OST and misuse of opioids in the Czech Republic Viktor Mravčík, MD, PhD
Estimates of PDUs Problem drug users in total Opioids users Methamphetamine users Injecting drug users Year Number Per 1,000 aged 15 64 Heroin Buprenorphine Other opioids Total Per 1,000 aged 15 64 Number Per 1,000 aged 15 64 Number Per 1,000 aged 15 64 2006 30,200 4.13 6,200 4,300-10,500 1.44 19,700 2.69 29,000 3.97 2007 30,900 4.20 5,750 4,250-10,000 1.36 20,900 2.84 29,500 4.01 2008 32,500 4.39 6,400 4,900-11,300 1.52 21,200 2.87 31,200 4.21 2009 37,400 5.04 7,100 5,100-12,100 1.63 25,300 3.40 35,300 4.75 2010 39,200 5.30 6,000 5,000-11,000 1.48 28,200 3.81 37,200 5.03 2011 40,200 5.51 4,700 4,600-9,300 1.27 30,900 4.24 38,600 5.29 2012 41,300 5.71 4,300 6,300-10,600 1.47 30,700 4.25 38,700 5.35 2013 45,200 6.32 3,500 7,200-10,700 1.50 34,500 4.82 44,400 6.22 2014 47,700 6.73 4,100 7,200-11,300 1.59 36,400 5.13 45,600 6.43 2015 46,900 6.68 4,500 7,100 1,150 12,700 1.81 34,200 4.87 43,900 6.25 source: Czech Annual Report on Drug Situation in 2015
Reduction of heroin black market source: Czech Annual Report on Drug Situation in 2014
Proportion of IDUs among PDUs in treatment (TDI register), in % source: Czech Annual Report on Drug Situation in 2014
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
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 0 5 000 10 000 15 000 20 000 Heroin Buprenorfin Pervitin 0 5 000 10 000 15 000 20 000 6
OST in the Czech Republic Officially registered: 2 113 2 290 2 298 2 311 2 314 2 248 1 356 1 555 533 560 789 866 825 938 1 038 245 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 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)
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 )
Distribution of preparations containing BUP and BUP with naloxone 3 330 3 099 2 804 2 880 3 157 1 366 2 095 1 777 1 479 1 816 1 569 265 418 504 567 918 2008 2009 2010 2011 2012 2013 2014 2015 Suboxone (buprenorfin plus naloxon) Přípravky obsahující jen buprenorfin * in grams of buprenorphine source: MoH(2015)
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
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
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( 100 500 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)
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 0.5 8 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
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
Thank you! mravcik.viktor@vlada.cz www.drogy-info.cz rvkpp.vlada.cz www.vlada.cz www.koureni-zabiji.cz
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