opioid maintenance treatment (omt) and reductions in mortality, morbidity and crime
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Opioid Maintenance Treatment (OMT) and reductions in mortality, morbidity and crime
Thomas Clausen Professor (MD, PhD)
October 8th, 2015 ISAM, Dundee
Conflicts of interest
None
Thomas Clausen is a full-time employee at the Norwegian Centre for Addiction Research, University of Oslo, Norway
Outline
Opioids and harms
The evidence of OMT
Reductions in mortality, morbidity and crime
Strategies for prevention of opioid related harms
The provision of treatment
Opioids and harms
Misuse and addiction Excess mortality Morbidity Crime Cost to society
Social relations Quality of life Individual development Productivity
Overdose deaths pr mill; EU, most recent
EMCDDA- Annual report 2013 EU-mean ca 22
Scandinavian OD-deaths
Polydrug use (lethal cocktails) 4-5 drugs detected in post mortem toxicology
Benzodiazepines (one or more) detected in 70-90% of cases
Primarily among illicit drug users (heroin, methadone, buprenorphine and fentanyl)
Simonsen et al 2015
The strong evidence-base
Gap between knowledge and practice
43% of UN member states provide OMT
Between 5-10% of target population for OMT receives treatment
Elisabeth Saenz, UNODC
Norway
Population: 5 mill +/- 10.000 opioid drug users 90% inject Heroin & polydrug 7400+ in OMT (2014) Universal health care system Free access to treatment
Norwegian OMT; Development 1998-2013
0
1000
2000
3000
4000
5000
6000
7000
8000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
No of pts
Total
Metadon
Bupr.
Year
Riksheim et al; 2014 JSAT Norwegian OMT evaluated annually by SERAF; «Annual Status reports»
Waiting lists for OMT; 1998-2011
0
100
200
300
400
500
600
700
800
900
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
East
South
West
Middle
North
Norway
Riksheim M. et al, JSAT 2014
Mortality in OMT; Norway
Year 2000 01 02 03 04 05 06 07 08 09
10
11
12
13
Norway, numbers 12 10 26 31 21 30 15 32 39 63
54
54
84
98
% of all in treatment/year 1,3 0,8 1,5 1,4 0,8 0,9 0,4 0,8 0,8 1,3
0,9
0.8
1,2
1,3
Annual «Status-reports OMT»
An ageing cohort of persons in treatment
Mortality before, during and after OMT in Norway
Clausen T. et al. Drug and Alcohol Dependence, 2008, Mortality prior to, during and after opioid maintenance treatment (OMT)
% pr year
Pre-treatment In treatment Post treatment
Overdose
Non-overdose
0
0,5
1
1,5
2
2,5
3
3,5
4
1998-2003
Somatic morbidity; before, during and after OMT in Norway
0
10
20
30
40
50
60
70
80
Pre-treatment
In treatment Post treatment
Drug related (all)
Overdose (Non-fatal)
% Inpatient hospital treatment
past year
Skeie I. et al, BMJ Open 2011
Crime prior to OMT (36 months) (n=3789)
0
5 000
10 000
15 000
20 000
25 000
30 000
Vinning Narkotika Trafikk Vold Andre
80 % of convictions
N= convictions
Total Convictions
Acquisitive Drug Traffic Violence Other
Bukten et al JSAT 2011
Convictions prior to, during and after OMT
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
2
Venteliste Behandling Ute av behandling
kontinuerlige Ikke-kontinuerligeCrime rate per year
Pre-treatment In treatment Post treatment
Continuous OMT Drop put from OMT
Bukten et al Addiction 2012
”Treatment effect” mortality, morbidity and crime; prior to, during and after OMT
Pre-treatment In treatment (OMT) Post treatment
Time
Standard Rate
1
0.5
Patients who terminate OMT – how do they fare?
Clausen et al; Tidsskr Nor Legeforen 2014; 134:1146 – 9
Main messages
OMT: reduces overall mortality by 50% and ODs by 80% + while in treatment (Norway)
OMT reduces somatic drug-related morbidity by 75%, while in treatment
OMT reduces crime by more than 60%, while in treatment
Barriers to treatment access and treatment drop-out should be reduced
Clausen T. The Norwegian OMT program – benefits and challenges. Norsk Farmaceutisk Tidsskrift 2014; 10: 39–42
Provision of treatment
Opioid maintenance treatment – 60+ % coverage of target population
– Medications together with psychosocial interventions
– Treatment provision in prison and following prison
Harm reduction facilities/interventions
Take-home naloxone
Residential treatment
Etc
Aims of treatment; opioid addiction
Rapid access to treatment Provide a range of treatments
OMT a central part of treatment provision
Individually adapted treatments (comorbidities) Multidisciplinary teams Long-term treatment and perspective Provide treatment concurrent with intensity of
disorder
Control disorder & reduce risk A continuum of care!