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Report on Addiction Treatment: Experience of a Viennese GP

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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  1. Report on Addiction Treatment:Experience of a Viennese GP Kristina Lion, MD

  2. Patients on substitution program in Vienna Total ~ 4500 patients at GPs = 3700 (73%) ~ 180 Viennese doctors involved

  3. 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

  4. Treatment of drug-addicted patients: Prerequisites for reimbursement 1. Basic training 2.Participation in quality control circles minimum 2x/year

  5. Reimbursement by insurance company 10 consultations per patient over a period of 3 months

  6. 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

  7. Accrual of patients Referral substitution centers other GPs(not involved in substitution) Recommendation by patients on the program

  8. 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

  9. 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®

  10. 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

  11. 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

  12. 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

  13. 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

  14. Selection of first-line substitutional agent Possible algorithm Sedation needed no yesMulti-drug abuse yesno+short history MethadoneSR-morphinesBuprenorphine

  15. 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 !!)

  16. Control measures Initially intake in pharmacy under control of pharmacist unstable/unreliable patients permanent control reliable patients own responsibility stable employment + stable psychosocial environment

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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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