Substitution and maintenance therapy of opioid addiction
According to the provisions of Finnish Government Decree no. 33/2008 (http://www.finlex.fi/fi/laki/alkup/2008/20080033), pharmaceutical products containing methadone or buprenorphine may be prescribed as detoxification or substitution therapy for the treatment of opioid dependency. This decree states that pharmaceutical treatment must be supplemented by other medical and psychosocial care of the patient as well as regular monitoring of the treatment. This new decree places a greater emphasis than before on the need for evaluation of treatment, starting treatment and implementation in basic health care, so that treatment is as easily accessible to patients as possible. Only difficult treatment cases are suitable for assessment and delivery of care in special addiction hospitals. The decree states that patients who have not come off opioids can be started on pharmaceutical substitution therapy.
The aim of detoxification therapy is to get the patient off opioids and any substitutes, i.e. to end their use of substitution medicines as well. Medical detoxification therapy may be delivered on an outpatient or inpatient basis, depending on the patient’s overall circumstances. The decree states that pharmaceutical substitution therapy is rehabilitation that aims to get the patient free of drugs, so the objective of treatment is to reduce harmful effects and improve the patient’s quality of life. Under the new decree, because of the long-term nature of treatment, efforts should be made to deliver treatment as close as possible to where the patient lives.
The evaluation of the need for pharmaceutical substitution therapy is based on a medical diagnosis of opioid dependency and an analysis of the patient’s overall circumstances by professionals from multiple fields. Delivery of medical treatment should generally be started on an outpatient basis, but if the patient’s use of intoxicants requires it (particular in cases of benzodiazepine use) inpatient treatment is justified to ensure successful treatment and safety. Afterwards, pharmaceutical treatment can be delivered in a monitored care environment. The patient may be issued with doses for self-administration if he or she displays good compliance with treatment. This is generally understood to mean that there is no additional substance use, the patient has learned the correct dosage and is prepared to observe it.
Medicines and their doses are specified for each patient individually. The aim of the medication is to “normalise” the brain functions disturbed by the use of drugs, so that the need to use drugs gradually disappears and the patient can concentrate on taking care of relationships, work etc. The effect of the medicines is, however, steadier and more constant, so they have no strong euphoric or paralysing effects nor will they cause sudden mood swings or changes in performance. According to studies made in other countries, substitution therapy is successful. The use of illegal substances stops or is at least reduced, crime is reduced, risk of death and illnesses decreases, the quality of life and social situations are improved. The patient can better benefit from other methods of treatment once stabilised by the substitution therapy.
Other psycho-social rehabilitation must also be arranged during the therapy. Regular assessments are made regarding a possible time period to stop using the medication and continue the rehabilitation with other methods. Substitution medication can be continued for several years if needed. Substitution treatment to reduce problems is understood to refer to patient treatment that places particular emphasis on reducing the harmful effects to the patient’s health and other effects of opioid use and improving their quality of life, even if they are not able to stop using drugs completely.
Substitution therapy must always be based on a treatment plan that is regularly updated. The plan must also define the psychosocial rehabilitation the patient requires. This is a key element of treatment, so it must be offered in sufficient amounts to benefit the patient. If a patient’s treatment needs change, the treatment offered to them should also change.
Under the new decree, a combined buprenorphine-naloxone substance may also be prescribed. The purpose of this change is to enable patients to be treated within the basic health care system, as with other long-term illnesses, at a stage when they no longer require intensive psychosocial rehabilitation. An agreement with a pharmacy is necessary in order to prescribe this medication (http://www.terveyskirjasto.fi/xmedia/extra/hoi/hoi50028a.pdf) and the product is generally provided to the patient at 1- or 2-week intervals. Basic reimbursement was granted for this combination treatment for a fixed period in August 2009, which has increased treatments in the basic health care system.
It is the responsibility of the municipality where the patient resides to arrange substitution and detoxification therapy in accordance with the Ministry’s decree and to cover the costs of treatment. The number of patients in treatment has increased significantly in recent years, but the problems leading to treatment are still prevalent in large cities, particularly in the greater Helsinki area. Unfortunately the difficult economic situation seems to be having a detrimental effect on the situation.
Pharmaceutical substitution treatment for opioid dependency has become an established part of Finnish substance abuse treatment, and discussions about its appropriateness have decreased significantly. Now the challenges are the content of treatment and developing differentiated approaches so that treatment addressing different levels can be offered to different types of patient groups according to their needs. The objective is to enable more patients to be treated without increasing costs unreasonably.
Espoo A-Clinic service
Medical superintendent (retired)
Järvenpää Addiction Hospital