Spain’s provision of methadone maintenance treatment for heroin dependence, combined with the distribution of sterile injecting equipment and access to treatment for AIDS, has led to a turnaround in the country’s HIV epidemic, according to a study published this month in the Bulletin of the World Health Organization.
Spain’s experience in this area is relevant to other countries where illicit drug injection is a common problem, such as those in eastern Europe and central, southern and eastern Asia
During the 1980s, Spain had some of the world’s toughest regulations on the treatment of heroin dependence and, at the same time, it had Europe’s highest rate of new HIV infections among people who inject illicit drugs. In the early 1990s, HIV prevalence in this group reached 60%.
Back then, virtually the only treatment available for heroin dependence in Spain was based on abstinence, but most patients relapsed and continued to inject drugs. That changed after two laws were passed in 1990 and 1996, making methadone and similar medicines widely available on prescription in public health-care centres in every region of the country free of charge to patients diagnosed with heroin dependence.
The study found that, as a result of these laws and the way Spain’s national programme was re-designed, by 2010, 60% of the people in the country who were injecting illicit drugs were on methadone maintenance treatment, up from 21% in 1996, and, thanks to these changes in the law and other HIV prevention initiatives, the number of new HIV infections among drug users had dwindled from an annual average of 6200 in the early 1990s to 690 new infections in 2010.
“Spain achieved this success by lifting unnecessary restrictions on which heroin-dependent people can receive methadone, by not limiting the dose or the duration of treatment and by allowing suitable patients to take some doses at home,” said lead author and researcher Marta Torrens, head of the Addiction Programme at the Institute of Neuropsychiatry and Addiction of Mar Health Park and coordinator of Substance Use Disorders Research Group at IMIM (Hospital del Mar Medical Research Institute) in Barcelona.
“Some drug treatment programmes discharge people from treatment at the first sign of difficult behaviour, but the Spanish methadone programme makes every effort to keep patients on treatment for as long as possible,” she said.
“Each day, patients receive a daily dose of medicine, usually methadone, and at the same time any other health care they might need, such as antiretrovirals for HIV infection,” said Torrens, adding that with this approach, which is consistent with WHO guidelines on the treatment of opiate dependence, they are able to maintain more than 72% of patients in treatment after the first year.
Methadone, which is usually ingested in syrup form, produces stable levels of opioids in the patients’ blood over the 24 hours between each dose. This results in patients experiencing neither intoxication nor withdrawal. Over time and with adequate doses, methadone blocks the effect of heroin and, as a result, patients eventually stop using it. Less heroin use means less use of dirty needles, fewer HIV, hepatitis and other infections, fewer overdoses and less crime. Methadone treatment helps patients re-build shattered relations with their families and reintegrate into society.
“Public perception of this treatment is positive in Spain, with 66% of the general public in favour of methadone treatment,” Torrens said, adding: “Governments are currently under immense financial pressure because of the economic crisis, but our message to them is: heed this sound evidence and maintain funding for these programmes.”
Methadone is not expensive, according to the WHO Opioid Substitution Therapy and Morphine database, which shows that treatment can cost as little as US$ 28 a year per patient. http://www.who.int/entity/hiv/amds/ControlledMedicineDatabase.xls
“HIV prevalence was as high as 60% in people injecting drugs in Spain 20 years ago. Since there is great potential for transmission of HIV from the drug injecting population to the general population, control of HIV in the drug injecting population is essential to controlling HIV in the general population,” said Dr Nico Clark, from the WHO Management of Substance Abuse unit. “By providing this kind of treatment, health authorities not only prevent drug-related deaths and help patients reintegrate into society, but they also prevent HIV from spreading throughout the general community.”
The study is one of a series of articles in this month’s issue of the Bulletin of the World Health Organization devoted to the theme of opioid substitution therapy.
“Methadone maintenance treatment in Spain: the success of a harm reduction approach”. Marta Torrens, Francina Fonseca, Claudio Castillo & Antonia Domingo-Salvany. Doi: 10.2471/BLT.12.111054
Institut Hospital del Mar d’Investigacions Mèdiques