substitution treatment programmes in croatia€¦ · substitution treatment programmes in croatia...
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SUBSTITUTION TREATMENTSUBSTITUTION TREATMENT
PROGRAMMES IN CROATIAPROGRAMMES IN CROATIA
VenijaVenija CeroveCeroveččkiki NekiNekićć , MD,GP, MD,GP
Hrvoje Hrvoje TiljakTiljak, MD, , MD, PhDPhD, , AssistentAssistent ProfessorProfessorDepartmentDepartment forfor FamilyFamily Medicine Medicine
UniversityUniversity ofof Zagreb, Zagreb, MedicalMedical SchoolSchoolAnte Ante IvanIvanččiićć, MD,GP, Pore, MD,GP, Porečč, Croatia, Croatia
VilniusVilnius, , LithuaniaLithuania, , MayMay 2929--30,2008.30,2008.
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HealthHealth Care Care SystemSystem inin CroatiaCroatia
� 3 levels PrimarySecondaryTertiary
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PrimaryPrimary HealthHealth Care (PHC)Care (PHC)
• general practitioners
• paediatricians• gynaecologists• dental care• occupational medicine • emergency medical care• medical care for school children• public nurse
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General General PracticePractice inin CroatiaCroatia
• about 2560 doctors work as GPs• gate-keepers• comprehensive care• 30 % Vocational trained GPs• patients list were introduced into PHC• average number of patients on GPs lists about
1700• free choice of GPs have been existing • 88 % of the population registered in general
practice
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General General PracticePractice inin CroatiaCroatia
• GPs are individual contractors withNational Institute for Health Insurance
• 84 % are individual contractors integratedinto the public sector
• 16 % GPs work as salaried doctors withinthe Health Centers
• GPs are paid by capitation (differentiatedby age) and fee for services
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HealthHealth InsuranceInsurance
• national health insurance • insurance fond (taxis)• all Croatian citizens are insured and have
free access to health care system• some participations for drugs and
diagnostic procedures-symbolic• private insurance funds- for better comfort
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WHO/UNAIDS/UNODC WHO/UNAIDS/UNODC
POSITION PAPERPOSITION PAPER
SubstitutionSubstitution maintenancemaintenance therapytherapy
inin thethe menagementmenagement ofof opioidopioid dependencedependence andand HIV/AIDS HIV/AIDS preventionprevention, 2004, 2004
• Treatment of large number of individuals with OD demands the development of MT programs that are incorporated within general primary health care and welfare services.
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Organisation of substitution treatmentOrganisation of substitution treatment (EMCCDA, 2002)(EMCCDA, 2002)
• General practitioner’s:
Austria, Belgium, France (buprenorphine), Germany, Ireland, Luxembourg, UK, Denmark
• Specialised centres:
Denmark, France (methadone), Italy, the Netherlands, Portugal, Spain
• Specialised centres,
limited number:
Finland, Greece, Sweden, Norway
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Advantages of Advantages of thethe treatmenttreatment of ODof OD in in
PPrimary rimary HHealth ealth CareCare
• Availability • Integrative - holistic care• Destigmatisation • Degetoisation = Normalization of • treatment• Lower costs
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Disadvantages of GPs involvement in Disadvantages of GPs involvement in
drug drug addictionaddiction treatmenttreatment
• Difficult to assure quality of treatment
• Easier diversion
• Lost of epidemiological data
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TreatmentTreatment modelsmodels of MT in PHCof MT in PHC
• GPs as primary prescribers: “office based prescribing”
• Referral model
• Shared care
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HystoricalHystorical backgroundbackground of of CroatianCroatian
addictionaddiction treatmenttreatment modelmodel
• Tradition of social psychiatry and alcoholism treatment (Hudolin)
• Tradition of social medicine in general practice ( Štampar)
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CroatianCroatian storystory::
• methadon start in 1991 – avaliable in PHC supervised by special units
• buprenorphine start in in 2004 – avaliable in PHC, but for price of approximately 20
Euro weekly payed by clients – At the same time practical no cost in methadone
treatment.• buphrenorphine become free of charge in 2007
– available in PHC supervised by special units care physicians
• cost of treatment become important issue for public resources
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Health policy background of STHealth policy background of ST in in
CroatiaCroatia
• Easy acces to health insurance• Addict if not insured will get insurance
because of his addiction• ST free of charge• Every person in Croatia has “own doctor“• GPs - “gate keepers”
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TheThe keykey premise of drug premise of drug addictionaddiction
treatmenttreatment in Croatiain Croatia
•Drug addiction is not substantially different than any other chronic disease •Drug addicts are not different than other patients•Opiate agonists are not substantially different than other medicine
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FollowingFollowing thisthis premise:premise:
• Treatment is integrated in existing health care structure
• ST provided exclusively by GPs
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Croatia Croatia factsfacts 2006.2006.
• Population 4 500 000• Heroin addicts (estimated) 12-15 000• Heroin addicts in treatment 5611*• Medication assisted treatment 3541*
*Croatian National Institute of Public Health, Annual Report for 2006
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SharedShared care modelcare model
Centres for Outpatient Treatment and
General Practitioners
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PositionPosition of of CentresCentres
• Centres - the only “new” structureorganized for treatment of addiction
• 25 Centres situated in all major cities • Centres are not “methadone centres”
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Centre Centre -- interdisciplinaryinterdisciplinary teamteam
• Medical practitioner (Psychiatrist or GP)• Psychologist• Social worker• Medical nurse
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The role of CentresThe role of Centres
• Clinical assessment • Recommendation of Meth – Bup treatment• Periodical evaluation • Urine testing• Psychosocial counseling• Collecting epidemiological data
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TheThe rrole of ole of GPsGPs in in OTPOTP
• prescribe methadone-buprenorfine,• supervise consumption, • prepare «take home» doses,• treat all other health problems.
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CroatianCroatian model model achievementachievement
• Availability : more than 50% GPs (1200) have addicts in OT
• Professional quality:GPs get specialised support form expertsin Centres
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GPsGPs prescribingprescribing methadonemethadoneIvancicIvancic,,TiljakTiljak: 6 th EUROPAD : 6 th EUROPAD ConferenceConference, , ParisParis, 2004, 2004
0
50
100
150
No doctors 193 = 8% GPs in Croatia
No Doctors
No Doctors 67 126
no yes
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DistributionDistribution of of patientspatients//doctorsdoctors
Mean patientMean patient/doctor=4,5/doctor=4,5
0
2
4
6
8
10
12
14
16
18
20
No doctors
1 2 3 4 5 6 7 8 9 10 11 12 15 19 23
No patients/docor, total 564 patients
No doctors
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OpiateOpiate agonistsagonists distributiondistribution MarchMarch 2008 2008
((estiamtedestiamted))
.
100,006250Total
43,52720buprenorphine
56,53530methadone
%Nr of patients
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PrescribingPrescribing and and dispensingdispensingregimenregimen -- MethadoneMethadone
•Recommendation from Centre•Prescription by GP•Supervised consumption in GP’s office ( the rule in the beginning of treatment) •“Take homes”(usual form of dispensing) –prepared by medical nurse
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PrescribingPrescribing and and dispensingdispensing
regimenregimen -- BuprenorfineBuprenorfine
• Recommendation by Centre • Prescribing by GP• Dispensing in pharmacy as any other
medicine• Exceptionally supervised consumption
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MortalityMortality of of addictsaddicts in Croatia 1997in Croatia 1997--2006, CPHI 2006, CPHI AnnualAnnual reportreport 20062006
852006
1042005
1082004
952003
862002
782001
752000
631999
431998
441997
291996
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CauseCause of of deathdeath of of addictsaddicts in Croatia in in Croatia in
20062006 CPHI CPHI AnnualAnnual ReportReport 20062006
11,810Others
2,42Accidents
2,42Suicide
11,810Other illnesses
20,017Methadone overdose
20,017Other opiates
31,827Heroin overdose
%Nr.Cause
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OutcomesOutcomes and and indicatorsindicators
• High coverage, estimated > 50%• Retention rate, estimated > 80% • Overal mortality < 1% annually *• HIV infection 0,5 %* ( 0,3-0,6 % )• HBV poz. 15,5%*• HCV poz. 46,2%*
*Croatian National Institute of Public Health, Annual Report for 2006
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ProblemsProblems
• Part of GPs do not follow the procedure (minimal controle)
• Problem to find the GP to provide ST ( in some places)
• Insufficient education of GPs and nurses• Leaking of methadone and „methadone
deaths”• Inadequate payment of GPs (providing ST is
not extra paid)
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CroatianCroatian suggestionsuggestion::
• more than one medicament • avaliable in PHC • same prescription and distribution policy
for all medicaments• individual approach in medicament choice• investigate addiction population needs• investigate public resource capacity
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When planning treatment programsWhen planning treatment programs::
• pharmacological issues• prescription and distribution policy• costs
– for client – public cost of treatment programs
• historical reasons
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When planning individual treatmentWhen planning individual treatment
• pharmacological issues• prescription and distribution policy• costs
– for client – public cost of treatment programs
• patient needs• illness characteristics
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