OST and misuse of opioids in the Czech Republic. Viktor Mravčík, MD, PhD

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1 OST and misuse of opioids in the Czech Republic Viktor Mravčík, MD, PhD

2 Estimates of PDUs Problem drug users in total Opioids users Methamphetamine users Injecting drug users Year Number Per 1,000 aged Heroin Buprenorphine Other opioids Total Per 1,000 aged Number Per 1,000 aged Number Per 1,000 aged , ,200 4,300-10, , , , ,750 4,250-10, , , , ,400 4,900-11, , , , ,100 5,100-12, , , , ,000 5,000-11, , , , ,700 4,600-9, , , , ,300 6,300-10, , , , ,500 7,200-10, , , , ,100 7,200-11, , , , ,500 7,100 1,150 12, , , source: Czech Annual Report on Drug Situation in 2015

3 Reduction of heroin black market source: Czech Annual Report on Drug Situation in 2014

4 Proportion of IDUs among PDUs in treatment (TDI register), in % source: Czech Annual Report on Drug Situation in 2014

5 Other substances than METH, heroin and BUP Increasing misuse of opioid analgesics: fentanyl patches morphine-based Vendal Retard hydromorphone-based Palladone oxycodone-based OxyContin codeine-based products (codeine, dihydrocodeine) tramadol, Raw opium during Summer season Manufacture of heroin from raw opium or morphine-based products by acetylation Manufacture of braun from codeine-based products No use of desomorphine( krokodil ) New synthetic drugs: some prevalence of cathinones(funky), but not as a primary drug no use of new synthetic opioidy (e.g. fentanyl derivates) 5

6 Regional differences in PDU Karlovarský Plzeňský Liberecký Ústecký Královéhradecký hl.m. Praha Středočeský Pardubický Moravskoslezský Olomoucký Vysočina Jihočeský Zlínský Jihomoravský 1,1 3,0 3,1 6,0 6,1 10,0 10,1 15,0 15,1 20,0 Hl.m. Praha Středočeský Jihočeský Plzeňský Karlovarský Ústecký Liberecký Královéhradecký Pardubický Vysočina Jihomoravský Olomoucký Zlínský Moravskoslezský Heroin Buprenorfin Pervitin

7 OST in the Czech Republic Officially registered: In total in 2015: 4,000 clients in substitution estimated, of them 3,300 on buprenorphine-based preparations, 700 on methadone 53 clients in OST in 7 prisons in 2015 source: National Institute for Health Information and Statistics (2016)

8 Marketed OST medications Methadone: prepared from an imported generic substance (available in specialised substitution centres only) (since 1997) Buprenorphine: Subutex (since 2000) Buprenorphine Alkaloid and Ravata (since 2011) Composite buprenorphine and naloxone: Suboxone (since 2008) Every MD can prescribe OST regardless of his/her specialisation, in a stricter prescription regime ( prescription with blue strip )

9 Distribution of preparations containing BUP and BUP with naloxone Suboxone (buprenorfin plus naloxon) Přípravky obsahující jen buprenorfin * in grams of buprenorphine source: MoH(2015)

10 Leakage of OST medications on the black market No diversion of methadone (unavailable as proprietary medicinal product in pharmacies) Almost no black market with Suboxone Substantial diversion of mono- BUP preparations: majority of problem opioid users are represented by BUP users Majority of problem drug users including BUP users are IDUs

11 Health insurance scheme for OST OST has no specific code in health insurance (it is claimed using codes for general psychiatric care) Methadoneis not covered by health insurance, but import of generic substance is financed directly by MoH Mono-BUP preparations are not covered by health insurance Suboxone is formally covered by health insurance, however criteria are difficult: Medicine can be prescribed by a psychiatrist or addiction medicine specialist Special contract is needed between insurance companyand treatment centre, costs are reimbursed to treatment centre (and not pharmacy) Treatment is not reimbursed in case of non-adherence

12 So in practice... Just insignificant reimbursement: According to the biggest insurance company (VZP): Suboxone was financed for 157 clients in 2014 According to NFP: Suboxone was financed for 75 clients in 4 centres The rest of 3200 patients on BUP have to pay the whole price( a month) Retail price (in pharmacy) of annually consumed amount of buprenorphine(suboxone : mono- BUP = 50 : 50): CZK 50 million at least (approx. 2 million)

13 So in practice... (2) Doctor shopping to finance one s own medication: Among IDUs in Prague, 37 % sold BUP on the black market in the last 12 months The price of one 8 mg tablet of Subutex : in pharmacy approx. CZK 200 ( 7.5) on the black market the price is usually doubled, but temporarily when buprenorphine is unavailable (like in Prague in April and May 2012) the price can be 6times higher The high price leads to use of suboptimal doses of BUP a daily dose of buprenorphine range between mg, on average reach 3 mg Higher frequency of BUP injecting: division of BUP into smaller pieces (one quarter of 8 mg tablet or even less) injected little by little

14 Summary Meth is dominating PDU (approx. ¾ of estimated PDUs), buprenorphine, heroin Substantial proportion of IDUs among PDUs Increase of misuse of opioid analgesics Substantial leakage of BUP from OST to the black market Majority of problem opioid users are recently on BUP, high prevalence of BUP injecting Low opioid-related mortality and limited heroin black market OST is not sufficiently covered by public health insurance scheme Low affordability of BUP leads to doctor-shopping and black market with BUP Underdosing of BUP and some increase in injecting-related risk

15 Thank you! rvkpp.vlada.cz

16 Sources FAREED, A., VAYALAPALLI, S., CASARELLA, J. & DREXLER, K Treatment outcome forflexibledosingbuprenorphinemaintenancetreatment. AmJ DrugAlcoholAbuse, 38, GLUZOVÁ, J Vzorce užívání buprenorfinu u klientů Terénního programu SANANIM (Patterns of buprenorphine use among clients of Outreach Programme SANANIM). Bc., Univerzita Karlova v Praze, 1. lékařská fakulta, Klinika adiktologie. MRAVČÍK, V. et al Výroční zpráva o stavu ve věcech drog v České republice v roce 2014, Praha, Úřad vlády České republiky. MRAVČÍK, V. et al Výroční zpráva o stavu ve věcech drog v České republice v roce 2015, Praha, Úřad vlády České republiky. ŠVŮGEROVÁ, H Spotřeba injekčního materiálu klienty pražských harm reduction služeb v závislosti na vzorcích užívání (Consumption of material for injectionclientsofprague harmreductionservicesdependingon use patterns). Mgr., Univerzita Karlova v Praze, 1. lékařská fakulta, Klinika adiktologie 1. LF UK. 16