 0 7 4 .7 5 0 4 .9 3 5 5 . 2 11 4 .3 2 5 5 . 3 4 4 5 . 5 15 5 .7 5 1 5 . 7 4 6

2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 N o v. 0 7 M a i.0 8 N o v .0 8 M a i.0 9 N o v .0 9 J un. 10

General Practitioners (76%)

Psychiatrists (10,2%)

Drug Institution(13,8%)


...prescription by: May 00 – June 10


...prescription by: May 00 – June 10


EMCDDA 22.9.2010 1414

OST in Vienna ...Duration of treatmentOST in Vienna ...Duration of treatment

> 5 Y.3 - 5 Y.1 - 3 Y.< 1 Y. new treatment


EMCDDA 22.9.2010 15

OST in Vienna …current situationOST in Vienna …current situation

• Number of problematic opiate drug users: ~ 10.000 pers. (2010)

• Number of patients in OST: ~ 7.000 (~ 70% coverage rate)

• 75% covered by GPs

• No waiting list, low threshold on demand

• Obligatory training of GPs (initially 40 h training program)

• Good cooperation with health authorities and drug institutions

• GPs get extra fee for treatment (also in Styria, Upper Austria,

Tyrol) – conducted to a special training program (quality circle).

• Diversification of treatment:

– Oral slow-release Morphine (Substitol®, Compensan®, Kapanol®)

– Buprenorphine, Bup/Nalox. (Subutex®, Suboxone®)

– Methadone

– L-Polamidon (since 26.8.2010)

• Number of problematic opiate drug users: ~ 10.000 pers. (2010)

• Number of patients in OST: ~ 7.000 (~ 70% coverage rate)

• 75% covered by GPs

• No waiting list, low threshold on demand

• Obligatory training of GPs (initially 40 h training program)

• Good cooperation with health authorities and drug institutions

• GPs get extra fee for treatment (also in Styria, Upper Austria,

Tyrol) – conducted to a special training program (quality circle).

• Diversification of treatment:

– Oral slow-release Morphine (Substitol®, Compensan®, Kapanol®)

– Buprenorphine, Bup/Nalox. (Subutex®, Suboxone®)

– Methadone

– L-Polamidon (since 26.8.2010)

EMCDDA 22.9.2010 16

OST in Vienna …specific problemsOST in Vienna …specific problems

• Overprescribing of benzodiazepins, mainley flunitrazepam

• Increase of psychiatric disorders especially deviant users orviolent users.

• Diversion of medication to the black market

OST-medication like OSRM and BUP

� control system implemented (Police � Health Authority � Physician)

• BZD: Flunitrazepam >> Oxazepam

• Injecting drug use of OSRM– no injectable OMT in Austria, but still in discussion (Vienna)

• Overdose: most OD-cases combined with opioid, BZD and alcohol

• Treatment (OST) of asylum seekers

• Treatment of Individuals without permission to stay.

• Overprescribing of benzodiazepins, mainley flunitrazepam

• Increase of psychiatric disorders especially deviant users orviolent users.

• Diversion of medication to the black market

OST-medication like OSRM and BUP

� control system implemented (Police � Health Authority � Physician)

• BZD: Flunitrazepam >> Oxazepam

• Injecting drug use of OSRM– no injectable OMT in Austria, but still in discussion (Vienna)

• Overdose: most OD-cases combined with opioid, BZD and alcohol

• Treatment (OST) of asylum seekers

• Treatment of Individuals without permission to stay.

EMCDDA 22.9.2010 17

OST in Austria – An OverviewAn empirical study by A.Springer and A.Uhl (LBI) 2010

OST in Austria – An OverviewAn empirical study by A.Springer and A.Uhl (LBI) 2010

176 Physicians, treating 6.926 Patients (66% of all Pat.

in 2007). 588 Patients was included.

• Methadone 24%

• Buprenorphine 17%

• OSRM 59%

176 Physicians, treating 6.926 Patients (66% of all Pat.

in 2007). 588 Patients was included.

• Methadone 24%

• Buprenorphine 17%

• OSRM 59%

Springer A, Uhl A (2010): Wr. Zeitschrift f. Suchtforschung 31(2): 5-18

EMCDDA 22.9.2010 18

How many patients do you treat that way?physicians: n = 176

How many patients do you treat that way?physicians: n = 176

21-50

28%

51-100

10%

more than 100

6% 3-5

20%

6-10

16%

11-20

20%

Source: Springer A., Uhl A. (2010)

EMCDDA 22.9.2010 19

Percentage of maintenance patients among all

patients? physicians: n = 176

Percentage of maintenance patients among all

patients? physicians: n = 176

51% - 99%

5%

exclusively

Substitution

6%

1% - 5%

73%

6% - 10%

8%

11% - 50%

8%

Source: Springer A., Uhl A. (2010)

EMCDDA 22.9.2010 20

• Easy and rapid (low threshold) accsess to OST

• High coverage rate

• No stigmatisation and ghettoisation

• Examination and basic treatment of somatic and psychiatric (drug related) diseases.

• GPs are used to network in case of polymorbidity like diabetes, etc.

• Low costs to the health system

• Easy and rapid (low threshold) accsess to OST

• High coverage rate

• No stigmatisation and ghettoisation

• Examination and basic treatment of somatic and psychiatric (drug related) diseases.

• GPs are used to network in case of polymorbidity like diabetes, etc.

• Low costs to the health system

Summary - OST in Austria

…benefits according to a prominent role of GPs

Summary - OST in Austria

…benefits according to a prominent role of GPs

EMCDDA 22.9.2010 21

• Suboptimal treatment of patients with severe mental disorders

� lack of psychiatric back-up (less, but even in thecity!)

• GPs with much more then 100-150 patients

• GPs with less than 10-5 patients

• Diversion to the black market in cause of..

� lack of experience in dosage-finding

� few time for examination

• Overprescription of benzodiazepines

• Suboptimal treatment of patients with severe mental disorders

� lack of psychiatric back-up (less, but even in thecity!)

• GPs with much more then 100-150 patients

• GPs with less than 10-5 patients

• Diversion to the black market in cause of..

� lack of experience in dosage-finding

� few time for examination

• Overprescription of benzodiazepines

Summary – OST in Austria:

…issues according to a prominent role of GPs

Summary – OST in Austria:

…issues according to a prominent role of GPs

EMCDDA 22.9.2010 22

Thank you

for your Attention!

Thank you

for your Attention!

Oral Substitution Treatment in Austria – the role of GPs · Oral Substitution Treatment in...

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