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STRESZCZENIA REFERATÓW Z III MIÊDZYNARODOWEJ KONFERENCJI: LECZENIE SUBSTYTUCYJNE I REHABILITACJA NARKOMANII Katowice, LESSONS LEARNED ABOUT COMMUNICABLE DISEASE CONTROL: HIV/AIDS IN POLAND, Philip Alcabes 1, Andrzej Zielinski 2 1 City University of New York, USA 2 Department of Medical Statistics, National Institute of Hygiene, Warsaw, Poland At the first Polish conference on substitution therapies, in 1994, American epidemiologist P. Alcabes quoted Simon Wiesenthal, saying History doesn t repeat itself; we re just keeping the same mistakes. To an epidemiologist who had studied AIDS in American cities, it seemed that Poland was making the same mistakes the U.S. had made and would experience the same AIDS disaster. In this talk we will examine why the dire prediction of 1994 turned into the less dire reality in In 1994, the prevalence of HIV infection among drug injectors in Polish cities was on the order of 25 to 40% just as it was in U.S. cities when AIDS was first recognized there in the early 1980s. If Poland s epidemic had followed the U.S. pattern, we would have seen over 50,000 AIDS cases by now, while the truth is closer to 15,000. HIV prevalence in Poland is about 0.1%; Ukraine, with similar drugs of abuse, has a prevalence of about 1%. What suppressed the spread of HIV in Poland? We will discuss a combination of factors: 1. Compartmentalization: little interchange between subpopulation of drug users and other populations. 2. Displacement of kompot by other drugs. 3. Harm-reduction programs. 4. General improvement in living standards. We will end by drawing conclusions for the control of HIV/AIDS and similarly transmitted infectious diseases. THE USE OF PSYCHOACTIVE SUBSTANCES (MAINLY ALCOHOL AND TOBACCO) BY PATIENTS IN METHADONE PROGRAM Helena Baran-Furga, Bogus³aw Habrat, Karina Steinbarth-Chmielewska, Anna Bogucka-Bonikowska, Przemys³aw Bieñkowski, Ewa Taracha Institute of Psychiatry and Neurology, Warsaw, Poland One of the main aims of substitution therapy is to reduce or decrease the use of opiates. This is well documented in hundreds papers. In our research we confirmed it in our population, whereas during one year of participation in methadone program the use of opiates by the participants was reduced by 95%. From a pharmacological point of view, there are no reasons to expect a reduction of other drug usage. Nevertheless, we found that after one year of participation in methadone program the percentage of patients using benzodiazepines was reduced from 67% to 5.3%, and barbiturate usage dropped from 52% to 3.5%. Similar phenomenon was observed with respect to amphetamine: the percentage of users decreased from 43% to 6.2%. 113 The influence of methadone on cannabinoids use in the population studied by us was less spectacular, mainly because of a low rate of such users at the beginning of the program (7.1%). After one year of treatment this percentage was 0.9. Results of research on the influence of substitution treatment on alcohol use are not conclusive. In our study, we found that during one year of methadone treatment the majority of patients increased alcohol consumption. Before the beginning of the program, 80% of patients drunk alcohol not more frequently than once a month, and after a year of treatment, 80% of them consumed alcohol several times a week. They drunk alcohol more frequently and in greater amount. In none of them a development of alcohol dependence was noted. General balance of the benefits of methadone treatments and the drawbacks of alcohol drinking shows a great domination of benefits over harms. To facilitate a more objective than self-reporting control of alcohol use, our team worked out a new urine marker for alcohol abuse. In this particular population urinary β-hexosaminidase was found more suitable than classical serum markers of chronic alcohol abuse: GGT and CDT. In a majority of studies an increase of nicotine use after methadone was observed. We found that our patients reduced number of cigarettes smoked daily, and spontaneously changed their favorite brands of cigarettes to those containing less nicotine. THE PROGRAM OF PROPHYLACTIC AID TO DRUG ADDICTS IN THE PERIOD OF ABSTENTION 114 Anatoly Chaplygin, Sergey Kulikov. Regional Narcological Clinic, Astrakhan, Russia We view the given project as the only possible surrogate substitute therapy in the framework of the Russian legislature. The objectives of this program are traditional for methadone program: reduction of HIV/hepatitis infection, reduction of the crime level antisocial behavior, getting contacts with drug users. The project has been working from to the on the base of the Narcology Dispenser in Astrakhan, and was financed by the Embassy of France in Russia, under supervision of the organization Medecins du Monde (France). Methodologically the project followed analogous rules as low-level methadone program. After anonymous checking and medical examination by narcologist, a person was ready to participate in the project. The pills of prolonged action, tramadol-retard (100 and 200 mg) were used. The conditions for taking this medicine were as follows: the absence of clinical drug symptoms, the taking of the medicine held in the presence of a doctor, the medicines were not handed away, maximum quantity of visits was limited (not more than 2 times a day) and a break between the taking of the medicine (not less than 6 hours) was observed. Monthly, from people participated in the program: 70% of the participants of the program reduced the quantity of drug injections from 4-5 to 1 daily. 20% of drug addicts did not use drugs from 1 day to 2 weeks, 5 % of the participants of the program gave up using drugs for a period of from 2 weeks up to 2 months. Hence, the risk of infection with HIV/hepatitis was considerably reduced at that period. The program showed its social importance and proved that drug users can care about their health. We have reasons to suppose that such program reduces the crime level in this social group. THE HOSPITALIZATIONS OF THE PATIENTS ON METHADONE MAINTENANCE IN KRAKOW DURING YEARS Jan Chrostek Maj 1, Wojciech Piekoszewski 2, Aleksandra Kamenczak 3, Zofia Foryœ 3 1 Outpatients Clinic for Drug Addicts, Rydygier s Hospital, Cracow, Poland 2 Toxicology and Industry Laboratory Department of Chair the Occupational Medicine and Environmental Diseases, Jagiellonian University Medical College Cracow, Poland 3 Detoxification Department of Chair the Occupational Medicine and Environmental Diseases Jagiellonian University Medical College, Cracow, Poland The co-operation of the hospital department with The Methadone Maintenance Program (MMP) is described in this paper. The MMP in Krakow was run from January of the year 2000 up to now (June 2004), according to the rules established in 1999 by the Health Ministry of Poland. Altogether, 120 persons were treated (a group had patients). They were given 80 mg methadone per day, and the mean concentration of methadone in blood was 352,15 ng/ml. There were 31 persons (25,8%) infected with HIV (to our knowledge). Among them, 15 persons were admitted to the infectious diseases departments, and 5 persons started with MMP in hospital according to extraordinary procedure. Four patients died due to the complications caused by the HIV/AIDS. During this time 12 children were born, also in hospitals. And 5 persons were admitted to other departments (laryngological, dermatological, nephrological, psychiatric). During all hospitalizations our outpatient clinic staff and volunteers from Monar applied the procedures of MMP but we had many logistic and administrative troubles. We suggest a simultaneous application of MMP during hospitalizations, and a possibility of continuation of substitutive therapy for opiate abusers. OVERVIEW OF HIV/AIDS AND HUMAN RIGHTS Joanne Csete Human Rights Watch, HIV-AIDS Program, New York, USA Human Rights Watch, New York, USA. Public health and human rights have been known to conflict. Quarantine and segregation, forced medical testing, and publicizing the names of those infected by a disease are examples of measures that may restrict human rights and reinforce stigma and discrimination in the pursuit of public health goals. From the beginning of the AIDS epidemic, visionary leaders understood that HIV/AIDS was different from other infectious diseases with respect to human rights. People such as drug users, gay and bisexual men, workers in the sex trade and prisoners, who faced stigma and abuse before AIDS was present, were first and hardest hit by AIDS. An understanding grew that adding draconian public health measures to the abuse already faced by these persons would undermine the fight against AIDS because it would only marginalize them further and drive them away from the services they need. There is a strong global consensus that respecting the human rights of 115 people affected by AIDS is important to combat the disease. Nonetheless, human rights linked to HIV/AIDS are perhaps more under attack than ever, and programmes to address abuses of those rights are few. This presentation reviews the factors that undermine the human rights of people with AIDS and those at risk of the disease and suggests some steps to improve protection of AIDS-related human rights. 116 POLISH RESEARCH CONCERNING METHADONE TREATMENT Bogus³aw Habrat, Helena Baran-Furga, Karina Steinbarth-Chmielewska Institute of Psychiatry and Neurology, Warsaw, Poland Substitution therapy is still controversial in Poland. Many decisions concerning treatment of addiction are based on opinion and impressions but not on evidence. There is a strong need to support public health policy by research. Unfortunately, in Polish medical universities interest on drug problems is small. Since 1992, when the first Polish experimental methadone program was established, several studies were conducted, mainly in the Institute of Psychiatry and Neurology in Warsaw. First published papers concerned the effectiveness of a six-month methadone program. It was shown that six-month program, although dramatically reduced heroin and other drug use, was too short for a radical rehabilitation of the participants. Next finding was that during 7th month (when doses of methadone were gradually reduced) majority of patients relapsed. It was one of the reasons for continuation of that experimental program. In the next paper it was shown that methadone patients stay in methadone program much more longer than in drug-free programs (after two years 24% vs. 1,8%). In other study we show how the participation in a methadone program significantly reduces the use of heroin, benzodiazepines, barbiturates, amphetamine and cannabinoids. Although consumption of alcohol was increased in our patients, it was shown that benefits of participation in a methadone program were much greater than harm caused by alcohol. Our program was very effective in prevention of HIV transmission. During 12 years no seroconversion case of HIV-seronegative patient was observed. After one year of treatment, significant improvement of physical health was observed. It concerned infections of veins and skin, mycoses, kachectic states, amenorrhea. Chronic hepatic failure associated with hepatitis C was common and significant improvement was not observed. In Jagiellonian University (Cracow) a study was made that confirmed the influence of methadone on improvement of many biochemical and other laboratory parameters. All that research was made for the country market to change the minds of professional therapists and policy makers. One of the studies described practices of non-compliance to the requirement of a daily visit in the methadone treatment facility.. It was a basis for changing the rules of the program in this respect. Some of the studies were original. In one of them we showed improvement of the quality of life (QoL) due to participation in a methadone program. Interestingly, QoL was rapidly improved after half-year treatment, but after next 6 months some worsening was observed. In a series of Cracow studies, the influence of a methadone program on many physical parameters was investigated, among others on the respiratory functions. Studies concerning the influence of methadone therapy on immunological parameters in HIV-positive patients were conducted on the patients from the Nowowiejski Hospital. In our study, we found that urinary marker of chronic alcohol use β-hexosaminidase can be more useful in methadone patients than serum markers: GGT and CDT. Currently, our Institute s program is engaged in international multicenter study concerning the effectiveness of substitution therapy on HIV/AIDS prevention and treatment. THE AMOUNT OF HIV POSITIVE DRUG USERS AMONG INJECTED DRUG USERS; THE KIND OF DRUGS AND THE PERIOD OF USING Yury Ivanov Tver AIDS Center, Tver Center Of Drugs Addiction Treatment, Tver, Russia Research goal: We wanted to define the amount of HIV positive drug users among injected drug users (IDUs); the kind of drugs and the period of using, with the aim of improving a system of medical care (antiretroviral and drugs addiction treatment) in Tver. Materials and methods: The Tver is situated between Moscow and St. Petersburg (170 km from Moscow). The population of the town is The amount of IDUs was 2000 at the last estimation. As of Novembe cases of HIV were registered in Tver, 52,2 % from which were among drug users (in 1997 drug users made up 95 %). Since April 1999 the project of Harm reduction among injected drug users has been operating in the town of Tver. For the last time we had the fact that most of IDUs participants of the project had HIV positive status. During two weeks in April 2002 a structured interview of IDUs and tests of blood from the utilized marked syringes were conducted. 75 IDUs from the 129 had HIV positive status. During one month of November 2003 a structured interviews of 100 IDUs were conducted. Results: 55 IDUs used drugs 3-6 years, 25 IDUs 7-10 years, 7 IDUs more that 10 years and 1 less that 1 year. 51 IDUs used mainly heroin, 30 IDUs used street methadone, 15 IDUs amphetamine. 32 IDUs informed about HIV positive status, 4 IDUs didn t know about results of HIV tests, 20 IDUs didn t answer. Conclusions: The major part of IDUs used drugs for 3 and more years; they used strong (heroin, street methadone ) drugs, and many IDUs had HIV positive status. Therefore medical treatment of IDUs must be a complex and long process, including antiretroviral and drugs addiction therapy. The substitutive methadone therapy is more preferable method, but this method is illegal in Russia. DRUG ADDICTION TREATMENT IN SOUTH-EASTERN EUROPE Andrej Kastelic, Tatja Kostnapfel Rihtar, Ante Ivanèiæ South Eastern European Adriatic Addiction Treatment Network The paper presents the overview of the situation in drug addiction treatment in South Eastern Europe, the obstacles for comprehensive treatment and advocacy efforts in the region as a good practice model for developing MMT. The opioid substitution treatment does not exist in Albania. MMT is going to be started in NGO Aksion Plus with the financial support of the IHRD-OSI NY. This project will be unique, as MMT will be provided by NGO. 117 Methadone can be applied in Bosnia and Herzegovina only in specialized institutions. Methadone detoxification programme has been started in January 2002 and MMT in July Bulgarian substitution treatment guidelines define two types of methadone treatment: detoxification and high-threshold MMT only in specialized outpatient clinics. Methadone in Croatia was introduced in Outpatient treatment is dominant and is based on cooperation between centres for outpatient treatment for drug addiction and general practitioners. Macedonian substitution treatment guidelines include low and high threshold programmes. Most of Macedonian psychiatrists do not support MMT. So far MMT has not been recognized as a treatment. There is no formal Serbian and Montenegro substitution treatment guidelines. There are different guidelines for Belgrade and Novi Sad (Vojvodina), neither officially approved. Basic obstacles are in poor political and economic situation and negative previous experience with MMT in Belgrade. There is a small MMT in Novi Sad. There is no substitution treatment in Montenegro at the moment. But HIV Prevention among Vulnerable Population Initiative (HPVPI) in Serbia and Montenegro with the support of British Government, Imperial College London and International Harm Reduction Development Program (OSI) will hopefully launch MMT program in these countries in National guidelines for management of drug users including MMT were adopted in Slovenia in MMT is one of the fundamental treatment and harm reduction programmes in current drug policy. New national Centre for Treatment of Drug Addicts was established in February South Eastern European Adriatic Network (SEEA) was established in 2003 to give support in training and developing substitution treatment programmes in the region and can hopefully be an example how to advocate for MMT in other regions. Databases on all experts and institutions are under construction and own web site page has been formatted. Odvisnosti-Ovisnosti-Zavisnosti-SEE Addiction regional magazine has been published and new regional conference Vanguard 2004 will be organised by SEEA network in Belgrade in May CORRELATION OF DRUG USE LEVEL AND DRUG TRAFFICKING IN TAJIKISTAN Murtazokul Khidirov NGO RAN, Dushanbe, Tajikistan Issue: Since the second half of the 90s, criminal structures began to use territory of Tajikistan for drug trafficking from Afghanistan to the countries of the former Soviet Union and further to other countries of the world. At the same time the problem of drug use has substantially grown in Tajikistan. Approach: The following data was analyzed: a) data from official registry of problem drug users by the Ministry of Health ; b) data about drugs withdrawn from illegal circulation by law enforcement bodies of Tajikistan ; c) various researches, assessing the prevalence of problem drug use, carried out by local and international experts in Key points: In 2001, the amount of withdrawn drugs was 806 times higher in comparison with Regarding the structure of withdrawn opiate drugs, a share of heroin has grown up from 2% in 1996 up to 70,9% in At the moment, heroin is the main used and transit drug in Tajikistan. A number of officially registered problem drug users increased 8 times from 1995 (823) till 2002 (6 840). In 2002, 75,2% of them were dependent on heroin, 34,1% used injected drugs. Experts estimate that the number of drug users in Tajikistan ranges between and ; 67% of them are injecting drug users. Implications: Despite of the U.S. anti-terrorism interventions in Afghanistan, drug trafficking, as well as drug use and injected drug use continues to grow in Tajikistan. The following situation demands further development of Harm Reduction programs, of substitutive treatment, of rehabilitation of drug abusers and expansion of educational drug demand reduction programs. METHADONE SUBSTITUTION TREATMENT FROM THE STANDPOINT OF INJECTING DRUG USERS Vyacheslav Matushkin Nongovernmental Organization Renewal, Kazan, Russia Goal. A survey on the attitude of injecting drug users (IDUs) in the city of Kazan, capital of Tatarstan, towards their possible participation in a methadone substitution treatment program. Introduction. The introduction of methadone substitution treatment pilot programs in Russia is being discussed among narcologists and experts of other agencies. The standpoint of target population of IDUs should be taken into consideration. Method. The survey is based on the analysis of 20 semi-structured questionnaires of IDUs that were collected in January Respondents were IDUs clients of the Renewal harm reduction project. The structured part of the questionnaire consisted of questions on social status
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