International access and availability of OST and how drug policy can improve this

Dr John Roche

INTERNATIONAL DOCTORS FOR HEALTHIER DRUG POLICIES

Overview

• What is the problem?• What is OST?• What is the evidence?• Global access• How to improve access

Key problems caused by heroin

• Overdose– Leads to respiratory depression and death

• Problems associated with IV use– Leads to spread of BBV – HIV, Hep C– Abscesses, DVT, endocarditis etc

• Dependence– Leads to withdrawal symptoms and need for further use

– funds criminal networks, crime to support habit• Direct health effects– Constipation, nausea, sedation

Basic Principles

• Opioid use can lead to tolerance and withdrawal symptoms

• NIDA estimate 23% of people who use heroin become dependent

• To avoid or stop withdrawal symptoms further opioid use is required

• Opioid substitution aims to prevent need for heroin

What is OST?

• Opioid substitution treatment (OST) is a type of treatment for those with heroin dependence.

• It includes the prescribing and administration of a pharmaceutical opioid as a ‘substitute’ for illicit opioids, in the context of care-planned treatment with psychosocial and recovery interventions, and regular review.

• The same medicines (methadone and buprenorphine) are used in both detoxification and substitution regimens.

• Advisory Council on the Misuse of Drugs

OST in the UK

• According to UK clinical guidelines OST is designed to: – Reduce or prevent withdrawals that typically lead to

further use of illicit heroin – Provide an opportunity to stabilise drug intake and

lifestyle while breaking with illicit drug use and associated unhealthy risky behaviours (including injecting)

– Promote a process of change in drug taking and risk behaviours

– Help maintain contact and offer an opportunity for therapeutic work with a patient or client

• Advisory Council on the Misuse of Drugs

WHO/UNODC/UNAIDS 2004

• Substitution maintenance therapy is a critical component of community-based approaches in the management of opioid dependence and the prevention of HIV infection among injecting drug users (IDUs)

Eurasian Harm Reduction Network (2012)

OST: Why do it?

• Individual– Improve health, reduce risk of overdose, access to

health/social care• Society– Reduce transmission of Hep C, HIV – Reduce crime to fund drugs– Reduce money going to criminal networks

World Drug Report 2014

• We have seen that countries that have adequately invested in harm reduction services have lowered remarkably HIV transmission among people who inject drugs.

• Yury Fedotov, Executive Director, UNODC

• Injecting drug use reported in 158 countries• Estimated global number of:– IVDU is 8.9-22.4 million– IVDU with HIV is 0.9-4.8 million

• UNAIDS (2011): 50% reduction in incidence of HIV in IVDU by 2015– Incidence (2010) 110,000 (2013) 98,000• 10% reduction

Global State of Harm Reduction

Global State of Harm Reduction

Continent Number of Countries

Harm reduction in national

policy

Needle exchange

programmes

OST operational

Drug consumption

rooms

Asia 19 19 17 15 0

Eurasia 29 26 29 26 0

Western Europe

21 20 19 21 6

Caribbean 3 1 2 1 0

Latin America

6 6 6 2 0

N America 2 2 2 2 1

Oceania 2 2 2 2 1

Middle East & N Africa

11 7 8 5 0

Sub-Saharan Africa

8 5 5 5 0

Total 101 88 90 79 8

Global State of OST

• Methadone, buprenorphine most common• More available in high income countries• 43 countries provide OST in prisons• Since 2012:– Only 2 countries (Burkina Faso and Turkey) have

newly implemented OST– Bahrain provides OST in rehabilitation– 25 countries increased provision– 5 countries decreased provision

Asia

Asia

• OST provision has continued to be scaled up in several Asian countries, with an estimated 297,000 people who inject drugs accessing these services.

• Between 2012 and 2014, Bangladesh increased from 1 site to 3 sites, India from 72 to 145 sites, Malaysia from 674 to 811 sites, Myanmar from 10 to 18 sites, Nepal from 3 to 12 sites, China from 738 to 763 sites, Vietnam from 41 to 80 sites and Indonesia from 74 to 85 sites.

Asia

• As with NSPs, OST provision in Asia is hindered by legal and policy barriers that restrict or prohibit its implementation and scale up. For example, in Malaysia, recent punitive enforcement and coercive action means that people who inject drugs have reduced trust in OST programmes, and therefore underuse them because of fear of arrest.

Eurasia

Eurasia

• Since 2012, a number of countries have removed barriers, facilitating access and improving the quality of OST programmes.

• In Latvia, new regulations to legalise OST provision resulted in a 28% increase in patients in 2012.

• In Bulgaria, buprenorphine was approved for the treatment of HIV-positive or high-risk people under 18 years, enabling OST to become accessible to this age group.

• Ukraine also removed a number of barriers, including a weakening of age restrictions for legal minors, which resulted in expanded access.

Eurasia

• According to the UNAIDS representative in Ukraine, Crimea’s OST provision was considered an example of best practice.

• Among the 800 people formerly enrolled in OST in Crimea, 38% were living with HIV and 50% of them were receiving antiretroviral therapy (ART).

AIDS Epidemic in Russia

• Almost 60% of those with HIV in Russia are injecting drug users and a further group are the sexual partners of the drug users.

• The HIV virus has spread via contaminated needles and syringes.

• Yet in Russia methadone is banned. The World Health Organization may see the synthetic opiate as essential in combating heroin dependence, but in Russia anyone caught using it or distributing it can face up to 20 years in prison.

AIDS Epidemic in Russia• About 1 million people live with HIV today in Russia and the rate of

infection is rising. 88,000 new HIV infections in 2013.

Western Europe

Western Europe

• In most of Europe, HIV rates among people who inject drugs appear to be stable or declining as a result of early scale up of harm reduction measures.

• However, recent severe outbreaks of HIV among people who inject drugs in Greece and Romania prompted the European Centre for Disease Prevention and Control (ECDC) and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) to undertake a risk assessment in 2013.

• They concluded that five countries in Western Europe are of concern for HIV risk: Estonia, Greece, Latvia, Lithuania and Romania.

Western Europe

• Over half of opioid users in Europe access OST, with an estimated 734,000 receiving OST in 2012 – a slight rise compared to 2011.

• The most significant increase in OST between 2011 and 2012 was in Turkey, which saw an increase of 250% from 8,000 to 28,656, followed by Greece, which saw an increase of 45% to 9,878.

Caribbean

Caribbean

• Puerto Rico remains the only territory in the Caribbean providing OST.

• However, the first OST pilot has now been approved in the Dominican Republic and should be in place towards the end of 2014.

Latin America

Latin America

• Opioid use is thought be rare in Latin America.• At present, Mexico and Colombia are the only

countries in the region that provide OST to people who inject drugs and/or use opiates, with approximately 18.6% of opiate users receiving OST in Mexico.

North America

North America

• OST is available in both countries, although access is by no means universal.

• Over 2,418 licensed facilities provide OST across the USA.

• The most recent available data indicate that in the USA in 2009 there were 640,000 individuals on buprenorphine or buprenorphine–naloxone combination for maintenance therapy (up from 96,000 in 2005) and 266,818 on methadone (up from 236,836 in 2005).

Oceania

Oceania

• Approximately 102,040 people inject drugs in Australia and New Zealand combined, a decrease of approximately 70,000 on figures from 2012.

• HIV prevalence among them is relatively low (1.2% and 0.2% respectively).

• Hepatitis C (HCV) rates have remained high, at 54% and 50% respectively.

Oceania

• Although OST provision is high in Australia, there has been little change since 2012.

• In New Zealand, current levels of OST provision are unclear, but in 2009 it was estimated that approximately 4,600 individuals were receiving OST, predominantly in methadone form.

Middle East and North Africa

Middle East and North Africa

• An estimated 626,000 people inject drugs in MENA (range 335,000–1,635,000), with injecting drug use appearing as the primary mode of transmission of HIV in Bahrain, Iran and Libya.

• With 80% of the global opium production occurring in Afghanistan, and the price of heroin markedly lower than in other parts of the world, the geographical location of many of the surrounding territories means that injecting drug use remains high.

Middle East and North Africa

• Six MENA countries provide OST to different degrees: Bahrain, Iran, Israel, Lebanon, Morocco and United Arab Emirates.

• In some countries such as Bahrain and the United Arab Emirates, OST is only available through detoxification and rehabilitation facilities, with people who inject drugs being reached through post-rehabilitation or prison programmes.

• In other countries, OST provision is not based on punitive measures or rehabilitative/detoxification programmes e.g. Iran, where OST is offered to people who inject drugs in 4,275 centres, 4,038 of which are privately operated. This represents an increase of 902 sites since 2012.

Sub-Saharan Africa

Sub-Saharan Africa

• An estimated 23.5 million people are living with HIV in sub-Saharan Africa, representing 69% of the global HIV burden.

• In 2012, 75% of all new HIV infections globally occurred in the region.

• Although reliable information on injecting drug use in sub-Saharan Africa is very limited, estimates suggest that there may be 1,020,000 people who inject drugs, with an extremely wide range of between 300,000 and 6,240,000, of which 5 to 10% are thought to be living with HIV.

Sub-Saharan Africa

• OST remains largely unavailable throughout Sub-Saharan Africa, with the exception of Mauritius, where over 6,000 people access services, and newly initiated programmes in Tanzania.

Policy

• World drug trade $320 billion (UN, 2013)– 0.9% Global GDP

• Over $100 billion spent on drug control and enforcement

• $160 million on harm reduction– IHRA campaign to redirect 10% of drug control

budget to harm reduction by 2020

10 by 20 Campaign• Advocate for a new focus on harm

reduction in the global drug policy regime, and for increased harm reduction funding to ensure that HIV targets can be met.

• Endorse a rebalancing of funding that prioritizes health, human rights and harm reduction, by reallocating funds from ineffective punitive responses.

• Ensure that health, human rights and harm reduction are central pillars in the high-level debate and in the lead up to the 2016 UNGASS on Drugs.

References

• United Nations Office on Drugs and Crime, World Drug Report 2014 (United Nations publication, Sales No. E.14.XI.7)

• Global Commission on HIV and the Law: Risk, Rights and Health (UNDP, 2012)

• Eurasian Harm Reduction Network (2012) pag.aids2012.org/PAGMaterial/PPT/1377_2717/final.pptx

• Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention : position paper / World Health Organization, United Nations Office on Drugs and Crime, UNAIDS (2004)

• The Global State of Harm Reduction 2014 (Harm Reduction International, 2014)

Thank you