a-clinic · a-clinic foundation ... clothing, social care and acess to a low ... pharmacokinetics...

A-Clinic FoundationSeminar-Lisbon 2017

Associação Ares do Pinhal

Mobile Outreach Programme – Lisbon*

MOP-L

* funded by SICAD-Ministry of Health (80%) and the Lisbon Municipality (20%)

ASSOCIAÇÃO ARES DO PINHAL (NGO)

• Ares do Pinhal is a nonprofit NGO for social inclusion which has worked since 1986 with

severe drug users starting with a Therapeutic Community (TC) for residential long-term

treatment (12-18 months)

• Since then Ares do Pinhal has established a therapeutic apartment for social

reintegration (1990), a vocational school for community educators (1991), two more TC´s

(1992 and 1995) and a Mobile Outreach Programme in the city of Lisbon (MOP-L) for health

and social support of severe opioid drug users (2001)

MOP - Lisbon

In 1998 Ares do Pinhal was invited by the municipality of Lisbon to

manage an outreach harm reduction project within the urban

regeneration of a run-down and drug trafficking neighbourhood

(Casal Ventoso)MOP - Lisbon

Our start in Drug Addiction Harm Reduction Approach

URBAN INTERVENTION PLAN OF CASAL VENTOSO

In the nineties ±6000 drug users moved every day to Casal Ventoso to buy all

kind of illicit drugs (mostly heroine at that time)

±400 severe drug users lived in the vacant plots of the neighbourhood in

improvised shelters

Sharing of drug comsumption paraphernalia was common.

MOP - Lisbon


MOP - Lisbon

• Address the drug users who lived in improvised shelters in the vacant plots of the neighbourhood to

accommodate them in a temporary reception centre located near to the area

• Provide this population with basic health, food, hygiene, clothing, social care and acess to a Low

Threshold Methadone Programme by a multidisciplinary team working in a set of containers located

near to the area

• Referral to conventional outpatient (treatment centres) and inpatient clinics (Detox, CT)


OUR GOALS

1998-2000 (N=558)

HIV 340 (61%); HCV 441 (79%); TB 75 (14%) PWID (80%)

Never sought treatment before (90%)

MOP - Lisbon



➢ In 2001 the urban regeneration project was completed by the municipality

➢ However this intervention revealed that severe drug users have great dificulty in

acessing the conventional drug addiction treatment facilities and even more the health

and social public services

MOP - Lisbon


SEVERE DRUG USERS

Key issues to take into account

• Completely unaware of their health condition

• Repeated and compulsive self-administration of drugs of abuse become their

way of life and their purpose in life

• Deep sense of mistrust in health professionals and conventional health

services

MOP - Lisbon


The following slides shows how far some PWID are prepared to go

MOP - Lisbon

MOP - Lisbon

Urban Intervention Plan of Casal Ventoso

• What we saw and experienced in the late nineties in Casal Ventoso showed us the

need to reshape some established paradigms within the drug addiction treatment

perspective and rethink the approach to severe drug users

MOP - Lisbon

Paradigms

Drug Addiction Treatment Approach

Wait for the drug user

Wait for drug user motivation

Main goal → Stop drug(s) use

Drug Addiction Harm Reduction Approach

Go out and be closer to the drug users

Address all drug users

Main goal → Safer use of drug(s)

Transition to Outreach Work – 2001

Main guidelines

• Go out and be closer to the drug users – Facilities should be near the

drug users spots and/or easy to get to

• Address all drug users - Meet them in their territories in order to give

them safer drug use conditions (e.g. exchange of needles and syringes,

pipes or any other comsumption paraphrenalia) and become someone with whom

they can talk

• Main goal → safer use of drugs - To show that our aim does not concern

their use of drugs but the personal health problems and social impairment

they cause

MOP - Lisbon

Transition to Outreach Work - 2001

MOP - Lisbon

Mobile Outreach Programme – Lisbon*

MOP-L

*funded by SICAD - Ministry of Health (80%) and the Lisbon Municipality (20%).

The MOP-L has started in 2001 with the following principles

• A drug user centred harm reduction programme that uses mobile units for medical and

psychosocial care within the ambit of a low threshold methadone programme* in the city of

Lisbon

• To reach opioid drug users (with polydrug use or not) who, that for whatever reason, do not

access conventional drug addiction treatment centres or other health and social services.

*Low threshold methadone programmes do not demand abstinence of drugs of abuse (licit or illicit)MOP – L

Mobile Outreach Programme – Lisbon

• MOP-L is frequented every day by approximately 1200 heroin users (85% men and

15% women; Mage = 45,40, SDage = 8.09), many of whom are polysubstance users

(Cocaine; Alcohol; BZD)

MOP - Lisbon


• Users are mostly engaged in high-risk behaviours and many present personal disorganization,

physical impairment or disease, psychiatric disease, psychological vulnerability and social

exclusion

• A significant part of them are PWID

HIV 14%

HCV 55%

HIV+HCV 11%

PWID ±20%

Homeless ± 10%

(January 2017)MOP - Lisbon


What We(try to)Do

MOP - Lisbon


MOP - Lisbon

UserCentredCare

Low Threshold MethadoneProgramme

Judicial support

Social support

Referral Drug

addiction treatment centers

Health care


How we(try to)do it

MOP - Lisbon


Main aspects

Low threshold methadone programme, health care and psychosocial support

• Ease of access (proximity to problematic neighbourhoods or transport interfaces)

• Prompt response to any request for admission (if indicated)

• Simplified admission procedures

• Main concern toward abstinence symptoms and craving

• Abstinence of drugs use is not required

MOP - Lisbon


Patient´s Admission and Follow up In Programme

➢ The admission in programme is granted directly by the psychosocial professionals and the nurses in the

mobile units with an interview in order to assess clients physical and social situation and a urine

analysis for opiates (women also do urine analysis for pregnancy)

➢ Patients are informed of the services provided and the programme’s operating rules and sign anagreement form

➢ Unless otherwise indicated, methadone substitution programme will start at that moment

➢ Taking of methadone is on-site and in Directly Observed Therapy (DOT) and individual dosages follows

medical guidelines

MOP - Lisbon


Patient´s Admission and Follow-up In Programme

• In a short period of time he/she will be assigned a case manager who start the follow-up by being aware

of the major problems and/or needs of the user (health, social, judicial, etc.). Then step by step the

case manager will try to create the best achievable helping relationship

• Within the first month of the programme, patients are tested for transmissible diseases (HIV,

Hepatitis, Syphilis) in the MU´s and do an X-Ray (TB) in an X-RAY mobile unit which stops near the MU

spots twice a month

• While in programme users have access to regular medical and psychosocial assessments

MOP - Lisbon

Low threshold methadone programme

Methadone - basic principles

Pharmacokinetics

Methadone ≠ Heroine

• Methadone and Heroine are opioid substances but they are very different in

pharmacokinetics terms

Psychoactive substances

Pharmacokinetics issues of psychoactive substances of abuse in the brain

Quick onset of action

• The quicker the onset of action the higher the effect (e.g. IV > Oral)

• The quicker the onset of action the shorter the action (e.g. crack > cocaine > heroine)

• The quicker the ups and downs the more addictive the effect (the ups and downs have

a crucial role on the neurobiological changes underlying the origin of addiction)

Disfunção neurobiologica => Euforia e sintomas de privação são alternados (1)

Estado clinico

Euforia

Normal

Sintomasdeprivação

Heroína

10 -8

Co

nce

ntr

ação

pla

smat

ica

(M)

Doses de heroína

I

0

I

4I8

I12

I16

I20

I24

-710

-610

(1) Dole V.P., Nyswander M. Pharmacological treatment of narcotic addiction. NIDA Res. Monogr. 1982 ; 43 : 5-9.

ADICÇÃONEUROBIOLOGIA e MEDICAMENTOS

Your Brain on Drugs

1-2 Min 3-4 5-6

6-7 7-8 8-9

9-10 10-20 20-30

Methadone

Pharmacokinetics

• Full agonist of mu opioid receptors

• Long half-life ( ˃ 25 hours )

• Distributed into lipid stores (mainly in the liver) “Accumulation process”

• Delayed onset and offset of action ( “no peaks”) low reward effect (⇩abuseliability )

(1) Dole V .P., Nyswander M. Pharmacological treatment of narcotic addiction. NIDA Res. Monogr. 1982 ; 43 : 5-9.

Estado clinico

Euforia

Normal

Sintomas de privação

TRATAMENTO DE SUBSTITUIÇÃO(

10-8

Co

nce

ntr

ação

pla

smat

ica

(M)

Dose terapêuticasubstituição

I

0I4

I8

I12

I16

I

20I

24

-710

-610

Heures

Estabilização neurobiológica=> Supressão dos sintomas de privação(1)


Safe use of Methadone

Short practical guidelines

• Maximum dose in admission - 20-30 mg

• Slow increase of doses in the first two weeks (induction phase) – MOP-L → 30-35-40-45-45-50-50...

(preventing sedation and respiratory depression due to the accumulation process / delayed development of

tolerence)

• Risk of overdose occurs basically during the first week of the induction phase

• After achievement of sustainable tolerance methadone remains very safe

• Doses should be adjusted to patient needs (main goal no craving)

• Awareness of drug interactions, medical or psychological comorbidity, individual genetic factors, etc..


Safe use of Methadone

Short practical guidelines

Methadone has no relevant toxicity to the body

Is not nephrotoxic (renal impairment does not require changes of doses)

Is not hepatotoxic (chronic liver disease does not require changes of doses)

Questionable cardiotoxicity (high doses ˃ 150mg: prolongation of the QTc interval?)

Methadone Programmes

• Reduce HIV and Hepatitis B/C risk behaviours

• Reduce risk of overdoses

• Increase compliance to health care and social support

• Reduce crime

Low Threshold Methadone Programmes

Distinctive aspects from Methadone Maintenance Treatments

• Abstinence of drug use is not required

• Main concern toward abstinence symptoms and craving safer use of drug(s)


• 2 “Methadone” Mobile Units (MU1;MU2) operating every

day in five strategic spots in the city of Lisbon and

with fixed schedules twice a day (morning and afternoon)

in each spot

• 1 Support car backing MOP and patients needs

• 1 Mobile Office (MO) for medical support operating side

by side with the MU´s four days a week and covering all

spots and schedules of each spot (mornings and

afternoons)

• 1 Backup office for clinical meetings, clinical

supervision, programme procedures, communication work

with the health and social public network and

administrative workMOP - Lisbon

Logistics


StaffThe staff is multidisciplinary: medical doctors, psychosocial professionals(psychologists and social workers), nurses, community educators andadministrative staff

• Psychosocial professionals – Work in the back office and on a shift

schedule beside the MU´s. Each of them must cover all spots and all

schedules of the MU´s during the week

• Nurses – Fixed workplace in the MU´s

• Community educators – MU´s and support car

• Medical doctors – MO and Backup office for medical evaluations andappointments

• Administrative staff – Backup officeMOP - Lisbon


Outreach Logistics

• 2 “Methadone”* Mobile Units operating every day in five strategic spots in the city of Lisbon

with fixed schedules twice a day (morning and afternoon) in each spot

* Low Threshold Methadone Programme

MOP - Lisbon


Outreach Mobile Units (MU1/MU2) schedule

MorningSta. Apolónia 08:30 -10:00 Bela Vista 10:30 -12:30

AfternoonLumiar 14:30 -16:00 Bela Vista 16:30 -17:30 Sta. Apolónia 18:00 -19:30

Weekends and holidays Sta. Apolónia 08:30 -09:45 Bela Vista 10:15 -12:00 Lumiar 12:30 -13:30

MorningAv. Ceuta 08:30 -09:30 Lumiar 10:00 -11:30 P. Espanha 12:00 -13:30

Afternoon Av. Ceuta 15:30 -17:00

P. Espanha 17:30 às 19:30

Weekends and holidaysAv. Ceuta 08:30 -10:30 P. Espanha 11:00 -13:30

MOP - Lisbon

MOP - Lisbon


• Administration and monitoring of medical drugs (methadone*; antiHIV; antiHCV*;

anti-TB*; antibiotics; antipsychotics; antidepressives, contraceptive

injection, etc.)

*Directly Observed Treatment (DOT)

• Blood Sampling for HIV, Hepatites B/C and Syphilis

MOP - Lisbon

Mobile Units

Key Tasks


• To teach safe injection practices to PWID

• Needles and Syringes Exchange or other comsumption paraphrenalia,

distribuition of condoms and harm reduction awareness

MOP - Lisbon

Mobile Units

Key tasks


• General coordination of the methadone programme

• Physical and mental evaluations

• Harm reduction practices for safer use of drugs

• Evaluation of patients who have been hospitalized

• Conseling about bloodbourne/infectious diseases

• Medical evaluation on demand

• Evaluation of demanding changes of methadone doses

• Evaluation of medical drugs interactions

• Supervision of clinical cases with the staff

MOP - Lisbon

Mobile Office

MEDICAL DOCTORS – Key Tasks


MU´s and Backoffice

PSYCHOSOCIAL PROFESSIONALS / Case Managers

Evaluation and follow-up of the user needs in personal and social life

➢Health issues

➢Social issues

➢Justice issues

➢Referral issues

MOP - Lisbon

Psychosocial support in close communication with drug addiction,health and social services of the community network


Mobile Units and Backoffice

Psychosocial Professionals/Case Managers

Some key tasks

• Building a trustworthy relationship (to be and to talk with the user as many time aspossible)

• To try hard to know as well as possible the major health problems and/or needs of the

user and help the users to be aware and to take care of themselves

• Follow-up of the medical cares in which users are envolved

• Understand the needs and respect the priorities of the users (e.g. we can not ask a user

to attend an appointment during his time of consumption)

MOP - Lisbon


Mobile Units and Backoffice

Psychosocial Professionals/Case Managers

Some key tasks

• Harm reduction awareness

• To develop peer work with some drug users (e.g. help in needles and syringes

exchange in open air shooting spots)

• Network, network, network…to open doors in health care and social public

services

Mobile Outreach Programme-Lisbon

Harm reduction approach

To be close

To be patient

To be persistente

To like what you do

THANK YOU

Have a nice stay in Lisbon

MOP - Lisbon

[email protected]@aresdopinhal.pt

mailto:[email protected]

mailto:[email protected]

a-clinic · a-clinic foundation ... clothing, social care and acess to a low ... pharmacokinetics...

Documents