SUBSTITUTION TREATMENTSUBSTITUTION TREATMENT

PROGRAMMES IN CROATIAPROGRAMMES IN CROATIA

VenijaVenija CeroveCeroveččkiki NekiNekićć , MD,GP, MD,GP

Hrvoje Hrvoje TiljakTiljak, MD, , MD, PhDPhD, , AssistentAssistent ProfessorProfessorDepartmentDepartment forfor FamilyFamily Medicine Medicine

UniversityUniversity ofof Zagreb, Zagreb, MedicalMedical SchoolSchoolAnte Ante IvanIvanččiićć, MD,GP, Pore, MD,GP, Porečč, Croatia, Croatia

VilniusVilnius, , LithuaniaLithuania, , MayMay 2929--30,2008.30,2008.

HealthHealth Care Care SystemSystem inin CroatiaCroatia

� 3 levels PrimarySecondaryTertiary

PrimaryPrimary HealthHealth Care (PHC)Care (PHC)

• general practitioners

• paediatricians• gynaecologists• dental care• occupational medicine • emergency medical care• medical care for school children• public nurse

General General PracticePractice inin CroatiaCroatia

• about 2560 doctors work as GPs• gate-keepers• comprehensive care• 30 % Vocational trained GPs• patients list were introduced into PHC• average number of patients on GPs lists about

1700• free choice of GPs have been existing • 88 % of the population registered in general

practice

General General PracticePractice inin CroatiaCroatia

• GPs are individual contractors withNational Institute for Health Insurance

• 84 % are individual contractors integratedinto the public sector

• 16 % GPs work as salaried doctors withinthe Health Centers

• GPs are paid by capitation (differentiatedby age) and fee for services

HealthHealth InsuranceInsurance

• national health insurance • insurance fond (taxis)• all Croatian citizens are insured and have

free access to health care system• some participations for drugs and

diagnostic procedures-symbolic• private insurance funds- for better comfort

WHO/UNAIDS/UNODC WHO/UNAIDS/UNODC

POSITION PAPERPOSITION PAPER

SubstitutionSubstitution maintenancemaintenance therapytherapy

inin thethe menagementmenagement ofof opioidopioid dependencedependence andand HIV/AIDS HIV/AIDS preventionprevention, 2004, 2004

• Treatment of large number of individuals with OD demands the development of MT programs that are incorporated within general primary health care and welfare services.

Organisation of substitution treatmentOrganisation of substitution treatment (EMCCDA, 2002)(EMCCDA, 2002)

• General practitioner’s:

Austria, Belgium, France (buprenorphine), Germany, Ireland, Luxembourg, UK, Denmark

• Specialised centres:

Denmark, France (methadone), Italy, the Netherlands, Portugal, Spain

• Specialised centres,

limited number:

Finland, Greece, Sweden, Norway

Advantages of Advantages of thethe treatmenttreatment of ODof OD in in

PPrimary rimary HHealth ealth CareCare

• Availability • Integrative - holistic care• Destigmatisation • Degetoisation = Normalization of • treatment• Lower costs

Disadvantages of GPs involvement in Disadvantages of GPs involvement in

drug drug addictionaddiction treatmenttreatment

• Difficult to assure quality of treatment

• Easier diversion

• Lost of epidemiological data

TreatmentTreatment modelsmodels of MT in PHCof MT in PHC

• GPs as primary prescribers: “office based prescribing”

• Referral model

• Shared care

HystoricalHystorical backgroundbackground of of CroatianCroatian

addictionaddiction treatmenttreatment modelmodel

• Tradition of social psychiatry and alcoholism treatment (Hudolin)

• Tradition of social medicine in general practice ( Štampar)

CroatianCroatian storystory::

• methadon start in 1991 – avaliable in PHC supervised by special units

• buprenorphine start in in 2004 – avaliable in PHC, but for price of approximately 20

Euro weekly payed by clients – At the same time practical no cost in methadone

treatment.• buphrenorphine become free of charge in 2007

– available in PHC supervised by special units care physicians

• cost of treatment become important issue for public resources

Health policy background of STHealth policy background of ST in in

CroatiaCroatia

• Easy acces to health insurance• Addict if not insured will get insurance

because of his addiction• ST free of charge• Every person in Croatia has “own doctor“• GPs - “gate keepers”

TheThe keykey premise of drug premise of drug addictionaddiction

treatmenttreatment in Croatiain Croatia

•Drug addiction is not substantially different than any other chronic disease •Drug addicts are not different than other patients•Opiate agonists are not substantially different than other medicine

FollowingFollowing thisthis premise:premise:

• Treatment is integrated in existing health care structure

• ST provided exclusively by GPs

Croatia Croatia factsfacts 2006.2006.

• Population 4 500 000• Heroin addicts (estimated) 12-15 000• Heroin addicts in treatment 5611*• Medication assisted treatment 3541*

*Croatian National Institute of Public Health, Annual Report for 2006

SharedShared care modelcare model

Centres for Outpatient Treatment and

General Practitioners

PositionPosition of of CentresCentres

• Centres - the only “new” structureorganized for treatment of addiction

• 25 Centres situated in all major cities • Centres are not “methadone centres”

Centre Centre -- interdisciplinaryinterdisciplinary teamteam

• Medical practitioner (Psychiatrist or GP)• Psychologist• Social worker• Medical nurse

The role of CentresThe role of Centres

• Clinical assessment • Recommendation of Meth – Bup treatment• Periodical evaluation • Urine testing• Psychosocial counseling• Collecting epidemiological data

TheThe rrole of ole of GPsGPs in in OTPOTP

• prescribe methadone-buprenorfine,• supervise consumption, • prepare «take home» doses,• treat all other health problems.

CroatianCroatian model model achievementachievement

• Availability : more than 50% GPs (1200) have addicts in OT

• Professional quality:GPs get specialised support form expertsin Centres

GPsGPs prescribingprescribing methadonemethadoneIvancicIvancic,,TiljakTiljak: 6 th EUROPAD : 6 th EUROPAD ConferenceConference, , ParisParis, 2004, 2004

0

50

100

150

No doctors 193 = 8% GPs in Croatia

No Doctors

No Doctors 67 126

no yes

DistributionDistribution of of patientspatients//doctorsdoctors

Mean patientMean patient/doctor=4,5/doctor=4,5

0

2

4

6

8

10

12

14

16

18

20

No doctors

1 2 3 4 5 6 7 8 9 10 11 12 15 19 23

No patients/docor, total 564 patients

No doctors

OpiateOpiate agonistsagonists distributiondistribution MarchMarch 2008 2008

((estiamtedestiamted))

.

100,006250Total

43,52720buprenorphine

56,53530methadone

%Nr of patients

PrescribingPrescribing and and dispensingdispensingregimenregimen -- MethadoneMethadone

•Recommendation from Centre•Prescription by GP•Supervised consumption in GP’s office ( the rule in the beginning of treatment) •“Take homes”(usual form of dispensing) –prepared by medical nurse

PrescribingPrescribing and and dispensingdispensing

regimenregimen -- BuprenorfineBuprenorfine

• Recommendation by Centre • Prescribing by GP• Dispensing in pharmacy as any other

medicine• Exceptionally supervised consumption

MortalityMortality of of addictsaddicts in Croatia 1997in Croatia 1997--2006, CPHI 2006, CPHI AnnualAnnual reportreport 20062006

852006

1042005

1082004

952003

862002

782001

752000

631999

431998

441997

291996

CauseCause of of deathdeath of of addictsaddicts in Croatia in in Croatia in

20062006 CPHI CPHI AnnualAnnual ReportReport 20062006

11,810Others

2,42Accidents

2,42Suicide

11,810Other illnesses

20,017Methadone overdose

20,017Other opiates

31,827Heroin overdose

%Nr.Cause

OutcomesOutcomes and and indicatorsindicators

• High coverage, estimated > 50%• Retention rate, estimated > 80% • Overal mortality < 1% annually *• HIV infection 0,5 %* ( 0,3-0,6 % )• HBV poz. 15,5%*• HCV poz. 46,2%*

*Croatian National Institute of Public Health, Annual Report for 2006

ProblemsProblems

• Part of GPs do not follow the procedure (minimal controle)

• Problem to find the GP to provide ST ( in some places)

• Insufficient education of GPs and nurses• Leaking of methadone and „methadone

deaths”• Inadequate payment of GPs (providing ST is

not extra paid)

CroatianCroatian suggestionsuggestion::

• more than one medicament • avaliable in PHC • same prescription and distribution policy

for all medicaments• individual approach in medicament choice• investigate addiction population needs• investigate public resource capacity

When planning treatment programsWhen planning treatment programs::

• pharmacological issues• prescription and distribution policy• costs

– for client – public cost of treatment programs

• historical reasons

When planning individual treatmentWhen planning individual treatment

• pharmacological issues• prescription and distribution policy• costs

– for client – public cost of treatment programs

• patient needs• illness characteristics

WelcomeWelcome to Croatiato CroatiaWelcome to Croatia