Opioid substitution therapy (ost) models of programme design and implementation

Opioid Substitution Therapy (OST):
Models of programme design and
implementation
Dr. M. Suresh Kumar MD DPM MPH
Consultant Psychiatrist
National CME: “Opioid Substitution Therapy: Policy and Practice”
Organised by NDDTC & AIIMS
New Delhi
April 18 2015Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Outline of presentation
1. OST in various settings and models of OST
2. OST as drug treatment vs OST as HIV prevention
3. Integrated OST services
4. Key gaps in OST program implementation
5. Summary
Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

1. OST IN VARIOUS SETTINGS AND
MODELS OF OST

OST in various settings
 OST in specialised exclusive clinics
 OST in hospitals
 OST in drug dependence treatment clinics
 OST in primary care settings
 OST in community settings
 OST in custodial settings

OST in various settings
 OST in hospitals
 Department of Psychiatry
 Department of General Medicine
 OST in primary care settings
 OST in primary health care settings
 OST delivery through Pharmacies
 OST in community settings
 Government sponsored OST Clinics
 NGO run OST Clinics
 With Outreach Programs
 With Peer Support
 OST in custodial settings

“Everyone deserves services
no matter what”
Client centeredness
Low threshold services

Low threshold OST
 Disagreement between professional groups and programs on
definition of ‘low threshold’ OST
 Abstinence from opioids and other drugs is not the treatment goal
 High involvement of GPs and community health providers
 Prescription of buprenorphine or slow release morphine
 Reduce barriers for admission
 Facilitate treatment retention
Strike et al, Int J Drug Policy 2013; 24(6):e51-6

Facilitators of OST
 Government sponsorship
 No dispensing fee
 Attractive to poor opioid dependent clients
 Mobile units

MMT in North America

Methadone: IRAN

MMT, Specialized clinic: Iran

MMT, General hospital: Iran

OST Clinic: Melbourne, Australia
WHO Jakarta

Pharmacy delivery: Australia

Community MMT Clinic: China

MMT Clinics in China

OST in Asia
 Methadone scaling up in:
 China, Malaysia, Indonesia
 Methadone established in:
 Hong Kong, Thailand, Myanmar, Vietnam, Cambodia
 Nepal, Bangladesh, Afghanistan, Maldives
 Buprenorphine substitution in:
 India
 Malaysia
 Detoxification using buprenorphine in Indonesia, Malaysia, India,
China, Myanmar

Models of delivery in South Asia
Model Bangladesh India Maldives Nepal
Drug used Methadone Buprenorphine
Methadone
Methadone Methadone
Beneficiaries PWID PWID People with
Opioid
dependence
PWID
Location GO run
hospital
NGO run TIs
GO-NGO
Model
Govt Dept of
Psychiatry,
Medical
College
Urine testing No No Random urine
screen
No
Rao et al, Bull World Health Organ 2013; 91:150-53

OST in Asia
Country Estimated no. of
PWID
No. of OST sites
in 2008
OST
in prison
Est. no. of PWID
covered by OST in
2008
China 1,800,000–
2,900,000
531 159,439
Indonesia 190,460–247,800 35 4 3300
India 106,518–223,121 47 1 4600
Malaysia 170,000–240,000 68 4 22000
Maldives 400–500 1 45
Myanmar 60,000–90,000 7 500
Nepal 28,000 2 192
Thailand 160,528 147 4000-5000
Viet Nam 135,305 6 1484
Adapted from: Chatterjee & Sharma / International Journal of Drug Policy 21 (2010) 134–136Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

OST Scale-up in India (March 2014)
29
104
147
94
32
175
350
250
0
50
100
150
200
250
300
350
400
No of states
with OST
No of Districts
with OST
Services
No of OST
Centres
No of OST
centres with
Govt
Current Status
Targets

Community based OST Clinic: Chennai

Community based OST Clinic: Delhi,
India

Implementation of OST within
prison
 OST reduces HIV transmission within prisons
 It serves as a conduit to care after release from prison
 It reduces the adverse consequences of injection drug
use, including overdose both within prison and after
release
Springer, 2010. Addiction, 105, 224–225Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

MMT in Prison Malaysia

OST in prisons: Malaysia
Attitudes of prisoners to MMT
 Secondary HIV prevention among prisoners in Malaysia
is crucial to reduce community HIV transmission after
release
 Half of the surveyed HIV+ prisoners believed that OST
would be helpful, only a third said they needed it to
prevent relapse after prison release
 Those reporting the highest injection risks were more
likely to believe OST would be helpful
Bachireddy et al, Drug and Alcohol Dependence 116 (2011) 151–157Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

2. OST AS DRUG TREATMENT
VS
OST AS HIV PREVENTION

Opioid Substitution Therapy (OST):
Triple Action
Objective Target population Responsible
sectors, agencies
OST as HIV prevention IDUs Ministry of Health
Prison authorities
NGOs
OST to improve treatment
adherence to ART and TB
DOTS
HIV + IDUs
IDUs with TB
Ministry of Health
ART Centres
Hospitals
Prisons / custodial settings
NGOs
Private Sector
OST as drug dependence
treatment
Opioid dependent persons
(includes both IDUs and
non-injecting drug users)
Ministry of Health
Public Security
Drug treatment and
rehabilitation centres
Prisons / custodial settings
NGOs
Private sector

COCKRANE REVIEW: MMT
 Methadone is an effective maintenance therapy
intervention for the treatment of heroin dependence
 It retains patients in treatment and decreases heroin use
better than treatments that do not utilise opioid
replacement therapy
 It does not show a statistically significant superior effect
on criminal activity or mortality
Mattick et al, Cochrane Database Syst Rev. 2009 Jul 8;(3)Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Impact of MMT Program, China
 In 2008 and 2009, respectively, an
estimated 2969 and 3919 new HIV
infections (excluding secondary
transmission) were prevented
 Consumption of heroin was
reduced by 17.0 tons - 22.4 tons
 $US939 million - US$1.24 billion in
heroin trade were avoided
 MMT program is supported
legislatively and financially by the
central government with multi-
sector cooperation
 Incorporation of MMT clinics into
existing medical infrastructure,
which has facilitated delivery of
services
Yin et al, International Journal of Epidemiology 2010;39:ii29–ii37

MMT Program, China
(128 clinics, 2-year follow-up)
Yin & Wu, 2008:
Presented at 19th International Conference on Harm Reduction,
11-15 May 2008, Barcelona, Spain

Components of effective methadone
treatment
 Flexible but adequate dose of methadone after
stabilisation (usual range 50–150 mg)
 Adequate duration of treatment
 Goal of maintenance
 Rapid and client-centred assessment and induction
Ward et al, 1999. THE LANCET, Vol 353

Components of effective methadone
treatment
 Psychosocial services to deal with social disadvantage
and psychiatric comorbidity
 Trained staff with positive attitudes towards MMT and
opioid dependent patients
 Affordable - cost of treatment should not exceed ability
to pay
 Engagement with clients rather than punishment of
continuing illicit drug use
Ward et al, 1999. THE LANCET, Vol 353

Buprenorphine and illicit drug
use
Fiellin et al, J Acquir Immune Defic Syndr 2011;56:S33–S38Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

OST in HIV settings:
OST as HIV prevention
Injecting
frequency
Injecting
risks
Sex risks HIV
infectivity
HIV
incidence
OST ↓ ↓ x -- ↓
Adapted from: Degenhardt et al, Lancet 2010; 376: 285–301

Evidence for MMT as HIV
prevention
Metzer et al, J Acquir Immune Defic Syndr. 1993 Sep;6(9):1049-56

Effectiveness of MMT
 MMT is associated with a significant decrease in
injecting drug use and sharing of injecting equipment
 MMT is associated with a lower incidence of multiple sex
partners or exchanges of sex for drugs or money, but no
change, or only small decreases, in unprotected sex
 Studies of seroconversion, suggest actual reductions in
cases of HIV infection
Farrell et al, International Journal of Drug Policy 16S (2005) S67–S75

Evidence for OST:
Other benefits in HIV integrated care
BHIVES Collaborative findings
• Established in 10 sites as integrated models of HIV primary care and
substance abuse treatment
• OST with buprenorphine/naloxone potentially effective in improving
health related QOL for HIV-infected patients with concurrent opioid
dependence
• Integration of buprenorphine/naloxone into HIV clinics increases
receipt of high-quality HIV care
• Buprenorphine/naloxone provided in HIV treatment settings also
decreases opioid use
J Acquir Immune Defic Syndr 2011;56Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Evidence for OST as HIV prevention:
Buprenorphine in reducing HIV related
risk behaviours
Sullivan et al, J Subst Abuse Treat. 2008; 35(1): 87–92Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

OST medications: Is there a
choice?
Methadone Buprenorphine
Most researched and proven
effectiveness as HIV prevention and
dependence treatment
Relatively less researched; evidence for
HIV prevention and dependence
treatment exists
Cheaper; cost effective option Expensive
Overdose not uncommon ‘Ceiling effect’ – Safety of the drug
Drug interactions with ARVs – need to
adjust doses
No clinically significant drug
interactions with ARVs

Key findings from WHO
collaborative study on OST and HIV
 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
Lawrinson et al, 2008; Addiction, 103, 1484–1492Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Methadone vs Buprenorphine
 Methadone clients have more severe substance abuse and
psychiatric and physical problems compared to buprenorphine
clients
 Clients on methadone are more likely to remain in treatment
 However, those retained on buprenorphine are more likely to
suppress illicit opiate use and achieve detoxification
 Buprenorphine may also recruit more individuals such as those
who do not want methadone to treatment
Pinto et al, J Subst Abuse Treat. 2010;39(4):340-52.
The SUMMIT Trial

Effectiveness of OST with
methadone or buprenorphine
 There is strong evidence that OST with methadone or
buprenorphine suppresses illicit opioid use
 Both access to and effectiveness of OST contribute to
sustaining adherence to HAART in HIV-infected IDUs
 There is also evidence that OST for HIV-positive IDUs is
associated with improved health outcomes
Farrell et al, International Journal of Drug Policy 16S (2005) S67–S75
Roux et al, 2008; Addiction, 103, 1828–1836Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Effectiveness of OST with
methadone or buprenorphine
 Buprenorphine is an effective medication in the
maintenance treatment of heroin dependence, retaining
people in treatment at any dose above 2 mg
 Compared to methadone, buprenorphine retains fewer
people when doses are flexibly delivered and at low
fixed doses.
 If high doses are used, buprenorphine
and methadone appear no different in effectiveness
care.
 Methadone is superior to buprenorphine in retaining
people in treatment
Mattick et al, Cochrane Database Syst Rev. 2014 Feb 6;2

3. INTEGRATED OST SERVICES

Integrated Services
 Different models of integration
 Co-located services
 Case management
 Referral networks
 Role of medical providers in screening and
interventionPresented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Integrated Services
 Different models of integration
 Clinic site level integration
Same physician delivering addiction and
medical services
Two physicians working together at the
same clinic

Integrated Services
 Psychosocial services
 Mental Health Services
 Pregnancy and reproductive health services
 Infectious diseases care services – HIV, HCV,
TB

Integrated Services
 Potential benefits of providing integrated
substance use and medical care services
 Increase drug treatment capacity
 Reduce health and administrative costs
 Diminish duplication of services
 Improve health and drug treatment outcomes

New Initiatives at Integrated
Services
 Integrating the Substance use and HIV
services
 Buprenorphine HIV Evaluation and Support
Services (BHIVES)
 Integration into community and hospital based
clinics
Weiss et al, J Acquir Immune Defic Syndr Volume 56, Supp 1, March 2011
BHIVES Collaborative

Evidence for OST:
Positive HIV treatment outcomes
Altice et al, J Acquir Immune Defic Syndr Volume 56, Supp 1, March 2011
BHIVES Collaborative

Reasons for poor adherence to
OST and ART
 Perception of adverse effects
 Alcohol consumption
 Depression
Roux et al, 2008; Addiction, 103, 1828–1836Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

Integration with mental health
services
 High prevalence of personality disorders
 Depression
 Co-morbid substance use disorders
 Integrated services

OST, Pregnancy and
Neonatal abstinence syndrome
 Methadone has been the recommended standard of care for
opioid-dependent pregnant women
 Buprenorphine is an alternative to methadone for the treatment
of opioid dependency during pregnancy
 The benefits of buprenorphine in reducing the severity of NAS
among neonates with this complication suggest that it should
be considered a first-line treatment option in pregnancy
Jones et al, N Engl J Med 2010; 363:2320-31Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

How to improve and ensure effective
linkages?
 Co-location of services
 Collaboration between various departments
 Cross training of health professionals
 Treatment literacy for IDUs
 Other supportive services
 mental health, psychosocial support, nutrition

4. KEY GAPS IN OST PROGRAM IMPLEMENTATION

OST adoption
 Despite evidence, detoxification is preferred than opioid
substitution therapy by several addiction programs
 Leadership qualities critical to OST adoption
 Leaders’ training treatment orientation, tenure determine
OST adoption
 Leaders less ideologically grounded in abstinence only
approaches
Friedmann et al, J Behav Heal Serv Res 2010, 37(3):322-37Presented at the national CME "OST: Policy and Practice" on 18th-19th April 2015 at AIIMS, New Delhi

OST: Key challenges for the
resource poor settings
 What is the most effective model for implementing
OST?
 How can OST become a fundamental component of
integrated HIV prevention?
 How can the quality of the OST programmes be
ensured and evaluated?
Kermode, Crofts, Kumar & Dorabjee, Bull World Health Organ 2011;89:243

Efficient ways of delivering opioid
substitution medication
 Prescription by general practitioners
 Community pharmacies
 Community based approach to OST
 Integration into primary care

Key obstacles to safe and effective
delivery of opioid substitution medication
 Restricted Government funding and support for
OST
 Limited patient capacity to pay for OST
 Prejudices against OST
 A balance between overregulation and laissez-
faire provision

Advocacy in Islamic Republic of Iran

Islamic Republic of IRAN
This order is to remind judges at all courts of justice and
prosecutors’ offices throughout the country that, since a major
element of criminal action is verifiable malicious intent, the
aforementioned interventions are clearly void of such intent and,
instead, are motivated by the will to protect society from the
spread of deadly contagious diseases, such as AIDS and hepatitis.
Therefore all judicial authorities must consider the lack of
malicious intent in the interventions of the Ministry of Health and
Medical Education as well as those of other centres and
organizations that are active in this field. They must not accuse
service providers of assisting in the criminal abuse of narcotics
and must not impede the implementation of such needed and
beneficial programmes. Seyed Mahmood Hashemi Sharoudi
Head of the Judiciary
24 January 2005

Policy and OST
 Policy shifts increase coverage of OST
 In Vietnam, Malaysia and China, shift from punitive
law enforcement to evidence based treatment has
increased coverage
 Policy shift in Ukraine increased OST coverage
 Russia’s stand against OST and closing down
access to information on methadone
Degenhart et al, Int J Drug Policy 2014; 25(1):53-60

Workforce and Training
 Limited training and teaching in addiction
medicine during MBBS
 Possibility for one day training course for
prescribing buprenorphine
 Training of nurses, pharmacists and other
healthcare workers

MMT in China: Barriers and
facilitators
Barriers to MMT for
clients
Requirement for registration in the police department
Perceived societal stigma; Logistic difficulties;
Side effects; Inappropriate perception of methadone;
Fear of being addicted to another drug;
Lack of additional services; Economic burden
Barriers for Service
Providers in MMT
Financial difficulties; Lack of professional training
Difficulties in pursuit of career; Lack of institutional
support
Concern for personal safety; Low income
Large work load; Misunderstanding by society
Factors associated
with successful MMT
MMT clinics affiliated with local CDCs have more clients,
higher retention rates
Longer operating hours
Incentives for compliant clients
Lin et al, J Subst Abuse Treat. 2010; 38(2): 119.
Lin et al, Int J Drug Policy. 2010; 21(3): 173–178
Lin, 2009. Dissertations & Theses, UCLA

Factors that maximise
participation in OST programs
Client related Ease of access
Extended opening hours at clinics
Sufficiently high doses
Service Providers
related
Non-judgemental clinicians
Professionally & technically competent to deal with
addiction related issues
High staff morale
Access to allied medical, psychological and welfare
services
Support related Significant peer support
Family support
Support groups

OST: Key gaps identified
• OST is available for a limited number of IDUs at present in
most countries of South Asia
• Lack of exclusive OST centres for women injecting drug
users
• Effective linkages with other services such as ICTC, ART,
TB DOTS, Drug dependence treatment is a significant
challenge
• Pharmacological options for OST need to be expanded
– Methadone; Buprenorphine; Buprenorphine-Naloxone; Oral morphine

Evidence for OST as HIV prevention:
Coverage is critical
Country IDU
prevalence
(%)
OST
availability
HIV
incidence
among
IDUs, 2005
HIV
incidence
among
IDUs, 2006
Russian
Federation
Current IDU
1.78
OST not available 72/million 79/million
Ukraine Current IDU
1.16 (1.00, 1.31)
OST mostly
unavailable (~1%)
134/million 153/million
USA Current IDU
0.96 (0.67, 1.34)
OST available
(1998–2004:
15%–25%)
18/million NA
Canada Lifetime IDU
1.3 (1.0, 1.7)
OST available
(2003: ~26%)
7.2/million 7.3/million
EU (27 countries) Current IDU
0.19 (0.16–0.21)
OST available
(2004: ~33%)
Australia Current IDU
1.09 (0.65–1.50)
OST available
(2006: ~50%)
Weissing et al, Am J Public Health 2009; 99:1049–1052.

Why OST is needed for non-injecting
opioid dependent users?
Strathdee et al, Lancet 2010; 376: 268–84

5. CONCLUSION

Conclusion
• OST is an effective evidence based drug use treatment for injecting
as well as non-injecting opioid dependent individuals
• OST is evidence based opioid use disorder treatment
• OST in HIV settings is primarily to prevent HIV and improve ART
adherence; often benefits go beyond HIV related issues
• Integrated OST services are essential
• The identified gaps in OST in Asia can be effectively addressed in
future through scaled-up efforts (in community & custodial settings)
and multi-sectoral collaboration

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