MA. Erlind Plaku Albania

MMT Aproach to young DU-sMMT Aproach to young DU-s

Drugs: Definition Psychoactive drugs are chemicals that change a

person’s mood, feeling, consciousness, perceptions and behavior

Very common features of drugs are:

Addiction/dependence Phsycological Physical

Tolerance

Withdrawal syndrome

What is opioid dependence? Opioids are a family of drugs used to relieve pain. Some opioids, such as

morphine and codeine, are made from the opium poppy plant. Other opioids are synthetically made from chemicals.

Heroin is a highly addictive, illegal opioid made by adding a chemical to morphine.

Opioids are effective painkillers. They can also create feelings of intense pleasure or euphoria. People who misuse or abuse opioids can easily become addicted to them.

Opioid dependence is not just a heavy use of opioids, but a complex health condition that includes both a psychological and physical dependence on opioids

People are psychologically dependent when a drug is so central to their thoughts, emotions and activities that the need to keep using the drug becomes a craving or compulsion.

With physical dependence, the body has adapted to the drug and will suffer withdrawal symptoms if use of the drug is reduced or stopped abruptly.

Continued

Substance Dependence Diagnosis DSM-IV Criteria (≥ 3 in last 12 months)

Tolerance Withdrawal Persistent desire to cut down or quit Spends time taking, obtaining, recovering Takes more than intended Given up important activities due to substance Use in spite of physical or psychological

problems caused by substance

What Are the Health Consequences? Heroin addicts have an increased risk of premature death from drug

overdose, violence, suicide, and alcohol-related causes, with opiate overdose the most frequent cause of death.

In countries with a high prevalence of HIV infection, AIDS is a major cause of death among opiate users. In parts of Asia, Eastern Europe, and the United States, sharing contaminated needles accounts for a substantial proportion of new HIV infections.

Injecting drug users are also commonly infected with hepatitis B and C viruses. Up to one-tenth of those with hepatitis C develop liver cirrhosis, which is often fatal.

What is MMT?  Methadone maintenance treatment (MMT) is a substitution therapy.

Substitution therapy replaces the drug that the person is dependent on with a prescribed substance that is pharmacologically similar, but safer when taken as prescribed.

People who are dependent on opioids can take methadone to help stabilize their lives and reduce the harm related to their drug use.

Methadone is a long-acting opioid drug. This means it acts more slowly in the body and for a longer period of time than most other opioids. By acting slowly, it can prevent withdrawal symptoms and reduce or eliminate drug cravings, without causing a person to “get high”.

continued MMT helps people who are dependent on opioid drugs stabilize their lives,

increasing the time and opportunity to deal with their health, psychological, family, housing, employment, financial and legal issues.

Medically supervised methadone treatment works best when combined with other types of health and social support services.

These services include addiction counselling, case management, mental health services, health promotion, disease prevention and education, and other community-based services, such as legal, financial, medical, child care, dental and housing services

Methadone Maintence Treatment (MMT)Methadone Maintence Treatment (MMT) Is recognized internationally, as an effective, safe and cost-effective

treatment option for opioid dependence. Although other forms of treatment continue to be explored, MMT remains the most widely used form of treatment for people who are dependent on opioids.

MMT can decrease the high cost of opioid dependence to individuals, their families and society (World Health Organization, 2004).

Methadone Maintenance Therapy First described 1965 (Dole) Methadone is a long acting synthetic opioid taken orally

once/day MMT effective in treatment of opiate substance

dependence as it reduces craving for, and withdrawal from, heroin/other opiates

Evidence among opiate dependent patients on sustained MMT

Reduced morbidity and mortality, Diminished involvement in crime Gain control of their lives Reduced transmission of HIV Cost-effective reducing major harms

Heroin Methadone

Route of administration intravenous etc oral

Onset of action immediate 30 minutes

Duration of action 3–6 hrs 24–36 hrs

Euphoria first 1–2 hrs none

Withdrawal symptoms after 3–4 hrs after 24 hrs

Heroin versus Methadone*

Methadone: blocks the euphoric and sedating effects of opiates; relieves the craving for opiates that is a major factor in

relapse; relieves symptoms associated with withdrawal from

opiates; does not cause euphoria or intoxication itself (with stable

dosing), thus allowing a person to work and participate normally in society;

is excreted slowly so it can be taken only once a day.

Methadone types

Tablets Powder Liquid

Treatement No single treatment is effective for all individuals

with opioid dependence. Two main treatment options are available:

addiction treatment counselling (e.g., withdrawal management, outpatient, day treatment, residential or self-help/support group settings)

substitution drug therapies using methadone or buprenorphine

Treatment with methadone is safe and effective for many people who are dependent on opioids, especially when combined with counselling.

Duration of the treatment MMT is a long-term treatment, lasting from

one to two years to 20 years or more (World Health Organization, 2004; Centre for Addiction and Mental Health, 2008).

The length of treatment depends on the person. Prolonged treatment with proper doses of methadone is medically safe and effective.

What are the benefits of MMT?  Opioid dependence creates significant costs related

to medical care, drug treatment, lost productivity, criminal activity and an increase in the transmission of human immunodeficiency virus (HIV), hepatitis C virus (HCV) and other blood-borne diseases.

Methadone is the most effective treatment currently available for opioid dependence. It has been rigorously studied and has yielded the best results.

MMT benefits not only the people receiving treatment (clients), but also their families, their communities and society as a whole.

Ongoing Monitoring Patients on long-term opioids require

monitoring, including urine toxicology testing Intensity of monitoring should reflect risk Frame monitoring as assuring safe prescribing

and, if past addiction, supporting sobriety Current addiction problems emerge over time

Research indicates that people receiving MMT will

spend less time using narcotics daily; reduce their use of illicitly obtained opioids (and continue

this pattern as long as they stay in treatment); reduce their use of other substances including cocaine,

marijuana and alcohol; spend less time dealing drugs; spend less time involved in criminal activities; spend less time incarcerated; have much lower death rates than individuals who are

dependent on opioids and not receiving treatment (the death rate for those not receiving treatment is more than three times higher than for those engaged in treatment);

Research indicates that people receiving MMT will

reduce injecting, and injection related risk behaviours; reduce other risk behaviours for transmission of HIV and

STDs; reduce their risk of acquiring HIV infection; potentially reduce their risk of acquiring HCV or other blood-

borne pathogens; improve their physical and mental health; improve their social functioning; increase their likelihood of being employed full-time; and

improve their quality of life. pregnancy outcomes

MMT

The longer clients stay in treatment, the more likely they are to reduce their illicit use of opioids and remain crime-free. Receiving treatment in a community that offers support through additional integrated components, such as counselling and health and social support services, gives clients more time and opportunity to deal with other important issues while they are in treatment.

For example, they can receive care and guidance about: major health and mental health concerns, as well as family, housing, employment, financial and legal

issues. This, in turn, increases the likelihood that clients will stay in

treatment

Benefits to clients and the community

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Cost benefits and cost effectiveness There is clear evidence that the benefits of MMT far

outweigh the costs of treatment.

MMT reduces the criminal behaviour associated with illegal drug use, promotes health and improves social productivity, all of which serve to reduce the societal costs of drug addiction.

Researchers in the U.S. found the annual costs of MMT to be considerably less expensive than the alternatives, such as no treatment, imprisonment or drug-free treatment programs.

Criminal activities related to opioid use resulted in social costs that were four times higher than the cost of MMT. For every dollar spent on MMT, there is a savings to the community of between US$4 and $13

QUICK FACT Providing comprehensive MMT to 15,000

people who are dependent on opioids costs an estimated $90 million a year. The personal and social cost to society for these individuals is seven times this amount: $660 million (Hart, 2007).

Methadone compared to buprenorphine for opioid agonist maintenance treatment

Comparing the evidence from clinical trials on the effectiveness of methadone and buprenorphine for opioid agonist maintenance treatment, both medications provide good outcomes in most cases.

In general, methadone is recommended over buprenorphine, because it is more effective and costs less.

However, buprenorphine has a slightly different pharmacological action; thus, making both medications available may attract greater numbers of people to treatment and may improve treatmentmatching.

The model of MMT must Be easily accessible Recognizes and accepts that every client enters

treatment with widely varying experiences, expectations and needs

Respects clients’ dignity Fosters a collaborative, relationship-building

approach between clients and program team members

Tailors treatment to meet individual clients’ needs

Outlines clearly articulated rules that are followed consistently.

Components of an MMT programAn integrated comprehensive program would include some or

all of the following:

methadone medical care other substance use treatment counselling and support mental health services health promotion, disease prevention and education links with community-based social support services outreach and advocacy.

Clients who have special treatment issues that require specific health and social supports. These include:

people with polysubstance-use behaviours women women who are pregnant youth homeless persons people living in rural or remote areas people living with HCV people living with HIV/AIDS people living with mental health disorders offenders in the corrections system.

Discussion Should pharmacological treatment for

adolescents with opioid dependence differ from that for adults?

vulnerable Children and young people aged under 25 and at risk of

misusing substances; among the most vulnerable are:

• those whose family members misuse substances

• those excluded from school, and truants

• young offenders

• those involved in commercial sex work

Consequences of youth substance abuseYoung people who persistently abuse substances often experience an array of problems, including

academic difficulties, health-related problems (including mental health) poor peer relationships, involvement with the juvenile justice system.

Additionally, there are consequences for family members, the community, and the entire society.

Initation of drugs Earlier initiation to drug use exposes young

people to more risks Earlier/riskier sex STI –HIV, hepatitis C Mental health Social and economic exclusion

MMT and YouthRecommendations for the management of adolescents (under the

age of 18) who are dependent on opioids include: Assessment of the route of use, amount used, frequency of use,

other substance use, withdrawal symptoms, prior attempts at withdrawal, medical problems, psychiatric problems, medications, social supports, etc.,

Withdrawal management using appropriate medications, initiation of treatment in either in-patient or, if possible, day treatment setting; monitoring of blood pressure (baseline and during treatment; and, treatment of associated withdrawal symptoms.

If client/patient is stable, continuation of tapering as an outpatient can be considered.

Adolescents should be advised that, once they have withdrawn from heroin or other opioids, it is essential to continue in treatment due to the high rate of relapse to opioid use.

Insights from the field MMT should be part of a full continuum of out-patient services

for youth - need links with housing, mental health, food, job skills, education, counselling for trauma and abuse issues

Need flexible treatment policies and a range of treatment options including low threshold programs which may be useful in engaging youth (no appointments, provide psycho-social services as needed, involve outreach workers/street workers in youth-focussed outreach).

Need separate programs from adult programs. "Maintenance" may be relatively short term (a couple of

years) rather than for a lifetime. Need specific criteria for maintenance - length of

involvement, lifestyle risks, etc. Need for parental consent may be an issue, depending on age

restrictions, which differ from one jurisdiction to another.

  Youth

The relative lack of research in young people and people with brief histories of opioid dependence is concerning, because this population may have the greatest capacity for change.

More research is needed on psychosocial assistance, including family-based approaches, and on the relative merits of opioid agonist treatment and withdrawal, and antagonist treatment.

Some adolescents may be brought to the clinic by their families, who are concerned about recent drug use that may not have reached the level of dependent use. On the other hand, many adolescents presenting to treatment services come from socially disadvantaged backgrounds, are living on the street and may have more severe dependence than many adult patients. In between these two groups is a third with dysfunctional families.

Studies suggest that the earlier that substance use commences, the higher the risk of dependence and adverse health consequences.

Working with youth DU-s Requires a sensitivity to the issues pertinent to adolescent

health in general, because drug use is often a result of events occurring elsewhere in an adolescent’s life

Assessment should be broad and should include medical, psychological, education, family and other aspects of the adolescent’s life. Treatment should cover as many aspects of the adolescent’s life as possible. Given their special treatment needs, adolescents with opioid dependence often benefit from special health services aimed directly at them

Working with youth DU-s Treatment approaches should accommodate adolescents,

who often have higher levels of risk taking, novelty seeking and responses to peer pressure than older individuals (probably due to incomplete development of brain areas of inhibitory control). Thus, training in self-control, resilience and decision-making should be included in psychosocial interventions.

To ensure that treatment is as effective as possible, the treatment programme needs to be individualised and comprehensive and needs to take into consideration an adolescent’s strengths, psychosocial supports, education, legal and medical status and history, and pattern of illicit drug use

Working with youth DU-s Adolescents may live with one or more parents, and are

likely to still be in the legal custody of one or more parents. Parents may play a central role in the lives of adolescents

entering substance abuse treatment, in comparison to adults entering treatment.

Adolescents may thus be in need of family counselling, to improve relationships with parents or to help parents learn how to be as supportive as possible of their adolescent while that person is in treatment for their substance use disorder.

High levels of parental involvement and low levels of parental detachment protect against opioid use among adolescents.

Groups and SubstanceAbuse Treatment Because human beings by nature are social beings, group

therapy is a powerful therapeutic tool that is effective in treating substance abuse.

This definition excludes self-help groups like Alcoholics Anonymous and Narcotics Anonymous.

Group therapy has advantages over other modalities.These include positive peer support; a reduction

in clients’ sense of isolation; real-life examples of people in recovery from peers in coping with substance abuse and

other life problems; information and feedback from peers;

a substitute family that may be healthier than a client’s family of origin; social skills training and practice; peer confrontation;

a way to help many clients at one time; structure and discipline often absent in the lives of people abusing substances; and finally,

the hope, support, and encouragement necessary to break free from substance abuse.

Counselling The overall goals of counselling relate to

changes in substance use behaviours and improvements in several areas of personal and social functioning, including family and social relationships, employment and crime

Family Therapy The interconnected relationships within a family

are widely recognized as crucial elements of substance use disorders and their treatment.

among family members can affect the emotional health of individual members and thus fail to prevent the development of substance use disorders

family-based interventions work at the level of family change (e.g., parenting practices, family environment, problem solving) and also aim to take into account the psychosocial environments in which the adolescent lives.

Self-help programmes These programmes are run and controlled by

people who are directly affected by a particular type of substance abuse problem, rather than by professionals.

One of the great advantages of self-help is the deep insight and understanding of problems that groups can offer their members. Many self-help groups can also provide valuable support services in intervention, treatment and aftercare

Self-help programmes As the true nature and extent of drug

problems among young people and their families are often discovered in self-help groups, these groups can serve as a vital link in the assessment, intervention and referral process.

Finally, it has been suggested that self-help groups may be effective in reducing relapse; however, there is little evidence at present to support this claim.

Continuum of careEarly detection/outreach

Assessment

Approaches Psychological (including these Modalities ) Biophysical(i.e., detoxification)Pharmacological(i.e., methadone maintenance)Therapeutic communitiesand boot campsTraditional healing

Treatment ModalitiesBrief interventionsShort-term counsellingLong-term counsellingGroup therapyFamily therapyDay treatmentIn-patient treatmentSelf-help programmes

Aftercareand social reintegration

Aftercare The objective is to facilitate the user’s return

to the community by maintaining recovery, preventing relapse, and improving social and psychological functioning by, for example, helping the young person build a social network that supports a drug-free lifestyle

Social reintegration entails working with individuals, their families,

and communities to help the adolescents to re-establish themselves in their community.

Skills training facilitates the re-entry of former abusers into school or the workforce

The establishment and maintenance of a support network is critical to social reintegration and aftercare

Employment Many people with drug abuse problems have

enduring difficulties with obtaining and retaining paid employment

Employment has been found to predict retention in treatment and good outcome

Services offered at MMT centers in Albania

Medical care and treatment by experienced physicians: neurologist, psychiatrist, Toxicologist.

psycho-social support Individual counseling one to one Family therapy Group therapy Health education Outreach (brochures, condoms, information) Referrals and follow up of MMT clients in other institutions Training and mentoring of intern students from the Faculty of

Sciences

Features of Aksion Plus Activities: psycho-social, friendly services Counseling/group therapy Networking, partnership, youth participation,

expertise, exchange Arts, sports and culture in Aids prevention “No Stigma and prejudices” Formal/informal training for students, sexual health

personnel and social workers Outreach Programs Emphasizing the human rights of HIV positive and

drug users Prevention, information education and peer education

Difficulties faced by young people:

Police harassment, mistreatment, incarceration

Health problems Family conflict Unemployment Discrimination ‘Mental torture’

Outreach workers: Punctual, respectful, friendly, non-dominating Slightly older than themselves Ex-users preferred Men did not mind if male or female; women

preferred female workers

Thank You