National Guidelines for Substitution Treatment of

Opiate Addiction in the Czech Republic

Petr PopovApolinar – Addiction Treatment Centre

General Faculty Hospital PragueCzech Republic

Substitution Treatment Standard

(Order of the Czech Ministry of Health; part 6/2000, part 4/2001)

• drug dependence diagnostic criteria (ICD - 10)

• substitution treatment definition• substances for substitution treatment• substitution treatment typology• indications, contra-indications• therapy (dosage, non-pharmacological components, assessment)

F11.2, F11.3(ICD – 10)

F11.22 : „At present abstain in clinical controlled maintenance

or substitute treatment“(e.g.. methadone; nicotine)

„abstinence-oriented treatment“

Substitution Treatment Definition

(Substitution Treatment Standard, Czech Ministry of Health )

•Standard treatment (therapy)•time unlimited (open-end)

therapy (maintenance therapy)•harm reduction

Personal Requirements

• Diagnosis and indication made by psychiatrist or adictologist

• Substitution treatment performed in specialised centre (with the exception of minimal substitution treatment)

• External supervision for facilities is required

Substitution Treatment of Opiate Addiction in the Czech

Republic - legal substances

1. methadone (HCl)2. buprenorphine (HCl)

(Order of the Czech Ministry of Health; part 6/2000, part 4/2001)

Substitution Treatment of Opiate Addiction in the Czech

Republic

methadone (pharmacopoeia substance)

(Order of the Czech Ministry of Health part 6/2000, part 4/2001)

Substitution Treatment of Opiate Addiction in the Czech

Republic

buprenorphine Subutex®

(tbl. subl. 0,4mg, 2mg, 8mg)Temgesic®

(tbl. subl. 0,2mg, inj.0,3mg)

(Order of the Czech Ministry of Health part 6/2000, part 4/2001)

Buprenorphine in Substitution Therapy

general purpose: • short-term treatment - detox (heroin,

methadone)

• „half-life“ treatment - stabilization• long-term treatment – maintenance

(event. undated/time-unlimited maintenance)

Substitution Treatment of Opiate Addiction in the Czech

Republic - treatment typology

1. Complete substitution treatment

2. Basic substitution treatment

3. Minimal substitution treatment

1. Complete substitution treatment

Administration (provision under control, expense, and/or prescribing) of substitution substance and services, provided within institution:

- treatment of somatic and psychic disorders - detoxification - group psychotherapy - individual psychotherapy - family therapy - counselling - health-risk education etc. (see your copy)

2. Basic substitution treatment

Administration (provision under control and/or prescribing) of substitution substance plus services, provided within institution (dtto)

3. Minimal substitution treatment

(in health institutions with other specializations) Administration (provision under control and/or

prescribing) of substitution substance • short-term - acute states of patients coming from different types of

substitution treatment - planned diagnostics or treatment of patients from

different types of substitution treatment - travels (work, holiday)

• long-term (maintenance) - psychiatric ambulatory - GP´s

Methadone treatment indications

• heavy and long-term dependency on high doses of opioid substances

• repetitive unsuccessful abstinence-oriented treatment

Supporting factors :– Positive experience with substitution treatment – HIV+

– pregnancy

Methadone treatment contra-indications

• possibility and suitability of abstinence-oriented treatment

• prevalence of non-opioid dependence• absence of physical dependence• age under 16• serious hepatic disorders (hepatic

failing)• acute/chronic alcohol intoxication

Buprenorphine treatment indications

opioid type dependence (daily dosage equivalent max. 60mg

methadone)

Buprenorphine treatment contra-indications

• prevalence of non-opioid dependence • age under 15• serious hepatic disorders (hepatic

failure)• IMAO therapy, incl.14 days after

termination• acute/chronic alcohol intoxication

Relative contra-indications of substitution

treatment• alcohol addiction• disability to stop psychoactive

substances intake in despite of adequate dose of substitution substance

• forthcoming imprisonment

Outlook

• Corrections and changes of Standards is continuous– based on practical experiences – according to changes of the system

(e.g. accreditations)– with regard to the future

(involvement of the GPs)

Still interested?Still some time?

What about the recent numbers?

Clients of substitution centres in the Czech republic

Institute of Health Information - ÚZIS (10.3.2003)

382 clients(V/2000 - III/2003: 1268/886)

Clients of substitution centres in the Czech

republic (ÚZIS, 10.3.2003)

methadoneactive: 319

intake (V/2000 - III/2003): 1140terminated (V/2000 - III/2003) 821

Clients of substitution centres in Czech republic

(ÚZIS, 10.3.2003)

buprenorphineactive: 63

admission (V/2000 - III/2003): 128termination (V/2000 - III/2003) 65

Reasons for treatment termination

1. other centre2. different treatment3. breaking rules4. imprisonment5. death6. other

115

228

591

5385

1 2 3 4 5 6

Substitution centres in the Czech republic

1. Apolinář – VFN Praha 22. AT ordinace Hradec Králové3. AT ordinace Mělník4. FN Olomouc5. Masarykova nemocnice Ústí n.

Labem6. DPS Elysium Brno7. DROP IN o.p.s. Praha 18. DROP IN o.p.s. Praha 49. FN Ostrava - Poruba

(Zdroj: MPK, 2001)

Substitution centres in the Czech republic

Centre Number of clients

VFN – Apolinář, Praha 2 56

DROP-IN o.p.s., Praha 4 (1) 101

Masarykova nemocnice Ústí n/L

146

DPS Elysium Brno 51

OAT Hradec Králové 13

OAT Mělník 7

OAT Olomouc 4

FN s poliklinikou Ostrava 4

Substitution treatment- problem drug users in Czech

republic

Prevalence of problem heroin and other opioid users in the Czech

republic (2000):12.000 – 18.000 (PAD, 2001)

Methadone maintenance in CR (2000):190 clients (< 2%)

actual (2003): 2,5 – 6%