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Report on Addiction Treatment: Experience of a Viennese GP PowerPoint PPT Presentation


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Report on Addiction Treatment: Experience of a Viennese GP. Kristina Lion, MD. Patients on substitution program in Vienna. Total ~ 4500 patients at GPs = 3700 (73%) ~ 180 Viennese doctors involved. Training program. 1. Basic training Duration: 1 day ( 8 hours) 40-60 participants

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Report on Addiction Treatment: Experience of a Viennese GP

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Report on addiction treatment experience of a viennese gp l.jpg

Report on Addiction Treatment:Experience of a Viennese GP

Kristina Lion, MD


Patients on substitution program in vienna l.jpg

Patients on substitution program in Vienna

Total ~ 4500 patients

at GPs = 3700 (73%)

~ 180 Viennese doctors involved


Training program l.jpg

Training program

1. Basic training

Duration: 1 day ( 8 hours)

40-60 participants

several experts

2. Quality control circles

4x/year 3 hours each session

small groups (max. 10 participants)

1 expert / 1 moderator

topics selected by participants

minimumparticipation: 2x/year


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Treatment of drug-addicted patients: Prerequisites for reimbursement

1. Basic training

2.Participation in quality control circles minimum 2x/year


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Reimbursement by insurance company

10 consultations per patient

over a period of 3 months


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Number of patients on substitution program taken care of by individual GPs

Patients per GP

Minimum: 2-3

Maximum: 250

Majority:20 - 70

my office 75 addicted patients


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Accrual of patients

Referral substitution centers

other GPs(not involved in substitution)

Recommendation by patients on the program


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Procedure

1. Consultation:type of addiction

duration of abuse

previous treatment

psychosocial status

motivation for treatment

information on treatment options

2. Urine test : abuse of which drugs?

3. Appointment for next consultation


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Substitution therapy in Austria

3 types of synthetic opioids registered and approved:

1.Methadone (MTD)

2.Slow-release morphines (SRM)

Morphine sulfate (Substitol® ret.)

Morphine hydrochloride (Compensan® ret.)

3. Buprenorphine (BN)

Subutex®


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Substitution therapy - 1

Methadone

oldest drug (since 1965)-formerly first choice

Indication:sedation required (multi-drug abuse)

Application:oral > liquid preparation

Dosage:average: 100 + 20 mg/day

Advantages:low price

no i.v. abuse

detectable in urine test

Disadvantage: side effects weight gain

sweating

depression


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Substitution therapy - 2

Slow-release Morphines:

authorization for substitution therapy by GPs since summer 2002

Indication:Methadone intolerance

Application: oral > tablets

Dosage: 600 + 200 mg/day

Advantage: low incidence of side effects

Disadvantages: i.v. abuse

no differentiation from heroin in urine


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Substitution therapy - 3

Buprenorphine - Subutex® :

approved in EU-countries since 1999

Indication: short history of addiction

clear mind required

Application:oral >sublingual tablets

Dosage:12 + 4 mg/day

Advantages:virtually no side effects

no sedation > clear mind

differentiation from heroin in urine

Disadvantages:initial withdrawal syndrome

poor response, if addiction severe


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Availability

Methadone:By prescriptiononlyExample for daily MTD dose:

Methadoni hydrochlorici 40,0 mg

Adde sirupis simplicis 5,0 g

Solve in aquae dest. 25,0 g

MTD concentration varies , total volume of preparation remains constant

Pharm.- CompanyRegistered name Tablets (mg)

SR-Morphines: MundipharmaSubstitol® ret. 120 mg +200 mg

Lannacher Compensan® ret. 200 mg Vendal ® ret.100 mg+200 mg

Buprenorphine : Aesca Subutex®2mg + 8 mg


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Selection of first-line substitutional agent

Possible algorithm

Sedation needed

no

yesMulti-drug abuse

yesno+short history

MethadoneSR-morphinesBuprenorphine


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Patient guidance

First week: prescription for 1-3 days control by pharmacist

determine optimum dose

Long term prescription:(max. for 30 days)

Permission by district magistrate (authorized physician) required

prevent double prescription (dealing !!)


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Control measures

Initially intake in pharmacy under control of pharmacist

unstable/unreliable patients permanent control

reliable patients own responsibility

stable employment + stable psychosocial environment


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Change of substitutional drug

Side effects: MTD SRM

Weight gain

GI discomfort

Patient´s request Subj. intolerance:MTD (BN) SRM

Interest to deal :MTD (BN) SRM

Suspicion of i.v. abuse: SRM MTD

Doctor´s decision Suspicion of dealing activity: SRM MTD

BN

Side effects (depression): MTD SRM

BN


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Multi - drug abuse

cocain

~ 30-50 % of patientson substitutionbenzodiazepines

cannabis

Aim:Single-agent substitution

Optimum dosage!!!

Dosage too low sleeping disorders

If single-agent substitution not possible

add low-dose benzodiazepines


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Problems of substitution treatment in GP office

Confrontation with other patients

Personal safety

Difficult replacement during holidays

Patients are used to seeing “their” doctor

Reliable patients long-term prescription

Unreliable patients outpatient centers

doctors not involved in program


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Common true untrue stories

Loss/theft of prescribed drug

Breakage of glass flask (MTD)

Attempt to obtain additional prescription

for personal abuse or dealing??

Replacement upon personal judgement


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Advantages of substitution treatment in GP office for patients on program

1. Drug addicts feel like „normal“ patients

self-confidencefeeling of being discriminated

2. Easier arrangement of appointments

3. Treatment by a single (i.e.“their”) physician

personal relationshipbetter psychosocial support


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Success, failure and drop out rate

Success: ~ 1/3 no drug abuse besides substitution agent

stabilization of social structures job

apartment

relationship

no illegal activities, if previously present

Failure rate: ~1/3 relapse to illegal use of drugs, despite continuous substitution

not irreversible

patience and persistence required

years success

Drop out rate: ~1/3 patients quit substitution program

patients transferred to substitution center/other physician

patients in prison


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