01.01.2013 International experts on substitution treatment meet in Geneva
Conferences on opioid dependence. Two conferences on the treatment of opioid dependence were held concurrently in Geneva on 18 and 19 October: NaSuKo (3rd national conference on substitution treatment) and TOD (3rd francophone international symposium on the treatment of opioid dependence). More than 450 experts from Switzerland and a number of other French-speaking countries attended the two conferences.
NaSuKo, the national conference on substitution treatment held every five years, takes stock of the situation of substitution treatment in Switzerland and discusses development opportunities. "Substitution treatment" is understood as the prescription of a legal drug (the substitution drug) by a physician as a substitute for an illegal opioid (usually heroin). The most important substitution drugs are currently methadone, buprenorphine und diacetylmorphine (pure heroin). Initial rudimentary recommendations for such substitution treatment were defined at the first NaSuKo, which was held in 2002. They were drawn up primarily for family doctors, who look after more than half of all patients receiving medical treatment for opioid dependence in Switzerland. This year the Swiss Society of Addiction Medicine (SSAM) presented revised, evidence-based clinical recommendations. Pascal Strupler, Director of the Federal Office of Public Health (FOPH), stressed the importance of this advance in his opening address, stating that one of the FOPH's oldest concerns in the drug policy field had been translated into action, i.e. providing a sound basis of empirical and clinical research for such treatment methods. What was taken for granted with every other disease had, he said, proved to be particularly difficult with regard to substitution-assisted treatment. Strong moral reservations about this form of treatment and widespread mistrust of the scientific rationale that stemmed from it still prevailed in many countries around the world – as indeed they had in Switzerland for many years.
Core topic: legal framework
The core topic of this year's francophone international symposium on the treatment of opioid dependence (TOD) was the legal and political framework of substitution treatment in various countries. TOD is held every two years, the first one having taken place in Montreal in 2008. The aim is to swap views on the benefits of this substitution method and discuss the progress made with it to date. Attending the conference for the first time were participants from Morocco, Tunisia, Algeria, Egypt, Lebanon and Cameroon, where substitution treatments have either just been established or are still viewed as possible options. A number of key presentations on the core topic of TOD were held in conjunction with NaSuKo. Among them was the address by former Swiss government minister Ruth Dreifuss who, as a member of the Global Commission on Drug Policy, talked about the criminalisation of dependent users and the effects on their health. She called for a pragmatic approach to the problem from politicians and for specific innovative projects. Professor Olivier Guillod from the University of Neuchâtel presented his FOPH-commissioned comparative study of the legislation on substitution treatment in France, Belgium, Canada, Tunisia and Switzerland. In this respect, Switzerland is one of the most progressive countries, in that diacetylmorphine can – though subject to stringent regulations – be prescribed by specialist doctors. But in France, for instance, only physicians in specialist clinics are allowed to prescribe methadone, while family doctors are restricted to the prescription of buprenorphine. In Lebanon, on the other hand, only psychiatrists may prescribe substitution drugs. These restrictive regulations can be interpreted as signalling mistrust of substitution treatment and substance-dependent patients on the part of legislators. This does nothing to make substitution treatment more attractive, and countries are familiar with the lack of physicians who are willing to take on opioid-dependent patients and to prescribe substitution drugs. Many of them are put off by the heavy administrative burden associated with substitution treatment and the difficulties that treating opioid-dependent patients can entail. In order to help family doctors with such patients, FOSUMOS (addiction-medicine forum Eastern Switzerland), FOSUMIS (addiction-medicine forum Central Switzerland), COROMA (the addiction-medicine network Collège romand de médecine de l'addiction) and Ticino Addiction joined forces to launch the website www.praxis-suchtmedizin.ch, where physicians can find detailed information on the treatment modalities of all addictive substances.
Switzerland as a model
Who is allowed to prescribe which substitution drugs, for whom and with what targets? How can we create broad access to substitution treatments? What kind of support do physicians need for this treatment? All the participating countries are currently addressing these questions. Drug experts from many of them envy Switzerland for its large degree of freedom in being able to try out new measures in the early 1990s and thus develop effective responses to the problems of the time. The experts assembled in Geneva accordingly called for such freedom to be granted to them by their own political decision-makers. But the trend in many places seems to be in the opposite direction. In Quebec, for instance, the government decided not to introduce heroin-assisted treatment despite the positive results obtained in a scientifically supported pilot study. In Switzerland, as a result of the difficulties many cities encounter in getting a grip on the drug trade on their streets, calls for a repressive approach are again attracting attention. However, hope is offered by France, where, in response to pressures exerted by large population centres, there are signs of a relaxation of the rigorous restrictions on the prescription of substitution drugs, and a similar development can be seen in Belgium. The key message of the experts at the end of the two conferences is: abandon rigid positions and retain and adapt any measures that are effec
René Stamm, Drugs Section, firstname.lastname@example.org