report on addiction treatment experience of a viennese gp l.
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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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patients on substitution program in vienna

Patients on substitution program in Vienna

Total ~ 4500 patients

at GPs = 3700 (73%)

~ 180 Viennese doctors involved

training program

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

treatment of drug addicted patients prerequisites for reimbursement

Treatment of drug-addicted patients: Prerequisites for reimbursement

1. Basic training

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

reimbursement by insurance company

Reimbursement by insurance company

10 consultations per patient

over a period of 3 months

number of patients on substitution program taken care of by individual gps

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

accrual of patients

Accrual of patients

Referral substitution centers

other GPs(not involved in substitution)

Recommendation by patients on the program

procedure

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

substitution therapy in austria

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®

substitution therapy 1

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

substitution therapy 2

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

substitution therapy 3

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

availability

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.- Company Registered 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

selection of first line substitutional agent

Selection of first-line substitutional agent

Possible algorithm

Sedation needed

no

yesMulti-drug abuse

yesno+short history

MethadoneSR-morphinesBuprenorphine

patient guidance

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 !!)

control measures

Control measures

Initially intake in pharmacy under control of pharmacist

unstable/unreliable patients permanent control

reliable patients own responsibility

stable employment + stable psychosocial environment

change of substitutional drug

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

multi drug abuse

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

problems of substitution treatment in gp office

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

common true untrue stories

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

advantages of substitution treatment in gp office for patients on program

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

success failure and drop out rate

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