Prevalence of high-risk drug use and coverage of opioid substitution treatment and needle and syringe programs in Lithuania in 2015-2016: A multi-method estimation study.

BACKGROUND AND OBJECTIVES: In Lithuania, injecting heroin and other illicit opioids has dominated high-risk drug use since about 2000. More recently, patients have reported a high-risk use of amphetamines. Newly diagnosed HIV cases among people who inject drugs peaked in 2002 and 2009 and drug-related deaths have been on the increase. Yet research has reported a limited number of available harm-reduction programs. This study aimed to estimate the size of high-risk drug using populations in Lithuania and to apply these estimates in assessing the coverage of opioid substitution treatment (OST) and needle and syringe programs (NSP). METHODS: We used indirect prevalence estimation methods (HIV and Mortality Multiplier, Capture-Recapture, Truncated Poisson and the Multivariate Indicator Method) to obtain annual prevalence estimates of the population of high-risk opioid users (HROU) and of people who inject drugs (PWID) in Lithuania in 2015/2016. We computed the coverage of OST (the annual percentage of HROU in these programs) and NSP (the number of provided syringes per PWID per year), using the prevalence estimates and the data from drug services. RESULTS: There were between 4854 and 12,444 HROU and between 8371 and 10,474 PWID in Lithuania in 2015/2016. In addition, we obtained a preliminary estimate of 4742-7000 high-risk amphetamine users. This constitutes around 2.5-6.5 HROU and 4.4-5.3 PWID per 1000 inhabitants aged 15-64. On average, 9.9-25.5% of HROUs were in OST and an average PWID in Lithuania obtained 19-29 syringes via NSPs during the study period. CONCLUSIONS: While the current prevalence of high-risk drug use in Lithuania is comparable to other European countries and for PWID, it is above the average; and the coverage of OST and NSP services in this population is markedly lower than in most countries of the European Union and warrants further investment.

Substance Misuse Education for Physicians: Why Older People are Important.

This perspective article focuses on the need for training and education for undergraduate medical students on substance-related disorders, and describes initiatives undertaken in the United Kingdom (UK), Netherlands, United States (US), and Norway to develop the skills, knowledge, and attitudes needed by future doctors to treat patients adequately. In addition, we stress that in postgraduate training, further steps should be taken to develop Addiction Medicine as a specialized and transverse medical domain. Alcohol use disorder is a growing public health problem in the geriatric population, and one that is likely to continue to increase as the baby boomer generation ages. Prescription drug misuse is a major concern, and nicotine misuse remains problematic in a substantial minority. Thus, Addiction Medicine training should address the problems for this specific population. In recent years, several countries have started an Addiction Medicine specialty. Although addiction psychiatry has been a subspecialty in the UK and US for more than 20 years, in most countries it has been a more recent development. Additional courses on addiction should be integrated into the curriculum at both undergraduate and postgraduate levels, as well as form part of the continuous training of other medical specialists. It is recommended that further research and mapping of what is currently taught in medical programs be undertaken, so as to enhance medical education in addiction and improve treatment services.

Evaluation of opioid substitution therapy in Kyrgyzstan

An evaluation of the opioid substitution therapy (OST) programme in Kyrgyzstan took place from 15 to 19 June 2015.This evaluation was a follow up of the previous one by a World Health Organization (WHO) mission in 2008. A delegation from the WHO Regional Office for Europe met with representatives of the Government, Drug Control Agency, Ministry of Health, Ministry of Justice, United Nations agencies, international nongovernmental organizations (NGOs), staff of drug treatment services and NGOs. Mission members conducted focus group discussions and one-on-one interviews with injecting drug users at several OST sites. This evaluation explored how the country had implemented the recommendations from the earlier evaluation in 2008.The WHO mission developed further recommendations on the sustainability of OST, how to increase its accessibility, and improve its quality in the civil and penitentiary sectors.

HIV programme review in Belarus: evaluation report, November 2014

This evaluation builds on a desk review and a country mission which took place on 18-21 November 2014. The preparation phase included a desk review and analysis of available documents (WHO guidelines, national policy/strategy/plans, clinical guidelines, publications, reports, etc.), as well as a review of the draft National Strategic Plan on HIV (NSP) and Concept Note (CN) to the Global Fund. The progress made during the implementation of the NSP 2011-2015 is acknowledged, in particular the increase in the number of people on ARV treatment and subsequent decrease in mortality, as well as the readiness of the government to take over funding of the HIV programme in the future. Overall the evaluation team agrees on the key priority modules as defined in the CN, which takes into account many of the recommendations presented in the evaluation from 2013.

HIV programme review in Georgia: March 2015

This WHO country mission conducted in March 2015 aimed to review three key components of the HIV/AIDS programme in Georgia: HIV treatment and care along the cascade of services; HIV services for key populations; and service delivery models for populations affected by the HIV epidemic from the perspective of the health system as well as review the draft new National Strategic Plan. This technical assistance was provided ahead of the submission of the Global Fund concept note, due on 20 April 2015. It follows a June 2014 WHO country mission carried out to assess the achievements, strengths and shortcomings in the implementation of the Georgian National HIV/AIDS Strategic Plan.Georgia has a concentrated HIV epidemic but is facing serious challenges in controlling it. In 2013, of the newly diagnosed HIV infections with information about transmission mode, 37% were transmitted through heterosexual contact, 29% through injecting drug use and 14% through sex between men. At the end of 2014, the number of people living with HIV in Georgia was estimated to be 6,800, and some 45% of these people were not aware of their status. The recommendations from the mission are presented as four priority areas: HIV testing, treatment, leadership and governance, services for key populations as well as suggestions for the revision of the National Strategic Plan.

HIV programme review in Armenia: March 2015

This WHO country mission conducted in January 2015 aimed to review five key components of the HIV/AIDS programme in Armenia: epidemiology; the HIV surveillance system; HIV treatment and care along the cascade of services; HIV services for key populations; and service delivery models for populations affected by the HIV epidemic from the perspective of the health system. Armenia has a low HIV prevalence overall with a concentrated epidemic specifically affecting people who inject drugs, migrant workers, men who have sex with men, and sex workers. According to 2014 data, an estimated 4,000 people are living with HIV in the country of whom fewer than two out of five are aware of their status and only one-third are linked to care. HIV and AIDS services are centralized at the National Centre for AIDS Prevention in the capital of the country and a key overarching recommendation for the country is to carefully fully or partially decentralize aspects of HIV prevention, treatment and care to reach those most in need including targeted testing to reach those unaware of their status. As a part of this process, additional training for health care providers as well as non-governmental organizations is needed and both stigma and discrimination will need to be addressed among health care providers and the general populations. Additional recommendations are made in this report for the rationalization of antiretroviral therapy regimens; expanded testing; the increased provision of opioid substitution therapy, and government supported needle and syringe programmes for people who inject drugs.

HIV/AIDS treatment and care in Estonia: evaluation report June 2014

This WHO country mission was performed in May 2014 to assess the achievements, strengths and shortcomings in the implementation of the Estonian national programme on HIV/AIDS treatment and care, and to generate strategic recommendations for improving key outcomes and impacts. The mission focused specifically on providing recommendations on the response of the health system to the many new HIV infections, on organization of procurement and provision of ART, and on improvement of prevention interventions. The mission found that HIV will remain a public health problem in the coming years in Estonia. This was echoed by all involved national stakeholders in the field. The epidemic is concentrated among people who inject drugs (PWID), but there are signs that it is increasingly affecting the general population. A worrying observation is the tendency that people with HIV are diagnosed late, that a large share starts treatment late; and there are many examples of non‐adherence to treatment or long‐term treatment interruptions. The problem of linkage and retention in care, particularly for the PWID population, needs urgent attention. The current health care system is not functioning to an extent that provides the PWID community with adequate treatment options and support. This needs to be addressed as high a priority in order to halt the HIV epidemic.

HIVi/AIDSi ravi ja hooldus Eestis: Hindamisaruanne Juuni 2014

WHO hindamisrühm hindas Eestis 2014. aasta mais HIVi ja AIDSi riikliku strateegia rakendamise edusamme, tugevaid ja nõrku külgi ning koostas strateegilised soovitused peamiste tulemuste ja mõju parandamiseks. Hindamisrühma peaeesmärk oli anda soovitusi, milliseid meetmeid peaks tervisesüsteem võtma seoses uute HIVi juhtude suure arvuga, kuidas korraldada ARV-ravimite hankimist ja ARV-ravi ning tõhustada ennetustööd. Hindamisrühm leidis, et HIV on Eestis lähiaastatel jätkuv rahvatervise probleem. Seda kinnitasid kõik valdkonnaga seotud sidusrühmad riigis. Epideemia on koondunud peamiselt süstivate narkomaanide hulka, kuid on märke, et see puudutab järjest rohkem kogu elanikkonda. Muret tekitab suundumus, et HIV diagnoositakse sageli hilises staadiumis, suur osa nakatunutest alustab ravi hilja ning paljudel juhtudel ei peeta ravirežiimist kinni või tehakse pikaajalises ravis katkestusi. Kiiresti vajab tähelepanu eriarsti poole pöördumise ja jälgimisel püsimise probleem, eriti süstivate narkomaanide puhul. Praegune tervisesüsteem ei toimi määral, mis tagaks süstivatele narkomaanidele sobivad ravivõimalused ja toe. HIVi epideemia peatamiseks peaks selle puuduse kõrvaldamine olema prioriteet.

A prospective, randomized, multicenter acceptability and safety study of direct buprenorphine/naloxone induction in heroin-dependent individuals.

AIMS: To provide controlled data on direct induction with buprenorphine/naloxone (BNX) versus indirect buprenorphine (BPN)-to-BNX induction. DESIGN: Phase 4, prospective, randomized, active-drug controlled, parallel-group trial consisting of a 2-day, double-blind, double-dummy induction phase followed by 26 days of open-label treatment with BNX. SETTING: Nineteen sites in 10 European countries from March 2008 to December 2009. PARTICIPANTS: A total of 187 opioid-dependent men and women ≥ 15 years of age. MEASUREMENTS: The primary objective was assessment of patient response to direct and indirect BNX induction [proportion of patients receiving the scheduled 16-mg BNX dose on day 3 (i.e. first day post-induction)]. Secondary assessments included illicit drug use, treatment retention and compliance, withdrawal scale scores, and safety. FINDINGS: Patient response to direct- versus indirect-BNX induction was similar [direct 91.4% (85/93) versus indirect 90.4% (85/94); 95% confidence interval (CI): -7.3%, 9.2%]. Rapid dose induction (16 mg of BPN equivalent on day 2) was acceptable and 72% of patients completed treatment (day 28). There were no significant differences in secondary measures across groups. An average BNX maintenance dose of 15.3 mg across groups was associated with substantial reductions in illicit opioid use and no self-reported intravenous misuse. Treatment compliance and retention rates were similar (98.5% and 81.3%, respectively). Treatment-emergent adverse event rates were comparable: 75% versus 74% for direct- versus indirect-induction groups, respectively. CONCLUSIONS: Direct buprenorphine/naloxone induction was a safe and effective strategy for maintenance treatment of opioid dependence. Response to high-dose direct buprenorphine/naloxone induction appears to be similar to indirect buprenorphine-to-buprenorphine/naloxone induction and was not associated with reports of intravenous buprenorphine/naloxone misuse.

Оценка эффективности опиоидной заместительной терапии в местах лишения свободы: предварительное исследование в Кыргызстане

В 2009-2010 гг. была проведена оценка результатов экспериментальной программы опиоиднойзаместительной терапии в исправительном учреждении – колонии № 47 в г. Бишкеке (Кыргызстан). В ходеисследования с целью оценки результатов программы на курс метадоновой поддерживающей терапии былопринято восемьдесят четыре пациента. Оценка состояния пациентов проводилась до начала курса и через 3 и6 месяцев после начала. Использовались принятые ВОЗ инструменты исследования, переведенные нарусский язык и применявшиеся в предыдущих исследованиях по изучению исходов опиоиднойзаместительной терапии. Они включали индекс лечения опиоидной зависимости, вопросник ВОЗ для оценкикачества жизни WHOQOL-BREF, вопросник для оценки риска передачи гемотрансмиссивных вирусов, шкалуЗанга для самооценки депрессии и другие. Результаты исследования показывают систематическое улучшениесостояния здоровья и качества жизни у пациентов, получающих опиоидную заместительную терапию, а такжезначительное снижение рискованных форм поведения при инъекционном потреблении наркотиков,связанных с передачей ВИЧ-инфекции и других гемотрансмиссивных вирусов.

Evaluation of opioid substitution therapy in prisons: pilot study in Kyrgyzstan

The evaluation of the outcome of the pilot Opioid Substitution Therapy programme in Penitentiary Institution No. 47 in Bishkek (Kyrgyzstan) took place in 2009–2010. The programme’s participants consisted of 84 patients enrolled in methadone maintenance therapy. Assessments were carried out at baseline and after 3 and 6 months. Instruments adopted by WHO, translated into Russian and applied in earlier opioid substitution therapy outcome studies, were used. They included the Opiate Treatment Index, the World Health Organization Quality of Life–BREF questionnaire, the Bloodborne Virus Transmission Risk Assessment Questionnaire, the Zung Self-Rating Depression Scale and others. Results of the study indicate the consistent improvement of health and quality of life among opioid substitution therapy patients, as well as the significant reduction of injecting risk behaviour in relation to transmission of HIV and other bloodborne viruses.

Feasibility of buprenorphine and methadone maintenance programmes among users of home made opioids in Ukraine.

BACKGROUND: Opioid substitution therapy (OST) in the Ukraine was not provided until 2004. Methadone maintenance therapy only became available in May 2008. Injecting drug users in Ukraine are predominantly injecting self-made opioid solution ('Shirka'). A feasibility study on buprenorphine and methadone maintenance treatment was conducted in 2008. METHODS: A total of 331 opioid dependent patients were given buprenorphine (n=191) or methadone (n=140) as a substitute, and a survey of substance use, HIV transmission risks, and legal and social status was conducted at baseline and at six months follow-up. RESULTS: Illegal substance use, illegal activities, incomes and HIV related transmission risks were highly reduced, whereas employment rates and psychiatric problems improved. Retention was comparatively high among the patients in buprenorphine (84.8%) and in methadone maintenance treatment (85.0%) after six months of treatment. CONCLUSION: These data show the successful implementation of OST in the Ukraine among drug users who were predominantly injectors of self-made opioid solutions. Continuing scale-up of OST in the Ukraine is therefore both feasible and highly recommended.

Feasibility of buprenorphine maintenance therapy programs in the Ukraine: first promising treatment outcomes.

BACKGROUND: Opiate substitution therapy (OST) in the Ukraine was not provided until 2004. As part of the introduction of OST, the first feasibility study was conducted in 2007. Six clinics in 6 cities were involved in providing OST and collecting data. METHODS: A total of 151 opiate-dependent patients were given buprenorphine as a substitute, and a survey of substance use, HIV transmission risks, and legal and social status was conducted at baseline and at 6 and 12-month follow-up. RESULTS: Illegal substance use and illegal activities and incomes were highly reduced, whereas employment rates and psychiatric problems improved. Retention was comparatively high (79.5%) after 12 months. No significant adverse events were reported. CONCLUSION: A successful implementation of OST in the Ukraine is feasible.

Key findings from the WHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS.

AIMS: Opioid substitution treatment has been studied extensively in industrialized countries, but there are relatively few studies in developing/transitional countries. The aim of this study was to examine the effectiveness of opioid substitution treatment (OST) in less resourced countries. DESIGN: Longitudinal cohort study. SETTING: Purposively selected OST sites in Asia (China, Indonesia, Thailand), Eastern Europe (Lithuania, Poland, Ukraine), the Middle East (Iran) and Australia. PARTICIPANTS: Seven hundred and twenty-six OST entrants. MEASUREMENTS: Participants were interviewed at treatment entry, 3 and 6 months. Standardized instruments assessed drug use, treatment history, physical and psychological health, quality of life, criminal involvement, blood-borne virus (BBV) risk behaviours and prevalence of human immunodeficiency virus (HIV) and hepatitis C. FINDINGS: Participants were predominantly male, aged in their early 30s and had attained similar levels of education. Seroprevalence rates for HIV were highest in Thailand (52%), followed by Indonesia (28%) and Iran (26%), and lowest in Australia (2.6%). Treatment retention at 6 months was uniformly high, averaging approximately 70%. All countries demonstrated significant and marked reductions in reported heroin and other illicit opioid use; HIV (and other BBV) exposure risk behaviours associated with injection drug users (IDU) and criminal activity, and demonstrated substantial improvement in their physical and mental health and general wellbeing over the course of the study. CONCLUSIONS: OST can achieve similar outcomes consistently in a culturally diverse range of settings in low- and middle-income countries to those reported widely in high-income countries. It is associated with a substantial reduction in HIV exposure risk associated with IDU across nearly all the countries. Results support the expansion of opioid substitution treatment.

Outpatient methadone maintenance treatment program. Quality of life and health of opioid-dependent persons in Lithuania.

BACKGROUND: The evaluation of quality of life and self-perceived health represents an assessment of the impact of treatment on patient functioning and well-being. OBJECTIVE: Our aim was to explore the impact of methadone maintenance treatment on quality of life and self-perceived health of opioid-dependent persons in Lithuania. METHODS: A total of 102 opioid-dependent patients were recruited in the study. A prospective follow-up study design was used. To assess quality of life, the WHOQOL-BREF 26-item version was used. The impact of methadone maintenance treatment on self-perceived health was assessed by Opiate Treatment Index (OTI). RESULTS: Following 6 months of methadone maintenance treatment, significant improvements in physical (P=0.004), psychological (P=0.004), and environmental (P=0.048) components of quality of life were observed; no statistically significant improvements were found in social component of quality of life. Study participants reported lower rates of medical morbidity associated with injection (P<0.001), cardiorespiratory (P=0.034), musculoskeletal (P<0.001), neurological (P=0.013), gastrointestinal (P<0.001), and general health (P<0.001). CONCLUSIONS: Methadone maintenance treatment substantially reduces morbidity associated with opioid dependence and improves the quality of life of patients.

Drug addiction maintenance treatment and quality of life measurements.

Quality of life measurements are increasingly incorporated into trials of pharmaceuticals. This can be applied to a wide range of medical areas including drug-addiction maintenance treatment programs. Maintenance treatment has been demonstrated to be an effective treatment for opioid addiction but still lacks quality of life specific measures to measure the maintenance program effects and until now there have been only few attempts to assess the impact of opioid dependence and its treatment on the drug-addicted patients' quality of life. The aim of this article is to describe quality of life concept, measurement instruments, selection criteria and its applicability in the drug addiction maintenance studies.

[Economic efficiency of methadone maintenance and factors affecting it]. / Pakaitinio gydymo metadonu ekonominis efektyvumas ir jam itakos turintys veiksniai.

UNLABELLED: Methadone maintenance is effective in reducing injection drug use, needle sharing, and the overall mortality associated with opiate abuse. Scientific literature describes that efficiency of methadone maintenance program depends on many factors. Our analysis is based on description of economic research methods and on factors affecting economic efficiency of methadone maintenance. METHODS: Computerized Medline data base was searched by key words: "economic evaluation", "cost-effectiveness", "cost-utility", "methadone", "methadone dosage", "ancillary services", "treatment duration". Review and analysis. RESULTS: Methadone maintenance therapy has higher economic efficiency with 80-100 mg per day methadone dose. Doses lower than 40 mg per day are considered as inefficient. Some methadone programs limit treatment to 90 days or less, but such short treatment episodes are not likely to be cost-effective. Ancillary services are more cost-effective at the beginning of methadone maintenance program, than in the later stages of the program. Economic efficiency is higher when program involves more participants, than when more ancillary services are provided. CONCLUSIONS. Effectiveness of Methadone maintenance program affects methadone dosage policy, treatment duration and ancillary services.