Heroin assisted treatment in Switzerland the picture now · medical prescription of heroin › Drug registration, approval and listing ®(Diaphin ) › Health insurance: definitive

1 28.10.2019 Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |

Heroin assisted treatment in Switzerland – the picture now

We talk – they die

October 8th, 2019

Marc Vogel, MD, MScPH University of Basel Psychiatric Clinics & Psychiatric Services Thurgovia


What is Swiss HAT and why is it working?

https://medium.com/@brought_on/the-elephant-sized-assumption-1f8c4d7153b5


A rational and evidence-based choice?

Opioid agonists used in OAT

EDR, 2018


› ...be long-acting

› ...have a slow onset of effect

› ...reduce craving and withdrawal

› ...block the effects of street opioids

› ...retain patients in treatment

› ...reduce illicit substance use

› ...have few adverse effects

› ... reach all patients

› ...minimize potential risks with acceptable effectivity

› ... be unattractive on the black market

› ...be cost-effective

The perfect agonist for OAT should...

Von Georg Mittenecker - http://kamelopedia.mormo.org/index.php/Datei:Wollmilchsau.jpg, CC BY-SA 2.5,


Beginning of the 70s in Switzerland

› Inpatient detoxification is only available treatment

› Largely missing follow-up concepts or treatments

› Alarming increase in number of heroin users despite of increased inpatient treatment slots

Increasing heroin use

[Source: picturesandperspectives.blogspot.com]


› Beginning of the 70s: first OAT (methadone)

› 1975: revision of the federal narcotics law: sanctions for use of illicit substances, licensing for doctors engaged in OAT

› Entry criteria: several failed withdrawal attempts and residential treatments

› Patients needed to be employed

› Opioid agonist: methadone, but also dihydro- codeine and sporadically buprenorphine

› OAT only offered to chosen, highly disciplined patients,«Privilege»

› Take Home dosages very high threshold

› Methadone dispensal in the morning before work (06:15 AM)

› Tapered dosing with abstinence as treatment goal

› From the beginning a comprehensive programme of psychosocial care and medical treatment

An example of how not to do it

First Steps of OAT in Switzerland


What are the main barriers from the perspective of opioid users?

Conditions of treatment entry that were hardest to meet*

Conditions of remaining in treatment that had most impact on daily life*

Having dose supervised every day 33% Having dose supervised every day

24%

Having to attend all appointments

28% Having to attend all appointments

22%

Having to completely stop all illegal drug use

26% Long-term aim of drug-free state 20%

Project Access CH, 2012 *Only the top 3 most frequently given answers are shown


1980s/1990s

Open drug scenes / «Needleparc»

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwj7lIu-_o3iAhWJzaQKHVyTDR8QjRx6BAgBEAU&url=https://www.tagesanzeiger.ch/extern/storytelling/needletrauma/chapter1&psig=AOvVaw00a6gMaxdTXLDNURBdSvKO&ust=1557475409092629


Swiss overdose deaths

52

84 85

102 88

107 109

144 133

120

136

196 205

248

280

405

0

50

100

150

200

250

300

350

400

450

1975 1980 1985 1990 1995 2000 2005 2010 2015


Newly diagnosed HIV-infections in Switzerland

BAG, 2009

Heterosexual contact

Homosexual contact

IDU

Other

Incidence & prevalence of high risk opioid use in Switzerland

Nordt, Vogel & Herdener, in preparation


Four-pillar-Strategy 1991

Pre

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on

Th

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py

Ha

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Law

En

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t


› needle exchange programs and drug consumption rooms (safe injection facilities, contact points)

› low threshold offers: social support, shelters, free meals, day structuring activities etc.

› supported employment (even on hourly basis), tailored reintegration

› access to methadone on less restrictive conditions for all heroin dependent persons seeking treatment

low threshold OAT with methadone

Harm Reduction measures broadly introduced in 1991


An example of how it can be done

› Opioid dependence is the only precondition, treatment is initiated on the day the patient first presents – no waiting list!

› Covered by health insurance (which is mandatory in CH)

› Optimal dose is determined clinically and individually together with the patient

› Ongoing substance use is not sanctioned

› Long-term treatment possible - no termination date, no mandatory dose reductions, abstinence is not a mandatory treatment goal!

› Comprehensive coverage and availability

o Specialized institutions

o Private practices and pharmacies

› Continuation of OAT in case of hospitalization, detention or imprisonment

› Take-home for the large majority of patients

Low threshold OAT


«We continually see a clinically relevant portion of opioid dependent patients not responding sufficiently to

adequately performed methadone treatment.»

[Advisory Council on the Misuse of Drugs, 1993]

About 20% of patients need a mode of application with rapid onset of effect, i.e. „flash-accepting treatment“

Oral OAT does not reach all patients


› Start of a national cohort study (PROVE) in 1994

› Federal ordinance concerning the medical prescription of heroin

› Drug registration, approval and listing (Diaphin®)

› Health insurance: definitive inclusion in the Narcotics Law

› expansion of outpatient clinics offering heroin assisted treatment

› Closure of open drug scenes;

› since its introduction several referendums on HAT were held, all in favour

Heroin Assisted Treatment (HAT)


› minimal age of 18

› documented opioid dependence of minimal 2 years

› documented health and/or social deficits

› at least 2 previous treatments that failed (not defined further)

Evidence-based?

No - chosen for pragmatic reasons, nevertheless these criteria are being used similarly in other countries

Entry Criteria for HAT


› available for injection (IV, IM) as IR and SR tablets, for inhalation (only NL)

› Diversification of diacetylmorphine (injectable DAM, IR tablets, SR tablets) allowing combinations and easier transition to lower risk routes of administration

› Tmax 2 min - 4.3 h, T½ (morphine) 2-4 h

› No fixed doses, no maximum doses, clinical and individual dose finding

› (injectable) DAM with more side-effects than oral methadone: available only in specialized centers

› Dispensing varies from once every three days to 5 times daily (2 times daily in Basel, open 3 hours each in the morning and afternoon)

› more effective than methadone in reducing illicit opioid use

Diacetylmorphine (DAM) in HAT


The simple fact is that it works…

Conclusion scientific report PROVE*):

Enrolment of patients not responding to conventional OAT

Safety of patients and staff was proven

The use of non-prescribed substances was reduced significantly

Health status was significantly improved

Homelessness was significantly reduced

Most spectacular was the reduction of criminal activities

Cost-effective

The results have since been confirmed by various studies in Germany, NL, UK, Canada, Spain, Belgium...

Heroin assisted treatment

[Uchtenhagen, 1997]

*) Prove: national cohort study: Projekt zur Verschreibung von Opioiden, starting 1994

70% 10%

Dramatic Decline of criminal activities

source: ISGF, HeGeBe-Monitoring, 2005

29. April 2015

Universitäre Psychiatrische Kliniken Basel | www.upkbs.ch |

| 20

delinquency at beginning of treatment delinquency after 18 month in treatment


„Overall the introduction of heroin assisted treatment constitutes one of the

most effective approved individual projects in the field of crime prevention.“

Prof. iur. Martin Killias Professor of Criminal Law, University of Lausanne

Evaluation of HAT effects on delinquency

[source: Schmid O, Müller T. Heroin - von der Droge zum Medikament; Pabst Science Publishers 2008]


IV DAM vs. oral Methadone


1200 HAT patients in 23 treatment centers

MMT- and HAT-centers in CH


› (Fairly) low-threshold, „flash-accepting treatment“

› Physician prescribes DAM, but does not need to be in-house for dispensing times; nurses can reduce dose when they see fit

› HAT is mostly continued in case of inpatient treatment (somatic or psychiatric)

› Heroin assisted treatment: interdisciplinary (nurses, physicians, social workers, psychologists), social support, psychotherapy, medication

› Patients inject IV (in peripheral veins, rarely the groin, never the neck) or IM

› Take home of DAM tablets for stable patients for 2 days

› Dispensing of reserve medication (alternative oral agonist) to prevent withdrawal symptoms in case of missed DAM dispensings

› Individualized treatment where patients can choose to return tablets in order to inject

› Dose finding is a mutual process with (mostly) the patient deciding

› Overdoses are very rare (Basel: 7 years, 4 ambulances, 1 naloxone)

› Police/security is neither involved nor necessary

The Swiss HAT


Nasal application of liquid DAM

› Significant proportion of opioid users use nasally or chase the dragon

› For this group, there is currently no option available with rapid onset of effect (apart from the Netherlands...)

› Alternative for patients in treatment with injectable opioids that

› Can no longer inject safely in peripheral veins (aging population!)

› Can no longer inject due to somatic problems such as COPD (aging population!)

› Inject IM (similar PK)

› Want to change to less harmful route of administration

› Patients that take tablets but are in need of more rapid onset of effect

› Pilot study planned

IV DAM doesn‘t reach all patients neither


Age distribution of HAT patients in Basel

Age (years)

< 20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 >= 60

Pro

po

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n o

f p

atie

nts

(%

)

0

10

20

30

40

Year 2001 n=130

Year 2010 n=156

Year 2019 n=151

www.focus12.co.uk

Mean age 48.6 yrs, Median age 49.8 yrs, Range 26-68 yrs


Benzodiazepines in OAT in Basel

n=193 Met/Mor/Bup

DAM p Overall n

Lifetime use of BZD

96 (85%) 68 (85%) .993 164 (85%)

Prolonged use of BZD*) (> 2 months)

61 (54%) 29 (37%) .018 90 (47%)

Current use 76 (67%) 41 (51%) .025 117 (61%)

Former users 25(25%) 27(40%) .039 52(31%)


Diazepam (Valium) 79 (88%)

Flunitrazepam (Rohypnol) 13 (14%)

Midazolam (Dormicum) 10 (11%)

Oxazepam (Seresta) 3 (3%)

Other 4 (5%)

Short- and medium-acting 4 (5%)

Long-acting 63 (75%)

Both 17 (20%)

BZDs used by prolonged users in OAT

n= 90 [Vogel et al., 2013]


HAT/OAT 65 (72%)

Other prescription 17 (19%)

Black market 41 (46%)

Other 3 (3%)

Total receiving prescription 75 (84%)

Source of BZDs in prolonged users

n= 90 [Vogel et al., 2013]


Motives for BZD use


One size does not fit all – diversification of opioid agonists

Nordt, C., Vogel, M., Dey, M., Moldovanyi, A., Beck, T., Berthel, T., … Herdener, M. (2018). One size does not fit all -evolution of opioid agonist treatments in a naturalistic setting over 23 years. Addiction


Zurich 1992-2015

› BUP: younger than methadone patients, more often male, higher social integration

› SROM: younger than methadone patients, more often male

› Diacetylmorphine: most homogenous group compared to other opioids, older, more injecting experience, lower social integration

Are there differences between patients in OAT on different agonists?

Injection experience

Duration of opioid dependence

Social integration (index)

Age

Nordt, C., Vogel, M., Dey, M., Moldovanyi, A., Beck, T., Berthel, T., … Herdener, M. (2018). One size does not fit all -evolution of opioid agonist treatments in a naturalistic setting over 23 years. Addiction.


OAT coverage

CH

EDR, 2019


52

84 85

102 88

107 109

144 133

120

136

196 205

248

280

405 419

353

399

361

312

241

210

181

205 197

167

194 182

211

193

152 143

171

137 125 121 126

134 132

0

50

100

150

200

250

300

350

400

450

1975 1980 1985 1990 1995 2000 2005 2010 2015

52

84 85

102 88

107 109

144 133

120

136

196 205

248

280

405

0

50

100

150

200

250

300

350

400

450

1975 1980 1985 1990 1995 2000 2005 2010 2015

Swiss overdose deaths


Other

IDU

Homosexual contact

Heterosexual contact

Newly diagnosed HIV-infections in Switzerland

BAG, 2009

Incidence & prevalence of high risk opioid use in Switzerland

Nordt, Vogel & Herdener, in preparation


[email protected]

https://www.researchgate.net/profile/Marc_Vogel

Thank you for your attention

mailto:[email protected]



Documents

Heroin assisted treatment in Switzerland the picture now · medical prescription of heroin › Drug registration, approval and listing ®(Diaphin ) › Health insurance: definitive