A review of the legislation, regulation and delivery of methadone in 12 Member States of the European Union

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Drug prevention
A review of the legislation,
regulation and delivery of
methadone in
12 Member States
of the European Union
Final report
The National Addiction Centre — London
Professor M. Farrell
1995
EUROPEAN
COMMISSION Cataloguing data can be found at the end of this publication.
Luxembourg: Office for Official Publications of the European Communities, 1996
ISBN 92-827-6094-4
© ECSC-EC-EAEC, Brussels · Luxembourg, 1996
Reproduction is authorized, except for commercial purposes, provided the source is acknowledged.
Printed in Belgium Acknowledgements
Special thanks to Ellie Hooper for secretarial support and to Samantha Howes for tech­
nical support. Thanks also to Kate Tidnam and Margaret Sheehan.
Particular thanks to Phillipe Roux and MD Véronique Wasbauer of DG V of the
Commission of the European Communities for supporting the execution of this project.
Thanks to all the national experts and service providers who have given much of their
time to provide information, support and advice. These include:
DENMARK: Peter Ege, Anne Sindballe, Ade Ojeniyi, Andreas Sorensen, Christian
Rasmussen.
GERMANY: Gerhard Buhringer, Jutta Kunzel, Manfred Mosch, Dr Austin, Dr Freibot,
Dr Knabbe, Michael Krausz, Peter Degkwitz.
GREECE: Anna Kokkevi, Dr Vasconcelos, Dr Narino Tralhao.
SPAIN: Maria J Bravo, L. de la Fuente Hoz, Antonio Rodriguez, Gregorio Martin,
Tomas Perez Marquez, Juan José Fernadez Miranda, Pedro A. Marina
Gonzalez, Maria del Carmen Veiras Vicente, Irma Carvajal, Montse Garcia
Folez, Marta Torrens, Claudio Castillo, Enric Serras, Gloria Mayral.
FRANCE: M. Jean-Francois, Philip Birier, Marc Auriacombe, Jean Tignol, Denis
Grabot, Didier Touzeau, Ann Coppel, Patrick Aberhard.
IRELAND: John O'Connor, Katherine Bailey, Brian Sweeney, Kathleen O'Higgins,
Gerard Bury, Arthur Dormán.
ITALY: Enrico Tempesta.
HOLLAND: Giel Van Brussell, Gerit Van Santen, A. W. Ouwhand, Dr Van Berkestijn,
Dr Sanderson, Dr Kuif, Wim Van den Brink.
UK: Alan MacFarlane, John Gerrard, John Merrill, Ron Alcorn, Hamid
Ghodse, Margaret Jackman, Anthony Thorley, Siobhan Riordan.
Neither the Commission of the European Communities nor any person acting in the
name of then is to be held responsible for the use made of the information
contained in this publication.
This project was supported by funding from the Commission of the European
Communities. >
7T
Further enquiries about this report should be directed to Dr Michael Farrell, Senior &·
Lecturer and Consultant Psychiatrist, National Addiction Centre, Institute of Psychiatry, 3
4, Windsor Walk, London SE5 8AF. Tel: 0171-919 3829 Fax: 0171 701 8454.
1 Aden owledgements
1 Executive summary
2 Introduction
3 Belgium
4 Denmark
5 France
6 Germany
7 Greece
8 Ireland
9 Italy
10 Luxembourg
11 The Netherlands
12 Portugal
Spain 13
United Kingdom 14
Results and conclusions 15
n
o
3
S
a Executive summary
Introduction
This report describes the development of drug problems and the evolution of policy,
legislation and services responding to thoses in 12 EU Member States. The
specific aim of this project was to provide a description of the organization and delivery
of methadone or other drug substitution services in the individual EU Member States.
The attitude to and the organization of drug substitution services and in particular of
methadone substitution services reflects national variation in attitude to and organization
of drug services probably more than any other single component of national drug services.
Method
A key national informant approach was used to provide information on policy, research
and service aspects. Between two and five services are described in each country with such
services. A semi-structured interview was conducted with national informants. A separate
semi-structured interview was conducted with individual service providers. National and
international data was aggregated to provide an overview of the trends in methadone ser­
vices in the European Union.
Results
In 12 chapters a detailed country-by-country report is provided which outlines the his­
torical, cultural, legislative, regulatory and financial framework of each country's substi­
tution services.
Each country now has a sizeable and comparable long-term opiate-addicted population
who make demands on criminal justice, health and social services.
One of the key features of the development of drug-related problems in Europe has been
the epidemic of HIV in 1980s among injecting drug users and their sexual partners. The
HIV problem has strongly shaped the development of drug policy and drug services with
a strong emphasis on harm reduction policies in many countries. There is striking vari­
ation in the HIV prevalence among injecting drug users within and between countries.
Methadone substitution services have a major role to play in HIV prevention and HIV
containment strategies. Methadone may be used for long- or for short-term interventions.
There is a striking variation between countries on the balance between long-and short-
term use. Longer-term use confers more benefit than short-term use.
There has been a dramatic growth in methadone maintenance services in Europe between
1988 and 1993 with a 2 to 5 fold increase in the total amount of methadone consumed
in different countries. The countries with the largest net increase, such as France and
Germany, started with a very low baseline and it would appear that the countries with sig­
nificant HIV problems have responded with the expansion of methadone programmes. Overall in Europe the growth of methadone consumption parallels the growth in inject­
ing drug use related AIDS cases.
Reasonable estimates of the size of the methadone service population are based on esti­
mates for longer term methadone places. The figures range from 40 to 80 places per
100 000 population, with provision in France and Germany at less than 10 places per
100 000, both France and Germany's treatment population have grown con­
siderably since 1993 and are still undergoing rapid expansion.
There has been limited success in linking substitute prescribing services with primary care
services but given the overall health needs of drug users many planning and policy mak­
ers appear to be prioritizing the need to link specialist drug services with primary care ser­
vices in order to achieve some degree of throughput with services and to improve the level
of healthcare delivery within the substitute prescribing services.
One of the most striking absences across all countries is the non-existence of detailed ser­
vice protocols and guidelines and limited service monitoring and evaluation. The link
between such guidelines and the operational details around the organization of services
will be an important influence on the future development and the evaluation of pro­
grammes.
The majority of services deliver methadone under controlled and regulated conditions
with most consuming the drug within a specialist service under supervision. The range of
variation in this is considerable with services in a few countries having substantial
amounts of non-supervised or take-home consumption and other countries legally pro­
hibiting such services.
There is striking variation in waiting times, time limits and dose limits.
Conclusion
It is reasonable to suggest on the analysis of provision in the Member States that a provi­
sion of between 60 and 90 methadone substitution places per 100 000 population would
significantly address the needs of the opiate-dependent population but in most countries
would not comprehensively address it by such provision. Substitute prescribing may be
viewed as considered along three key dimensions.
Firstly the nature and type of drug — whether it is short-acting or long-acting, whether
it is taken by mouth, smoked or injected.
Secondly the process of administration — whether it is dispensed by the service or by a
community pharmacist, or whether the consumption is supervised or not.
The third dimension of consideration is the nature and extent of adjunctive interventions
broadly described under the term 'psychosocial interventions'. The variations in these
three key dimensions will determine the nature and effectiveness of the service delivered.
To date there is relatively little empirical service evaluation data to indicate the relative
contribution of each dimension.