OB DESETLETNICI ORGANIZIRANEGA ZDRAVLJENJA ODVISNOSTI OD PREPOVEDANIH DROG V REPUBLIKI SLOVENIJI
Andrej Kastelic1, Tatja Kostnapfel Rihtar2
Zdravstveni svet je leta 1994 potrdil doktrino zdravljenja odvisnih od prepovedanih drog in sprejel Priporo~ila zdravnikom za zdravljenje odvisnih od drog, ki vklju~ujejo tudi zdravljenje z metadonom. Zdravljenje z metadonom je eden klju~nih programov zdravljenja odvisnosti v okviru zmanj{evanja {kode. U~inkovit je pri zmanj{evanju nedovoljene uporabe opiatov, tveganju okužbe z virusi HIV in hepatitisov, prepre~evanju drugih zdravstvenih težav, umrljivosti, kriminalnega vedenja... Ker omogo~a velikemu {tevilu uživalcev opiatnih drog stike z zdravstveno službo, pomeni tudi vstopna vrata za iskalce pomo~i ter obravnavo uživalcev v drugih programih: od t. i. nizkopražnih do programov usmerjenih v abstinenco. S sklepom Ministrstva za zdravje so bili v letu 1995 vzpostavljeni Centri za prepre~evanje in zdravljenje odvisnih od drog v devetih slovenskih mestih. Danes je teh Centrov že 18, poleg teh sta tudi dve ambulanti. Vsi zaposleni so bili vklju~eni v dodatno izobraževanje.
V	letu 2003 je bil vzpostavljen nacionalni Center za zdravljenje odvisnih od prepovedanih drog.
V	letu 2005 se je pri~elo zdravljenje z dvema dodatnima substitucijskima zdraviloma za nadomestno zdravljenje. To sta buprenorfin ter dolgodelujo~i morfin.
V	Zakonu o prepre~evanju uporabe prepovedanih drog in o obravnavi uživalcev prepovedanih drog (Ur. list RS {t. 98/99) je med drugim opredeljeno zdravljenje ter ustanovitev in delovanje Centrov za prepre~evanje in zdravljenje odvisnosti.
V	skladu s sklepi Zdravstvenega sveta je Ministrstvo za zdravje imenovalo Koordinacijo Centrov za prepre~evanje in zdravljenje odvisnih od prepovedanih drog ter Komisijo za nadzor nad delom Centrov za prepre~evanje in zdravljenje odvisnosti od prepovedanih drog.
Tako je bila vzpostavljena mreža programov zdravljenja odvisnosti v Sloveniji.
Poleg že omenjenih Priporo~il za zdravljenje odvisnih od prepovedanih drog uporabljamo tudi metadonske smernice Evropske komisije. Pri pripravi teh smernic smo tudi sodelovali. Izdal jih je EuroMethWork leta 2000, priredbo v sloven{~ino pa je septembra 2001 izdalo tudi Ministrstvo za zdravje RS. Na Koordinaciji Centrov za prepre~evanje in zdravljenje odvisnosti od prepovedanih drog smo istega leta v skladu z
Uvodnik
zakonskimi pooblastili, posodobili slovenske smernice za zdravljenje z metadonom. Pripravili smo tudi nova navodila za uporabo, ki povzemajo že ute~eno dobro prakso zdravljenja z metadonom v Republiki Sloveniji. V letu 2005 smo izdelali tudi smernice za zdravljenje z buprenorfinom ter dolgodelujo~em morfinom. Že leta 1995 smo izdelali smernice za obravnavo uživalcev drog v zaporih ter vzpostavili dobro sodelovanje med Aktivom terapevtov v zaporih in Koordinacijo centrov za prepre~evanje in zdravljenje odvisnosti. Vzpostavljeni so bili t. i. »~isti - brez drog (drug free)« oddelki v treh zaporih in prevzgojnem zavodu za mladoletnike Rade~e. Smo ena od 22 držav v svetu, kjer se metadon uporablja za zdravljenje odvisnosti tudi v zaporih.
Vzpostavljeni so bili programi obravnave mladih uživalcev drog v nekaterih vzgojnih zavodih. Organizirali smo ve~ kot 80 izobraževalnih sre~anj za delo z uživalci drog, za zdravstvene delavce, zaposlene v mreži javne zdravstvene službe za prepre~evanje in zdravljenje odvisnosti od prepovedanih drog, specialiste ginekologe, infektologe, pediatre in {olske zdravnike ter izobraževanje po psihiatri~nih bolni{nicah. Izobrazili smo tudi delavce v zaporih, centrih za socialno delo in v policiji.
Organizirali smo tretjo Evropsko metadonsko konferenco (1997), Slovenski konferenci o odvisnostih (1999, 2004), Simpozij mednarodnega združenja za medicino odvisnosti (2001), skupaj s Svetovno zdravstveno organizacijo Sre~anje srednje- in vzhodnoevropskih držav o zdravljenju odvisnosti (2001), Svetovno konferenco o zmanj{evanju {kode zaradi uživanja drog (2002) in skupaj s hrva{kimi kolegi prvo Jadransko konferenco in simpozij dežel jugovzhodne Evrope o zdravljenju odvisnosti (2003), Vanguard 2004 ter 2. Jadransko konferenco o odvisnosti (2005).
Na{i programi so bili uvr{~eni kot primer dobre prakse v priporo~ila združenih narodov - UNDCP (United Nations - Best Practice Case Study). Vklju~eni smo v razvoj programov zdravljenja odvisnosti v Bosni in Hercegovini, Srbiji in Črni Gori, Makedoniji ter Albaniji. Na{e strokovnjake pa kot svetovalce za to podro~je vklju~ujejo Svetovna zdravstvena organizacija, UNAIDS, IHRD-OSI (International Harm Reduction
1Center za zdravljenje odvisnih od prepovedanih drog, Psihiatrična klinika Ljubljana, Zaloška 29, 1000 Ljubljana
2Prohealth d.o.o., Stegne 13, 1000 Ljubljana Kontaktni naslov: e-pošta: andrej.kastelic@guest.arnes.si
Development Program), IHRA (International Harm Reduction Association) in Imperial Collegue iz Londona. Za organizacijo in delovanje mreže centrov za preprečevanje in zdravljenje odvisnosti od prepovedanih drog smo prejeli več mednarodnih ter domačih priznanj: »Nyswander-Dole 'Marie' Award« na konferenci AMTA leta 2001 v Washingtonu, »National Roleston Award 2002« na Konferenci za zmanjševanje škode v Ljubljani marca 2002, »The EUROPAD Awards 2002 - Chimera d'Argento« na konferenci EUROPAD maja 2002 ter leta 2005 priznanje Uprave za izvrševanje kazenskih sankcij Ministrstva za pravosodje RS za razvoj programov zdravljenja odvisnosti v zavodih za prestajanje kazni zaporov.
Za promocijo in pomoč dobrim programom zdravljenja so vodje centrov za preprečevanje in zdravljenje odvisnih od drog in člani Koordinacije Centrov leta 1998 ustanovili Ustanovo odsev se sliši. Skupaj z njo smo organizirali prej omenjeno izobraževanje in konference, izdali številne priročnike za strokovnjake in uživalce drog in njihove svojce (zbirka Droge med nami). Izdajamo tudi poljudno revijo Odsev in strokovno revijo Odvisnosti. Ta je v letošnjem letu z ustanovitvijo mreže za centralno, vzhodno Evropo in Jadran postala tudi mednarodna revija te mreže.
Javna zdravstvena služba seveda poskuša odgovarjati na vse zdravstvene potrebe uživalcev drog, tako tistih, ki eksperimentirajo kot odvisnih, pa tudi njihovih svojcev. Pri tem pa bolnikov zaradi njihove »nemotiviranosti«, kadar iščejo pomoč, ne odklanja. Z mnogimi strokovno ustreznimi in do bolnikov prijaznimi programi jih celo skuša čim več pritegniti v obravnavo ter jim ponuditi takšne oblike zdravljenja, za katere so sposobni in zmorejo v njih tudi ostati.
Z odprtjem novih centrov je skokovito poraslo število ljudi, ki so v njih iskali pomoč. Šele ko je ta možnost postala dovolj dostopna, so uživalci drog in njihovi svojci poiskali stik z zdravstveno službo tudi v krajih, za katere se je menilo, da je v njih zelo malo ljudi, ki jemljejo droge. Manjšal se je pritisk na službe nujne medicinske pomoči in na dežurne ambulante, bistveno
manj je bilo nezadovoljstva in napadalnosti bolnikov, saj imajo v centrih možnost za ustrezno zdravljenje. Spoštljiv odnos, pripravljenost za pomoč in strokovnost lahko olajšajo marsikateri nesporazum. Dobra povezanost z nizkopražnimi programi, ki so pretežno v domeni socialnega skrbstva in nevladnih organizacij, in sodelovanje s programi socialne rehabilitacije, za nekatere tudi v terapevtskih skupnostih in komunah, je pogoj za dobro oskrbo uživalcev drog. Ena izmed dejavnosti v centrih in ambulantah je tudi detoksikacija z metadonom in vzdrževalni metadonski program, v letu 2005 pa tudi zdravljenje z novimi substitucijskimi zdravili, kot sta buprenorfin (Subutex) in počasno sproščujoči morfin (Substitol). Vzdrževalni programi za nadomestno zdravljenje so tudi eni osnovnih programov za zmanjševanje škode (harm reduction) pri uživalcih opiatnih drog. Prav ponosni pa smo, da je bil 28. januarja 2003 odprt Center za zdravljenje odvisnosti od prepovedanih drog Psihiatrične klinike Ljubljana z dejavnostmi: svetovanje, ambulantno in bolnišnično zdravljenje, dnevni center, izobraževanje, raziskovanje, založništvo, koordinacija. Uspeli smo razviti torej celovit model za preprečevanje in zdravljenje odvisnosti od drog ter vzpostavili t. i. center odličnosti pri zdravljenju odvisnih, ki služi tudi za izobraževanje udeležencev številnih drugih držav. V kratkem pa upamo, da bo ta naziv prejel tudi Center za preprečevanje in zdravljenje odvisnih od drog na primarni ravni.
In kaj bi radi še razvili? Predvsem bi radi širše pritegnili tudi zdravnike na primarni ravni. Zavedamo se, da so že sedaj preobremenjeni. Toda boljšo dostopnost z manj ožigosanosti naših bolnikov bomo dosegli le v primeru, ko bodo njihovi izbrani zdravniki želeli prevzeti zdravljenje svojih bolnikov, v začetku vsaj tistih bolj stabilnih, katere bi tja napotili iz Centrov za preprečevanje in zdravljenje odvisnih. Predvsem pa je pomembno, da bodo hitreje prepoznali simptome te bolezni pri svojih bolnikih in ne oklevali, temveč tudi ustrezno ukrepali. Na voljo je dovolj izobraževalnih programov.
TEN YEARS OF ORGANISED DRUG ADDICTION TREATMENT IN
THE REPUBLIC OF SLOVENIA
Andrej Kastelic1, Tatja Kostnapfel Rihtar2
Editorial
The Health Council confirmed the illicit drug use policies and adopted the Recommendations on Drug Addiction Treatment for physicians, which include methadone maintenance programme. Methadone maintenance is one of the key drug addiction treatments and harm reduction programmes that effectively decrease illicit substance use, diminish the risk of HIV infection and hepatitis, and prevent other drug-related health problems, mortality and criminal behaviour. It enables large numbers of opiate drug users to contact the health service for assistance and treatment, and affords access to many other treatment programmes, from low-threshold to abstinence-oriented. In 1995, The Ministry of Health established Centres for the Prevention and Treatment of Drug Addiction in nine Slovene towns. Currently, the management of drug users is provided in 18 such centres and in two outpatient clinics staffed by specially trained personnel. The National Centre for Treatment of Drug Addicts was established in 2003. In 2005, substitution treatment buprenorphine with two new drugs, buprenorphine and long acting morphine, was introduced. The Law on the prevention of illicit drug use and the treatment of drug users (Official Gazette 98/99) defines the forms of treatment and the establishment and operation of Centres for the Prevention and Treatment of Drug Addiction. In accordance with the conclusions adopted by the Health Council, the Ministry of Health set up a body for the coordination of Centres for the Prevention and Treatment of Illicit Drug Addicion and a committe supervising their activities, and thereby established the Slovene network of drug addiction treatment programmes.
In addition to the above mentioned Recommendations on drug addiction treatment, we have adopted the methadone treatment guidelines set out by the European Commission. We took active part in the preparation of the document, which was issued by EuroMethWork in 2000, and adapted and published by the Ministry of Health of the Republic of Slovenia in 2001. The same year, the Coordination of Centres for the Prevention and Treatment of Illicit Drug Addiction updated and adopted the national guidelines concerning methadone treatment. New guidelines of methadone use were prepared on the basis of good practice established in
Slovenia. In 2005, guidelines of buprenorfin and long acting morphine treatment were formulated. As early as 1995, recommendations on the management of drug addicts in prisons were adopted, and close collaboration with the therapists caring for drug users in prisons and the Coordination of Centres for the Prevention and Treatment of Illicit Drug Addiction was initiated. Drug-free units were set up in three prisons and in the Rade~e Correctional Home. Slovenia is one of the 22 countries in the world providing methadone treatment for drug addicts in prisons. Programmes for young drug addicts have been launched in some correctional institutions. More than 80 training courses on the management of drug users have been organised for health professionals in the network of public health services concerned with the prevention and treatment of drug addiction, as well as for gynaecologists, specialists of infectious diseases, paediatricians, school doctors and psychiatric hospital staff. In addition, training courses were held in prisons, social work centres and police departments.
We organised the 3rd European Methadone Conference in 1997, Slovene Drug Addiction Conference in 1999 and 2004, Symposium of the International Addiction Medicine Association in 2001, the Meeting of Central and Eastern European Countries on Addiction Treatment - jointly with the WHO- in 2001, World Conference on Reduction of Drug Related Harm in 2002 , the 1st Adriatic Drug Addiction Conference and Symposium of Southeastern European Countries (together with the colleagues from Croatia) in 2003, Vanguard in 2004 and the 2nd Adriatic Drug Addiction Conference in 2005. Our programmes were included as examples of good practice into the UNDCP recommendations (United Nations - Best Practice Case Study). We participate in the development of drug addiction treatment programmes in Bosnia and Herzegovina, Serbia and Montenegro, Macedonia and Albania. Slovene experts provide counselling services for WHO, UNAIDS, IHRD-OSI (International Harm Reduction Development Program), IHRA (International Harm Reduction Association) and Imperial College, London.
We have received several national and international awards and for the organisation and operation of the
1University Psyhiatric Hospital, Centre for Treatment of Drug Addictions, Zaloška 29, 1000 Ljubljana
2Prohealth d.o.o., Stegne 13, 1000 Ljubljana Correspondence to: e-mail: andrej.kastelic@guest.arnes.si
network of centres for the prevention and treatment of illicit drug addicition, including: the Nyswander-Dole "Marie" Award at the AMTA conference in Washington in 2001, the National Roleston Award 2002 at the Harm Reduction Conference in Ljubljana in March 2002, the EURORAD Awards 2002 - »Chimera d'Argento« at the EUROPAD conference in May 2002. In 2005 the Agency of Penal Sanctions Execution of the Ministry of Justice of the Republic of Slovenia gave us the award for the development of drug addiction treatment programmes in penal institutions.
In order to promote and support good treatment policies, the leaders of Centres for the Prevention and Treatment of Drug Addiction and the Coordination body members set up the Sound of Reflection Foundation. It participated in the organisation of the above mentioned training courses and professional meetings, as well as in the preparation of publications for health care providers, drug addicts and their relatives, including the publication »Drugs among us«, the magazine »Reflection« and the professional journal »Addictions«. This year, the latter became the international journal of the newly founded Central Eastern European Adriatic Addiction Network.
Public health care providers make every effort to meet health needs of drug addicts , persons experimenting with drugs and their families. Patients looking for help are never refused because of lack of motivation, on the contrary, they are offered various forms of appropriate and user-friendly treatments. As they are tailored to individual needs and consider individual coping skills, they improve the patient's chances for staying in treatment.
With the setting up of new centres the number of persons seeking assistance increased dramatically. It is only after these services became readily accessible that the number of drug users and their relatives contacting treatment centres increased even in areas with supposedly low rates of drug use. These centres took pressure off emergency service and outpatient out-of -hours clinics. Provision of appropriate forms of treatment in these centres reduced significantly patient insatisfaction and aggressiveness.
Respectful attitude to patients and the availability of professional services may prevent many conflicts and overcome many misunderstandings. Close links maintained with low-threshold programmes, offered mostly by social services and NGOs, and good cooperation with providers of social re-entry programmes, which may be followed in therapeutic communities and communes, are the prerequisites for quality management of drug addicts. Detoxication followed by methadone maintenance treatment constitutes one of the services provided in the centres and outpatient clinics. Substitution treatment with buprenorphine (Subutex) and long acting morphine (Substitol) was introduced in 2005. Substitution treatments are fundamental harm reduction programmes offered to opiate drug users. We take great pride in the setting up of the Centre for the Treatment of Illicit Drug Addiction in the Psychiatric Hospital Ljubljana on 28 January 2003. Its functions include: counselling, outpatient and hospital treatment, day-care centre services, education, research, publishing and coordination.
We have thereby succeeded to develop a model of prevention and treatment of drug addiction and to establish the so-called »treatment centre of excellence«, which offers training courses to participants from many other countries. We hope that the title will soon be awarded to the Centre for the Prevention and Treatment of Drug Addiction at the primary health care level. Our main challenge for the future is to attract a larger number of primary health care physicians to participate in our programmes. We know that primary health care physicians are overworked, yet to increase the effectiveness of addiction treatment programmes and to reduce stigmatisation of drug addicts, they should take over care for their drug addicted patients, beginning with the stabilised addicts referred to them by Centres for the Prevention and Treatment of Drug Addiction. Also, it is very important that primary care physicians learn how to recognize the early symptoms of addiction and take appropriate measures in time. Currently, a sufficient number of education programmes for physicians are available.