|Articles - Opiates, heroin & methadone|
|Written by Michael Farrell|
METHADONE COUNTRY REPORT
Michael Farrell, Jan Neeleman, Michael Gossop, Paul Griffiths, Emily Finch and John Strang
The National Addictions Centre, London, UK
Neither the Commission of the European Communities nor any person acting in the name of the Commission is to be held responsible for the use made of the information contained in this publication.
This is an edited part of a report on the delivery of substitution programmes in 11 European Union countries (Farrell et al., 1996). The full report on Denmark contains a detailed description of three treatment programmes and attempts to describe the practical working of programmes to provide a content for the national overview.
Denmark has the highest level of methadone consumption per capita of any European country This high level of provision has been by default rather than by design. Consumption has risen between 1988 and 1992 (Figure 1). Provision of methadone to 3700 patients in 1993 was through a mixture of specialist services and primary care services with 30% of clients in specialist services, 36% in shared and 34% managed exclusively by GPs since 1995. There is much current debate about the balance between specialist and primary care provision but there is little substantive research to clarify these issues. Legislation has been recently introduced to restrict primary care involvement but the implications of this new law has yet to be fully reported on.
EVOLUTION OF PROBLEMS
As with most other European countries the first evident drug problem erupted in the mid to late sixties in Copenhagen where an open drug scene developed in an area close to the central station; it was also associated with other aspects of counterculture movements of the time. There was a gradual growth in the size of the drug addict population and its dissemination throughout the whole country. This problem appears to have reached relatively stable proportions by the mid 1980s. There is a predominance of opiate injectors in the treatment population but heroin smoking has developed among ethnic minority populations and amphetamine use occurs, although the level of problems associated with it is unclear. The management of the long-term opiate population with associated social problems continues to present significant problems to social service, health and criminal justice agencies.
RESPONSE TO PROBLEM
The development and organisation of drug services
As with virtually every country in Europe the initial key response to providing help for drug addicts was the establishment of residential therapeutic communities. This was developed alongside a crisis walk-in centre close to the original open drug scene ('Halm torvet' or Corn Market) in Copenhagen. This service also had a day and night shelter as well as inpatient facilities for detoxification.
Two religious style therapeutic communities were established around the same time.
At the earliest stage of the evolution of drug services the psychiatrists and other mental health professionals actively avoided involvement in the development of responses to the drug-dependent population except where frank psychiatric morbidity coexisted. Thus social services were to play .the key role in service development and provision over the past two decades.
Administratively the present Danish situation still reflects these early beginnings. Responsibility for addiction care is delegated to the social services of the 13 Amter (County Councils) and the 160 Kommuner (municipalities). General practitioners continue to play a major role in community-based services especially in those areas where social services have not set up treatment centres (yet) or where demand surpasses service provision. Social pedagogues (compare social workers) are numerically the most important staff in the social treatment system. Private practice still plays a limited but sharply criticised role in Copenhagen city (Danish Medical Association,1994)
The development of substitute prescribing services
In the 1970s the 'social pedagogical treatment institutions' (subsequently referred to as 'drug services') did not provide methadone maintenance and increasing numbers of addicts sought methadone from general practitioners. Within a matter of years there were substantial numbers of addicts on methadone prescriptions from general practitioners.
There was concern that 'uncontrolled' methadone prescribing would result in diversion on to the black market and would also reduce addicts' motivation to become drug free. There was also considerable scepticism about the benefits and therapeutic efficacy of methadone maintenance (Kontaktundvalget Verdrorende Alkohol og Narkotikamisbrug, 1973). There was some change of attitude in 1979, when a policy statement by the Alcohol and Narcotics Commission (Kontaktundvalget Verdrorende Alkohol og Narkotikamisbrug, 1979) recommended that every county should have a regional multi professional 'Social Medicine Committee' to screen all applicants for long-term methadone.
In 1979 it was estimated that there were 3 00 long term methadone 'slots' nationally provided by the social services, compared with the 2000 drug-free places. It was not clear, however, who looked after these 300 or more individuals. It was stated that they should be accommodated within the existing (drug free) treatment structure alongside the other core treatment modalities. However, in the early 1980s there were at least 400-500 patients on long term methadone prescriptions being managed by general practitioners. The National Board of Health seldom implemented sanctions against GPs who initiated long term methadone prescribing without consulting, or against the advice of, the Regional Social Medicine Committees. There was also opposition from within the existing treatment facilities to accommodate methadone maintenance clients so that GPs were the main providers of methadone treatment.
A descriptive outcome study was published in 1983 (Winslow and Ege,1983) comparing a cohort on methadone with a single general practitioner with a second group who were treated by a specialist drug service. The first group apparently did worse on a number of outcome measures. As a result of this recommendations were made that the Local Medical Officers or the National Board of Health should have a statutory responsibility to regulate GPs' involvement in the prescribing of long-term methadone and it was viewed that GPs w ere no ideally placed to provide long-term methadone pre scribing because they could not ensure sufficient control and provide adequate social and psychotherapeutic input. This report proposed the establishment of separate methadone maintenance programmes because it was thought that staff working in units with an abstinence based philosophy would be unable to accommodate both perspectives
In 1984, the Alcohol and Narcotics Commission (Alkohol og Narkotikaradet) published a report which specified conditions under which long term methadone treatments should and could take place in a multi professional, outpatient setting, based on principles of graduated objectives and flexible with respect to individual needs. Following this report the drug services have developed more outpatient activities and have reduced inpatient services. In 1985 there were inpatient facilities at the social treatment centres in 8 of the 13 County Councils; in 1991 only 5 of the 13 County Councils offered inpatient treatment
Between 1984 and 1986, the Fyns Amts Behandlingscenter (originally a drug-free service) conducted a pilot study comparing 4 months' outcome between dependent drug users who received drug-free counselling and support and a group who had psycho social counselling combined with a methadone prescription from their GP (organised by the centre). Psychological, physical and social outcomes were better in the methadone group, and in 1988 the Fyns Amts Behandlingscenter started working with long term methadone as a significant component of their service.
Based on the experiences of the Copenhagen and the Fyns centres, prompted by the potential HIV epidemic in the mid 1980s and in the light of explosively increasing numbers of GP-treated methadone patients, the Alcohol and Narcotics Commission (Alkohol- og Narkotikaradet) published revised guidelines for long-term methadone prescribing in 1988. It was submitted that, given the actual widespread existence of long term prescribing, this treatment modality should be 'normalised', i.e. become just one of the treatment modalities available to drug
users alongside more traditional ones such as detoxification, and that appropriate funding should be allocated to establish services. It was stated that long-term methadone should only be initiated as one element in a comprehensive management plan and that GPs should have no more than 5-10 methadone patients at one time. Problems of lack of coordination are thought to be present especially in private practice (Copenhagen) where clinics are run by doctors alongside their regular job, and are only opened for a few hours in the afternoon.
Long term methadone prescribing is becoming available in the management package of the drug services of most of the Counties. Some programmes are in their early days and in some counties, such as the west and south of Jutland, there is still widespread resistance to the idea of maintenance. In such areas where the need is low, ad hoc arrangements are made between social services and general practitioners.
In 1995 new legislation was introduced further restricting the primary care involvement in methadone prescribing. It is not clear how the significant gap between the capacities of specialist services can be expanded to meet the demand that is presently being met by general practitioners.
CURRENT SITUATION: EPIDEMIOLOGICAL INDICATORS
It is estimated that there is a total of 10 000 opiate addicts in Denmark (total population 5 million), 90% of whom inject and 50% of whom live in the Copenhagen area. These estimates are based on the assumption that, at any one given time,30% of all addicts are in receipt of a methadone script of some sort, whereas 10% are in other services.
Official statistics concerning 'narcotics' related crime show a sharp increase from 10 000 implicated people in 1986 to over 16 000 implicated people in 1992 (Sundehetstyrelsen, 1993). In 1992, 30% (1081) of all prison inmates were opiate addicts. Of all imprisoned addicts ( all substances), between 37 % (1985) and 46% (1992) are injecting drug users. A 1988 report reviewed the issue of HIV risk behaviour among imprisoned drug users. It was accepted that it was appropriate for some offenders to continue on methadone while in prison but there were problems about linking offenders on release with appropriate local services.
There has been a sharp increase in drug-related mortality over the past decade. The total number of drug-related deaths in 1993 was 210. The number was less than 40 in 1970. In the 1980s numbers were between 110 and 160 yearly. From 1990 (about 120 deaths a year) to 1991 there was a 63% increase. In 1993 drug-related mortality rate was 2-3%; 50% of these deaths occur in Copenhagen. The mean age of victims in 1992 was 32.5 years. Eighty per cent of deaths are related to overdoses and in 1991 methadone was reported to have been implicated in 3 1% of lethal overdoses (Sundehetstyrelsen, 1993).
In 1990 a new centralised HIV notification system was introduced and it is estimated that 10% of Copenhagen injecting drug users are HIV positive (numbers are lower in other areas). Twelve per cent of HIV positive patients have injection as a risk factor. The number of IVDUs with AIDS was 2 in 1986 and 72 in 1992 ( i.e.6.4% of all Danish AIDS cases) (Sundehetstyrelsen,1993).
Table 1: Treated addicts
*50% of the new recruits are intravnous users
Table 2: Patients on methadone
Table 1 gives information on numbers of patients who received treatment (of any description; in and outpatient) within the social system since 1985; these numbers do not include exclusively GP-man aged cases.
Table 2 gives information on the total number of patients on methadone prescriptions in the December months from 1985 to 1993. The second column gives the number of patients who were on a long-term script (>5 months) in the same months; these numbers include those case treated by GPs or physicians as well as those scripted via a day service institution.
Bach estimates that up to 65-70% of methadone prescribing is done by GPs with 36% of this GP work shared with the specialist centres and 30% of clients being managed exclusively by specialist centres (Bach,1992). In 1993 in Copenhagen city there were a total of 700-800 slots in the outpatient service, of which 750 are taken up by patients receiving methadone (on-site dispensing). This contrasts with a total of 1300 daily methadone deliveries by retail pharmacists in Copenhagen, the bulk of which is being prescribed by general practitioners. (The specialist treatment centres visited all had high levels of staff provision with the maximum load in any service being one member of staff for ten clients.)
Psychiatric hospitals play a minimal role in the treatment of addiction. In 1992, less than 50patients were admitted for the first time to psychiatric departments with a main diagnosis of opiate addictions (175 admissions and readmissions) (Sundehetstyrelsen, 1993). Homeless individuals, including opiate addicts, have under Danish social security legislation access to so called 'paragraph 105 institutions', for shelter- these institutions have in recent years catered more and more for destitute psychiatric patients, and, in all likelihood, also for addicts. However, they do not provide treatment. The management of dually diagnosed patients i an increasing problem given the limited involvement of psychiatrists in services; the need for special clinics catering for this group have been advocated (Sundehetstyrelsen, 1993) and, in 1994, central government funded a special project for dually diagnosed patients in the north of Jutland.
The relevant legislation is contained in the Euphoriant Substances Act. The Health Department has issued specific guidelines (Sundehetstyrelsen, 1995 ) on the prescribing of substances with addictive potential and on notification procedures. It is not clear how the most recent legislation ( 1995) has changed the arrangements as described below.
Methadone prescribing must be reported on a special form to the regional public health authorities. Each Council (Amte) has a social medicine committee in place which decides on applications for methadone treatment (there have been difficulties in implementing this part of the governmental guidelines) . Bach states that 50% of methadone prescriptions are started by GPs without consultation with the treatment centres (80% in Copenhagen) .
The guidelines stipulate that there should be controls in methadone maintenance treatment including supervised intake, regular urine checks daily attendance, at least initially. Pick-ups from retail pharmacists are only felt to be acceptable for 'socially stable patients'. Methadone mixture mg/ml is the only substance to be used in order to minimise the risk of injecting.
Notification occurs in 100% of cases. Any doctor who fails to notify will be detected via the regional supervising doctors. The scrutiny of prescriptions is organised via retail pharmacies who send lists of dispensed medication (including details of patients and prescribing doctor) to the regional supervising doctors. On site dispensing clinics complete monthly returns comprising details of dispensed medication and registered patients to the supervising doctor. Notification forms need to be completed at the start and at the termination of methadone treatment and are centrally registered at the National Board of Health.
Denmark has a social security-based healthcare system; every Dane has a GP and prescribing is catered for within this arrangement. The drug services are part of the social system. Normally, 50% of health expenses are paid by Amte and 50% by Kommunes. However, the exact balance may differ according to region (e.g. in Fyn it is two-thirds versus one third). The total Danish 1994 budget for the social care of addicts, the socially weak and those with social problems is to the tune of 72 million Dkr (Justits, Socialog Sundehetsministeriet, 1994). Much of this budget is being made available to local initiatives on a project basis and reviewable annually on the basis of performance. Local councils are expected to top up the central subsidies.
Methadone maintenance has become one of the principal methods of service provision in Denmark. Denmark consumed, in 1992 per million population, more methadone than any other member state of the European Union.
There is a good deal of concern about diversion of methadone on to the black market. From 1982 to 1991, police seizures of liquid methadone rose exponentially from about 500 ml in 1982 to over 17 000 ml in 1992. A further point of concern has been the fact that methadone is implicated in a rising number of opiate related deaths (overdoses); in 1984-5, in less than 15% of opiate overdoses methadone was implicated whereas this was 31% in 1991. Of all methadone related overdoses, only 50% are in receipt of an actual methadone script.
The recently introduced legislation increases the control on GP prescribing but there is a difficult balance to be struck between controlling the quality of the service and ensuring adequate access to treatment. There appears to be an imbalance between intensive psychosocial counselling in specialist services and a virtual absence of such in primary care. There is a need for detailed cost effectiveness evaluation comparing specialist with primary care delivered drug substitution where issues of quality control, optimal levels of psychosocial input and cost effectiveness are properly addressed in the design of the evaluation. The role of psychosocial counselling and its impact on the overall effectiveness of methadone maintenance delivery appear to be central to the issues of service delivery in Denmark.
The selective lack of facilities for supporting GPs involved in substitute prescribing with a third involved in unsupported prescribing has resulted in legislative change. Although there is some evidence that oral methadone alone is better than no treatment in reducing heroin use, there is also some experimental evidence (McLellan et al., 1993) to show that patients given counselling in addition to methadone show a greater range of behaviour change and improvement.
Overall the development of standards for the delivery of methadone maintenance and their specific adaptation to particular modes of delivery (Farrell et al., 1994) are required for the enhancement of the quality of methadone maintenance delivery in Denmark. Denmark appears to be in a similar position to those countries such as the Netherlands and the UK where there is over two decades of methadone prescribing. Services are being required to provide high-quality monitoring and evaluation to justify the cost of ongoing funding. Also as these services come of age the centrality of the role of methadone has been questioned. In Denmark a research programme comparing buprenorphine with methadone is underway. The evaluation of a variety of pharmaco therapies in substitute prescribing may increase treatment options and may also help to clarify the essential goals and components of such services and help to set reasonable performance standards for the systematic assessment of substitute prescribing services.
The authors would like to thank Dr Ege for his extensive help with the material for this Report.
Dr Michael Farrell, National Addiction Centre, Institute of Psychiatry, 4 Windsor Walk, London SE5 8AF, UK.
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