An overview of addiction and HIVspread,

Michael Farrell

1 National Addiction Centre, Kings College London

London, United Kingdom

Estimated size of IDU population (1998/2003)

Political and moralvalues of the socialsystem

ResearchEvidence

SERVICEProviderAND USERVIEW

A model for evidence-based clinical decisions(from Hayneset 01,1996)

111

AIDS travels through the fault lines ofsociety

Jonathon Mann

Challenge to the GlobalCommunity

Develop Treatment Systemsthat can meet the needs of

large scale and evolvingproblems of opioid dependence

and other injecting drug use

HIV a major challenge inPrevention

1mEmerging Epidemics

Controlling Epidemics

1mDownturning Epidemics

1mComprehensive Harm reduction provision ofmultiple interventions targeted at injection druguse are a key tool of HIV Prevention andControl

m Systematic Reviews by Farrell et al 2003,

Gowing et al 2004, Sorenson et al 2000, Marschet al 1998, Zadic et al 2000, Valdiserri et al

1

Aw~ .:. t~i<"J 1;

BAYERPharmaceuticalProduts

HER

f>. ~< "..,. :;'410

A 33 year follow-up of narcoticaddicts

l.u",roW""0..' a",,,~\~i!fDE$~\1I.,,6P.qJ,J'iO~I~'.Ab,"~= I

72 8876 80 64

43935.8(5.4)

354475(5.1)

The global response: UN support for goodtreatment

WHO/UNODC/UNAIDS position paper: Substitutionmaintenance therapy in the management of opioid

dependence and HIV/AIDS prevention

"Substitution maintenance treatment is an effective, safeand cost-effective modality for the management of opioid

dependence. Repeated rigorous evaluation hasdemonstrated that such treatment is a valuable and

critical component of the effective management of opioiddependence and the prevention of HIVamong IDUs."

Drug Addiction: chronic relapsing disease(H"" el ai, 2001; ""LeUa, el ai, 2000; aBrie, & McLeUa" 1993; GoI"e', & HeITeCa, 1995)

It Drug addiction is a chronic,lifelongrelapsingdiseasewith frequent medical complications (e.g. HIV, HVC, TB)and a high fatality rate

~ Each detoxificationis followed by 80-95% relapsem long-term stable abstinencerates range between 10-25%

m Estimatedheritabilityof drug dependence is about 40%. Personal responsibilitysimilar to other chronicdiseases, e,g. diabetes. Biologicalsubstrates identified for drug seeking behaviorand relapse. Pharmacologicalinterventions rather ineffective in cure of drug addiction.. Pharmacologicalinterventionsquite effective in care for drug addiction. Treatment compliance similarly probiematicas in other chronic diseases. (Wim Van den Brink2004)

Follow up studies

1MA study in Thailand (Celentano 2002)recruited over 1000 drug users enteringtreatment in Northern Thailand and

followed the group for over 2 years afterdischarge from inpatient detoxification.Ninety six per cent of users relapsed toheroin use within two years and 82 percent within six months.

HIV infection rates in and out ofsubstitution treatment (Metzger et ai, 1993)

39 39 42 48 49 51

Out %

In %

~\<I" ,*,,'" ~~'" ,*,,'" ,*,,'" ,*,,'" ,*,,'" ~~'" ~~'" ,*,,'" ,*,,'"'0",'" Q'" ~'Io'" ~'/,'" ~'" ",,<I>'"""Q'" ~'Io'" ri>'" Q<I>'"1'10'"

2

100

80

60

40

20

0

56 60 64 68

N 581Ag, 24.5(3.9)

22%2%5%7%4%

48%

12%

92 96

242

57.4 (4.0)

Drug Substitution Treatment

iii Strong evidence for the benefits of oral methadonetreatment RCTs +++ REASONABLE EFFECT SIZE

fI REDUCES DRUG CRIME .70fI REDUCES OPIATE CONSUMPTION .35

iii REDUCES INJECTING & RISK TAKING 0.22

iii Now good evidence for buprenorphine and LAAM

RCTs ++ (LAAM CURRENTLY UNDER REVIEW)

iii Use of injectable diamorphine and other drugsbuilding evidence base for comparative effectiveness.more dicussion on comparative cost effectiveness.

Drug Users in SubstitutionTreatment per 100,000

200

150

100

50

0

IIIAustralia

DItaly0 Francel1liChina

IIISpainl1liUK[iJCanadaIUndia

D United States IIINetherlands

D Germany IIIDenmarkD Sweden IIIThailand

IIINepal

Numbers (per mil pop) receivingmethadone in 15 EU member states

3000 1993-20002500

2000

1500

1000

500

0

1993 1995 1997 2000

Source: EMCDDA, 2001

Availability of substitution treatment

- "g'o'o'- Ch'o.- C.o.li.- lodi.- lodooo'"- '.M- Ky'gy"'o- M.I.y'"- Moldo,.- N.p.1- S'og_.- Th.IIMd- Uk.'oo.??rm.nk, to Gony S'ro'M

Evolving treatment programmes

WiIt is estimated that there are over 67 treatment

centres providing opioid agonist therapies andthe overall number of patients in these centres isroughly 7000 patients in total.

WiHONG KONG

mITHAILAND

M:IRAN

WiMALAYSIA

CHINA

...EL.

3

Background -HIVspread among IDUs

I!iAustralia:

early methadone, rapid expansionlow incidence of HIV in IDUs-miiEuropean Union:

Increase in drug substitution servicesreduction in AIDS cases related to IOU

EasMr"nEurope, Russia and new IndependentRepublics: New epidemics of HIV in IDUs

Background -HIVspread among IDUs

v South America - Long standing cocaine crack problemsubstantial contribution to HIV through risk behaviour and aisoless so through transition to injecting

iii Africa evolving drug and injecting problem butdrowned out by scale of general HIV and socialinfrastructure problems in many countries

II Central & Eastern Europe- Rapidly evolving HIV probiem in IDUs

Other Major Infections

1MTuberculosis, major problem whereestablished HIV among IOU

PiHepatitis Cover 90% plus in those with along history of injecting drug use

Background -HIVspread among IDUs

Asia Pacific- relatively new problem for some countries

need to develop culturally appr opriate services

Methamphetamine Epidemic Presents new challengesto treatment a nd research community to define itscontribution to risk of HIV spread

IiiUnited States of America & Canada- initial evaluator and pioneer of methadone

- lack of public funding have limited thecomprehensiveness of approaches

- substantial containment of HIV in IDUs but still majorongoing problem in US

HIV in European IDUs

wGenerally well contained except for recentincreases in Portugal

PiSpain, France and Italy experienced majorHIV epidemic in IDUs successfullycontained through broad preventionstrategy including expansion ofsubstitution treatment,

Substitution in prisonsEstimated that over 30 million imprisonedannually

IlK Major risk for blood borne virus spreadI!i In most countries where measured between one

third and half have drug dependence@RCT of methadone in prison (Dolan et al)

demonstrates role in reduction of blood bornevirus, and general improvement, and postrelease reduction in mortality for those whocontinue

@Rapid expansion in Europe in substitution inprisons

Ii Huge challenge for Asia pacific region whereinsitutional incarceration standard response toopioid dependence

@Consistently 90% relapse to heroin use, no

4

Drug Overdose and Mortality

II!!Mean of 5+ non fatal overdoses in heroin

using cohorts

II!!Mortality 1 to 2%

II!!In methadone treatment down to 0.2%

II!!Recent Hser 33 year longitudinal studyreports over 50% mortality in cohort

II!!Suicide completion rates high andsignificant contributor to overall suicide

The odds of a drug-related death inthe first week of release

_.n.wom~

. ~w 10""''''''''''~''atob''''odat~.Y..«OR1D.6; 96%<:14.8-22.0)

Iii70 ""'highw"~", ~""od...w.pop""~

Wh.ng m..

. w~'d8 'me' ,'.alw"~ at on. Y'" (OR 8.30 96%CI 5.0-13.3).

Ii 30 'me, hi,h.,"~ ago mal","" ,",,,01 pop.latlon

(S.~.'on. FeooD.' 012003)

II! IN SUMMARY A 8-10 FOLD INCREASED RISK OFMORTALITY IN THE EARLY RELEASE PERIOD

Excessmortalityratiofordifferenttimeperiodspost;eleasebycauseof death(Singleton,Farrell,Marsdenetal 2003)

45:840~ 35~30

~ 25e20::15~ 10~ 5

0

. [)-ug-relateddeaths 0 Notdrug.related

\0\ \01. \O~ \0'0 \'0 1.~ <:,'! .,..<:'1. ,\o"~

'0"< ,~"< 1.~"< ~~"< '0~"<\0 ,'0 ~"<\0 1.,,;,>,,<\0

Tilliesi1ce release (weeks)

Consequences of drug usewithin correctional settings

I!illPressures on prison environment- health services

- prison staff- security

I!illHIV, hepatitis Band Cm:Tuberculosis

II!!Recidivism- use of drugs is a predictor of recidivism

5

Changes in ATS Abuse (1995-1997)

~A.owi"

:::.,,"m~,

~Are"wiili

:::~,,,'"m=

HILL CRITERIALOOKING AT THE CRITERIAH STRENGTH OF ASSOCIATION

H CONSISTENCY

1MPLAUSABILITY

H!COHERENCE

R!EXPERIMENTAL EVIDENCE

R!SPECIFICITY OF EFFECT

H HONG KONG**

rmBANGKOK**

rmIRAN

rmMALAYSIA

mmCHINA

R! INDONESIA

rmVIETNAM

Other Changes to be considered

1mChanges in the alcohol industry

n Other mood altering drug availability

1MChanges in sexual behaviour aroundmood altering drugs including alcohol

n Reconsideration of role of alcohol and

other drugs in high risk takingenvironments and indiviudals, from a

health education perspective

But does this evidence apply indeveloping countries?

I!JThe majority of countries that have developedsubstitution therapies outside the United Stateshave introduced the programmes as part of apilot feasibility study where the main assessmenthas been to determine the capacity of thetreatment system to operationalise the treatmentwithin particular cultural settings, and to assessthe impact of treatment on those individuals whoundergo treatment

What sort of delivery system isrequired

mlNeeds integrated health care system

mlPublic Health Strategy to achievemaximum coverage

HIPrimary care training in delivery oftreatment

R!Family Practice Approach

WiPrisons based care linked to communityongoing treatment

6

Direct Observed Therapy

. Enables implementation of Anti TB Therapy

. Enables delivery of HAART

III:Enables future delivery of Combination therapies forHepatitis C

II: Complex multidisciplinary teams required to gen erateappropriate treatment programmes, much work to bedone

iii Agonist therapies are a critical component of theimplementation of HAART as part of the International 3by 5 initiative in many countries particularly in the AsiaPacific Region

Further details.....

Dr. Michael Farrell

National Addiction Centre

4 Windsor Walk

London SE5 8AF

m.farrell(Q2ioD.kcl.ac.uk

Summary

Ii Evidence for major benefits of treatment inreducing spread of HIV

1mStrongest evidence for maintenance agonisttreatment with methadone or burprenorphine orother mu opoid agonists

1mStrongest evidence for treatment in broadercontext of comprehensive social response tosocial problem of drug use, dependence andinjecting.

1mBelief systems are a greater obstacles toimplementation in many countries that areresource limitations.

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