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Opioid Maintenance Therapy in Switzerland: an Overview of the Swiss IMPROVE Study

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Opioid Maintenance Therapy in Switzerland: an Overview of the Swiss IMPROVE Study Original article | Published 31 March 2014, doi:10.4414/smw.2014.13933 Cite this as: Swiss Med Wkly. 2014;144:w13933 Opioid maintenance therapy in Switzerland: an overview of the Swiss IMPROVE study Jacques Bessona, Thilo Beckb, Gerhard A. Wiesbeckc, Robert Hämmigd, André Kuntze, Sami Abide, Rudolf Stohlerf a Service de psychiatrie communautaire – PCO, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland b Arud Centres for Addiction Medicine, Zurich, Switzerland c Centre for Substance Use Disorders, Psychiatric Hospital of the University of Basel, Switzerland d Universitäre Psychiatrische Dienste Bern, Switzerland e Réseau Fribourgeois de Santé Mentale, Fribourg, Switzerland f Department of Psychiatry, University of Zurich, Switzerland Summary CONCLUSION: The subset of IMPROVE data presented gives a present-day, real-life overview of the OMT land- BACKGROUND/AIMS: Switzerland’s drug policy model scape in Switzerland. It represents a valuable resource for has always been unique and progressive, but there is a need policy makers, key opinion leaders and drug addiction re- to reassess this system in a rapidly changing world. The searchers and will be a useful basis for improving the cur- IMPROVE study was conducted to gain understanding of rent Swiss OMT model. the attitudes and beliefs towards opioid maintenance ther- apy (OMT) in Switzerland with regards to quality and ac- Key words: opioid maintenance therapy (OMT); cess to treatment. To obtain a “real-world” view on OMT, methadone; buprenorphine; Switzerland; survey; the study approached its goals from two different angles: IMPROVE study from the perspectives of the OMT patients and of the phys- icians who treat patients with maintenance therapy. The Introduction IMPROVE study collected a large body of data on OMT in Switzerland. This paper presents a small subset of the data- As estimated 25 million people worldwide are drug-de- set, focusing on the research design and methodology, the pendent and a large majority of these (approximately 15.6 profile of the participants and the responses to several key million) are illicit opioid users. Opioid dependence is a re- questions addressed by the questionnaires. cognised chronic relapsing condition associated with high METHODS: IMPROVE was an observational, economic burden, not only in terms of direct healthcare questionnaire-based cross-sectional study on OMT conduc- costs, but also expenditures in social welfare, productivity ted in Switzerland. Respondents consisted of OMT pa- loss, depression and law enforcement [1]. tients and treating physicians from various regions of the Switzerland’s drug policy model has always been unique country. Data were collected using questionnaires in Ger- and progressive and is based on “four pillars”, consisting man and French. Physicians were interviewed by phone of measures in the following four areas: prevention, ther- with a computer-based questionnaire. Patients self-com- apy, harm reduction and law enforcement [2]. The first pleted a paper-based questionnaire at the physicians’ of- European supervised drug-consumption room was estab- fices or OMT treatment centres. lished in Bern in 1986. In the years that followed, more of RESULTS: A total of 200 physicians and 207 patients par- these facilities were established all over the country, which ticipated in the study. Liquid methadone and methadone gave status to medical institutions in Switzerland [3]. A tablets or capsules were the medications most commonly great deal of the evidence base on opioid substitution treat- prescribed by physicians (60% and 20% of patient load, re- ment was collected from these settings [4–7]. spectively) whereas buprenorphine use was less frequent. A recent United Nations survey reported that about 0.6% of Patients (88%) and physicians (83%) were generally satis- the Swiss population aged 15 to 64 years are opioid users fied with the OMT currently offered. The current political [8]. Of the estimated 22,000 opioid-dependent individuals framework and lack of training or information were cited in Switzerland, more than 85% are in therapy [9]. Cur- as determining factors that deter physicians from engaging rent clinical guidelines from the Swiss Society of Addic- in OMT. About 31% of OMT physicians interviewed were tion Medicine (SSAM), the Swiss Association of the Med- ≥60 years old, indicating an ageing population. Diversion ical Officers of the Cantons (VKS), and the Federal Office and misuse were considered a significant problem in of Public Health (FOPH) fully support opioid mainten- Switzerland by 45% of the physicians. ance therapy (OMT), with methadone and buprenorphine Swiss Medical Weekly · PDF of the online version · www.smw.ch Page 1 of 15 Original article Swiss Med Wkly. 2014;144:w13933 as the recommended first-line OMT medications [10]. collection was conducted from 14 May to 07 September Substitution-assisted treatment is covered by the Swiss ob- 2012. ligatory health insurance system, but with certain limita- The study protocol, patient information and questionnaires tions. Take-home medications on weekends and holidays were approved by local independent ethics committees. Pa- are generally allowed, albeit with restrictions. tients had to sign an informed consent form before study However, although the Swiss model at first glance seems entry and study conduct followed Good Clinical Practice to work smoothly, there is a need to reassess this system in (GCP) guidelines. Confidentiality of the participants was a rapidly changing world. Over the years, new legislations, observed at all times. The IMPROVE study flowchart is treatment options and drug-related problems have arisen. shown in figure 1. Regional differences across the country still abound. In addition, the main players in OMT are changing. The Study participants and questionnaires demographics of the drug scene have been transformed as the drug addicts of the 1980s have aged and a new gen- Physicians eration of drug users is emerging [6, 10]. In parallel, the The key inclusion criteria for physicians were active in- profile of the treating physician may also be changing as volvement in OMT and willingness to answer the question- the OMT pioneers of 30 years ago go into retirement and a naire. Physicians’ data were collected through telephone younger generation of doctors take over treatment respons- interviews using a 54-item computer-based questionnaire. ibilities. The questions addressed knowledge about and attitudes to- It is important, now more than ever, to determine the “real- wards OMT, illicit drug use, guidelines and administrat- world” perspectives on OMT to help optimise decision ive requirements, and difficulties in treating patients. Re- making regarding treatment provisions. sponses were entered directly into the computer by the in- The IMPROVE study aimed to gain understanding of the terviewer. On average, an interview lasted for 27 minutes. attitudes and beliefs towards OMT in Switzerland with re- Patients gards to quality and access to treatment. To obtain a “real- A total of 250 opioid-dependent patients on OMT were world” view of OMT, the study approached its goals from planned to be recruited from seven sites in Switzerland, two different angles, from the perspectives of the OMT pa- 50% of whom would come from physician’s offices, and tients and of the treating physicians. 50% from substitution treatment support centres. The ra- The IMPROVE study collected a large body of data on tionale behind this recruitment strategy was based on data OMT in Switzerland. This paper presents an overview of from the methadone case register of canton Zurich, which the IMPROVE study using a small subset of the dataset, fo- indicated that 48.0% of OMTs are managed by general cusing on the research design and methodology, as well as practitioners (GPs) and 47.6% by specialised treatment the demographic profile of the participants. In addition, the centres [11]. responses to several key questions are presented, includ- ing medication choices, therapy satisfaction, diversion and misuse. Other important data will be presented in subse- quent publications. Subjects and methods Design and recruitment IMPROVE was an observational, questionnaire-based, cross-sectional study on OMT conducted in Switzerland. Respondents consisted of OMT patients and treating physi- cians from various regions of the country. Recruitment was implemented through the Swiss drug treatment centres that offer help and support to patients and drug users, as well as through physicians who are active in the field of drug sub- stitution research and practice. The recruitment centres were selected on the basis of the size of the canton where the centre is located, the size and importance of the centre and membership of OMT-relevant networks (e.g., SSAM). On the basis of these considera- tions, sites from the biggest cities in Switzerland were iden- tified. For political reasons, the city of Geneva could not be included, but other parts of French-speaking Switzerland were covered. Lugano was excluded for logistical reasons; thus the study did not cover the Italian-speaking region. Data were collected using questionnaires in the local lan- Figure 1 guages of German and French. The physician interviews The Swiss IMPROVE study flow chart and disposition of subjects. were performed from 10 May to 15 June 2012. Patient data OMT = opioid maintenance therapy Swiss Medical Weekly · PDF of the online version · www.smw.ch Page 2 of 15 Original article Swiss Med Wkly.
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