SUMMARY
Methadone prescribing increased tenfold in the last four years in
Belgium. This has been made possible through involvement of general
practitioners in methadone treatment. Drug overdoses, crime and even
presence of methadone on the black market have decreased at the same
time.
Introduction
During the last four years, methadone consumption in Belgium
increased tenfold (From 6 kg/year in 1990 to 58 kg/year in 1994). This
fact may seem insignificant because it concerns a country with a
population no higher than that of New York City and whose precise
geographic location may not be known to everyone. However the Belgian
experience might demonstrate that it is possible to overcome certain
limitations of methadone treatment as it is generally
practiced.
Legal Confrontation
Methadone has been available with a prescription in pharmacies since
the 1970's. But physicians who began to prescribe it to addicts at the
beginning of the 1980's, when the heroin epidemic was worsening, were
often subjected to disciplinary sanctions by the Belgian Medical
Association and sentenced by courts of justice.
At the beginning of the 1990's a group of physicians, including
myself, requested that the Supreme Court revoke the Medical Association's
regulations permitting the indictment of physicians prescribing methadone
and other substitution treatments. This request was granted. Subsequently,
the regional authorities of the French speaking part of Belgium began to
encourage physicians to treat opiate addicts with methadone. The
authorities became aware of drug addiction's impact on criminality and on
the AIDS epidemic. They knew that it would be impossible to extend rapidly
the number of methadone clinics and they also wanted to avoid stigmatizing
heroin addicts. To encourage the treatment of addicts in normal settings,
they allocated funds for training sessions for general practitioners on
treatment of drug addiction.
Consensus Conference
Another measure which permitted a rapid expansion of methadone
treatment was the organization of a Consensus Conference on Methadone
Treatment by our Minister of Health. The conclusions of the Consensus
Conference were sent to every doctor in the country, as new guidelines for
methadone treatment. They stated the following points:
- Methadone is an effective medication for the treatment of heroin
addiction.
- Methadone reduces heroin consumption and injection, reduces
mortality related to heroin addiction, reduces the risk of infection
with HIV as well as hepatitis B and C, improves therapeutic compliance
of HIV-positive drug addicts, facilitates detection of illness and
health education strategies and is associated with an improvement in
socio- professional aptitude and a reduction in delinquency.
- Prolonged treatment with proper doses of methadone is medically
safe. At present, methadone has not been shown to be toxic for any
organ.
- There is no scientific reason to limit the overall number of
heroin addicts admitted for methadone treatment.
- Availability of methadone treatment should be increased to
respond to the need for such treatment, including by private
practitioners.
- Psycho-social support is not compulsory and should be adapted to
the individual needs of patients.
These conclusions are in no way revolutionary on the scientific
level, but as official guidelines for methadone treatment, they represent
a significant innovation, compared to what happens in a lot of countries.
Methadone is now dealt with as an ordinary medication. Its effectiveness
is recognized without ambiguity. No longer is it considered an
experimental treatment, accessible only to a limited number of patients
and subject to rigid controls. No longer are patients required to have
attempted previous withdrawal treatments. Addiction can be ascertained by
spontaneous withdrawal attempts recounted during patients history.
Urinalysis is done only following doctor's decision.
It is specified in our new guidelines that dosage and duration of
treatment should not be limited, but adapted to each patient by the
physician. It is acknowledged that short-term methadone treatment are
appropriate only in certain very particular cases. Daily administration of
methadone is not compulsory, but recommended at the beginning of treatment
and will generally take place in a pharmacy chosen by the patient. The
physician is free to prescribe larger quantities of methadone at less
frequent intervals, depending on how the patient evolves.
Conclusion
The number of heroin addicts undergoing methadone treatment is
increasing and now reaches 5.000, out of an estimated total number of
heroin users of 20.000 to 30.000. More than 80% of these patients are
being treated by general practitioners. Hundred of general practitioners
are currently involved in methadone treatment. Most patients receive
methadone provision for one or two weeks, but the presence of methadone on
the black market has decreased, since less addicts are seeking methadone
on the streets. Drug overdoses and criminality have decreased. Thus the
very flexible method of prescribing methadone used today in Belgium seems
to have resolved some problems and does not seem to have created
any.
Marc REISINGER
European Methadone Association
27 rue de la
Vanne
1050 Brussels, Belgium
Tel + Fax : 322 640 46 28
Notes
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Presented at the European Methadone Association Forum, AMTA Methadone Conference Phoenix, Arizona; October 31, 1995.
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