Treatment with pharmaceutical substitutes
Substitution treatment for opiate (heroin) addicts consists in prescribing pharmaceuticals such as methadone and buprenorphine. The pharmacological properties of substitution treatment substances are different than those of heroin. Compared to heroin, the substances in question require a longer period of time before they start to act and to withdraw. On the contrary, heroin brings about, almost immediately, a feeling of euphoria ('getting high') to be soon followed by a 'low' phase. Substitutes, therefore, help avoid the quick affective changes caused by heroin which generate the need for frequent use. Moreover, substitutes not only lack the euphoric effects of heroin but, also, prevent the sort of exalted mental state caused by heroin. At the same time, the desire for drug use lessens significantly.
Substitution Treatment Units provide pharmaceutical treatment together with psychosocial support and treatment for psychiatric and physical comorbidity. Substitution programmes aim for less drug use and less drug-related (social and health) problems, as well as for public health protection from infectious diseases. Apart from harm reduction, these programmes also provide assistance to persons wishing to and being able to detoxify. Their main objective is stabilisation through a normal life pattern, together with improved family and social relationships, and a renewed interest in education/training and employment.
Substitution treatment accounts for about two thirds of the treatment capacity of EU Member States. All European countries are unanimous about the benefits of this treatment, given the scientific data showing that substitution treatment helps bring shown to help with the social reintegration of successfully treated addicts.
Substitution treatment is not a panacea nor a treatment of choice for all opiate addicts. This is why not everyone is eligible for substitution treatment in Greece; there are prerequisites to be met, such as age and time spent in a drug-free treatment programme. It is better for someone to detoxify completely than to be on medication, possibly for a long time. However, there are chronic and severely addicted users who cannot attain detoxification in drug-free programmes (neurobiological components). These people are in need of a long-term substitution treatment. It is our duty to offer them the kind of treatment they need, just like we would have done in the case of any other chronic patient suffering from diabetes, hypertension, epilepsy or schizophrenia.
Drug addiction started to grow in Greece in the late seventies, as had already happened in other European countries. From 1985 onwards, indicators relating to deaths, arrests, convictions, seizures etc. were skyrocketing. The situation escalated further due to the AIDS virus and its rapid spread among heroin users. At the same time, drug (especially heroin) availability was also on the increase. Given the above, it became evident that the national legislation had to be amended accordingly in order to provide for the pharmaceutical treatment of chronic heroin addicts ('substitution treatment').
Law 2161 of 1993 (the constitutent instrument of OKANA) provides for substitution units, while ministerial decision number GΕΟ/25/6-4-95 sets the standards for creating and running Experimental Substitution Programmes for addicted heroin users. In January 1996, OKANA offered Greece's first methadone programme and substitution units, one in Athens and one in Thessaloniki.
By early 2010 OKANA had already been running 25 Substitution Units throughout Greece, catering to the needs of 4.771 patients and with 5.558 more persons on the waiting list to integrate the program. In August 2011, a special understanding reached between OKANA and all public hospitals in Attica, Thessaloniki and in other geographical departments of the country resulted in the doubling of the number of its units. OKANA has now 54 substitution treatment units in cooperation with public general or psychiatric hospitals; 23 in Attica (Athens, Piraeus), 12 in Thessaloniki, and 1 in each of the following cities: Larissa, Chania, Rhodes, Lamia, Agrinio, Chalkida, Livadia, Herakleion, Corfu, Preveza, Katerini, Volos, Patra, Kavala, Rethymno, Alexandroupoli, Komotini, Kalamata, Veria.
The increase in the number of treatment slots along with the full development of the new units is expected to lead to a further shortening of the current waiting list, so much as to say that if the actual plan goes through as projected, there should practically be no more such waiting list in the Department of Attica by August 2012. As a result of the completion of the development of OKANA units in Thessaloniki, the waiting list in that zone has been shortened by 91% whilst waiting times were reduced to 1 month, down from 52 months under the previous circumstances, bringing the whole scheme closer to the internationally applying standards.
'Drug-free' treatment programmes
These programmes revolve around psychosocial treatment, the aim being detoxification from all substances and social reintegration without any substitution medication at all. Greece's first 'drug-free' programmes were offered in the early eighties by the Attica Psychiatric Hospital (18 ANO) and the Treatment Centre for Addicted Persons (KETHEA) in the form of therapeutic communities where the clients had to live in for at least one year. Other bodies, such as the Thessaloniki Psychiatric Hospital, followed suit. Given the need for pluralism in treatment for user needs to be better met, the above as well as other bodies gradually started to offer various types of 'drug-free' treatment programmes, such as day programmes, outpatient programmes, night programmes for those who work, special programmes for adolescents, women and persons with psychiatric comorbidity or self-help programmes. OKANA created drug-free programmes for adults and adolescents, and works with other bodies for similar programmes.
About one third of the treatment capacity of EU Member States is provided by 'drug-free' treatment programmes. Generally speaking, such programmes work better with strongly motivated, younger and less severely addicted persons. Admission and treatment in a drug-free programmes is recommended for all addicts prior to their applying for a substitution programme.
OKANA runs an Adolescents Unit in Athens, one Multiple Intervention Programme in Rethymno and a Treatment Services Network in Patra and in Chania. Also, OKANA is a contributor in the 'ATHENA' Programme of the Psychiatric Clinic of the University of Athens, and in the 'Self-Help Promotion Programme' of the Aristotle University of Thessaloniki.
Admission, Information and Orientation Centers
Given the need to upgrade the system of evaluation of the needs of addicted persons seeking treatment in order to be able to refer them to the programme that best meets their needs (be it an OKANA programme or a different one), OKANA created the first Admission, Information and Orientation Centre in Athens in 2002. In November 2011, the second Admission, Information and Orientation Centre was launched in Thessaloniki aiming at covering the same needs in North Greece.
OKANA's Admission, Information and Orientation Centers are responsible for:
- receiving applications for the substitution treatment programme
- informing interested applicants about treatment programmes and about the substitution treatment programme in particular, as well as providing them with reading material
- asking for each applicant's history and evaluating his/her case by means of an interview and special diagnostic tools
- discussing with applicants and, if appropriate, suggesting that they attend a drug-free programme
- creating client files for those admitted to the substitution treatment programme
- managing the programme's waiting lists for substitution treatment of Attica (Athens, Piraeus) and Thessaloniki respectively by order of priority depending on each application's registration number and on the admission rules of the substitution programme (exceptional admissions, readmissions etc.)
Admission, Information and Orientation Center in Attica: 21, September 3rd St., 10432, Athens, (+30)210-5201985, (+30)210 5200391 fax:(+30)210-5229224
Admission, Information and Orientation Center in Thessaloniki: 44A, Anagenniseos St., 54627, Thessaloniki, tel.: (+30)2310 566134-5 & (+30) 2310 518492
OKANA's Substitution Treatment Units provide a complete treatment package to opiate addicts, including the rehabilitation of their physical and mental health, as well as their social reintegration.
The difference between substitution treatment programmes and drug-free programmes is the prescribed opiates like methadone and buprenorphine.
These substances have helped lots of people to keep a check on or discontinue their use of heroin and other opiates (suspensions, painkillers), as well as to improve their health. It is possible for someone on methadone or buprenorphine to stop using heroin without any concomitant withdrawal syndrome or the irresistible desire for heroin. They continue to act for several hours (or days) during which there are no quick and sudden affective changes like the ones caused by heroin. Besides, they do not generate the euphoric effects of heroin, they can prevent the sort of exalted mental state it causes, and they lessen the desire for heroin use significantly.
Moreover, methadone and buprenorphine:
- are checked and administered by doctors (or prescribed on a later stage of treatment), they cannot be mixed with inert or dangerous substances and they present no overdose risks
- they are prescribed for free, so addicts no longer need their drug dealers (and can, therefore, break ties with them)
- they are administered in the form of a suspension or tablet, thus limiting risks from intravenous or intramuscular heroin use (abscesses, thromboses, transmission of diseases etc)
In addition to administering or prescribing substitutes, substitution units provide psychosocial support with their psychiatrists, psychologists and social workers, as well as the following services:
- Medical services: basic health care, follow-up of chronic diseases (AIDS, hepatitis etc.), psychiatric care, prescription of methadone
- Psychological services: individual counselling, self-esteem group, relapse prevention
- Psychotherapy: individual, group and family therapy
- Social services: social skills group, psychosocial support, counseling on employment issues
- Legal services: legal advice, representing and defending the cases of successfully treated addicts in court
For someone to be eligible for an OKANA substitution proramme, they have to be long-term heroin users aged over 20 who have already tried to detoxify in a drug-free treatment programme. Long-term intravenous heroin users aged more than 35 may be admitted, even if they have not previously tried to detoxify. HIV positive opiate drug users enter the programme in priority after applying for an exceptional admission.
The pharmacological properties of substitution treatment substances are different than those of heroin. Compared to heroin, the substances in question require a longer period of time before they start to act and to withdraw. On the contrary, heroin brings about, almost immediately, a feeling of euphoria ('getting high') to be soon followed by a 'low' phase. Substitutes, therefore, help avoid the quick affective changes caused by heroin which generate the need for frequent use. Moreover, substitutes not only lack the euphoric effects of heroin but, also, prevent the sort of exalted mental state caused by heroin. At the same time, the desire for drug use lessens significantly.
Methadone belongs to the pharmacological category of opiates, whose chemical structure and action are similar to those of morphine. Natural and semi-synthetic opium derivatives such as codeine, morphine and heroin are opiates, too. Opiates are considered to be sedatives because they slow down the functions of the nervous system. Other sedatives include alcohol, cannabis and benzodiazepines (such as Stedon, Hipnocedon and Vulbegal).
Methadone is synthetically manufactured and used in substitution treatment for persons addicted to heroin or other opiates. Its action lasts a lot longer than that of heroin. One dose is effective for at least 24 hours, contrary to heroin which can last only for a few hours. In Substitution Treatment Programmes, methadone is administered in the form of a suspension.
Initial daily dosage usually ranges from 60 to 120mg, and can gradually and slowly decrease without any withdrawal symptoms.
What does methadone offer?
When prescribed in the right dosage, methadone does away with the withdrawal symptoms of heroin and other opiates while lessening the addict's desire for heroin use.
In addition, methadone brings several other bodily functions back to normal, thus providing the potential for improved physical/mental health and social interaction.
However, there is something we all need to know:
- For an addict to change his/her life, methadone is not enough. This is why professional counselling, medical follow-up, and psychosocial support from substitution treatment programmes are necessary.
- One is still physically addicted to opiates as long as they are on methadone.
- Just like any other type of medication, methadone too can have side effects.
- Methadone, like heroin, is a potent drug and can be very dangerous if not used properly.
- It is very important not to use methadone together with sedatives such as alcohol and sleeping pills (Vulbegal, Hipnocedon), because this combination can have an overdose effect.
Buprenorphine is an opiate like methadone which is used in heroin addiction treatment. It has been proved to be effective in heroin substitution treatment, and in the physical detoxification from heroin and methadone. Like several other opiates, buprenorphine has also been used as a potent analgesic.
In substitution treatment programmes, buprenorphine is prescribed in the form of subglossal tablets that must not be swallowed or chewed but slowly left to melt in the mouth for 15-30 minutes. It takes about 30 minutes for it to act, and its action lasts up to three days, depending on the dosage. Daily dosage usually ranges between 4 and 16 mg.
What does buprenorphine offer?
When prescribed in the right dosage buprenorphine eliminates the withdrawal symptoms of heroin and other opiates, while lessening the heroin addict's desire for use. Its effects are, therefore, similar to those of methadone.
In addition, buprenorphine has the following advantages, compared to methadone:
- Compared to methadone, buprenorphine has the advantage of being a heroin antagonist. This means that if one uses heroin, they won't feel euphoria. Therefore, buprenorphine does away with one of the main reasons for using heroin.
- Also, buprenorphine lasts longer than heroin and methadone. If properly prescribed, it can be effective for up to 72 hours and, consequently, addicts do not have to present themselves at the treatment centre every day but only three times a week and, therefore, be free on weekends.
- If someone is on buprenorphine only, they are highly unlikely to suffer from an overdose, even if their dose is considerably high.
- The withdrawal symptoms of buprenorphine are considerably less than those of methadone, so it is easier for someone to detoxify from buprenorphine instead, especially those who find it difficult to detoxify from methadone.
However, there is something we all need to know:
- For an addict to change his/her life, buprenorphine is not enough. This is why professional counselling, medical follow-up, and psychosocial support from substitution treatment programmes are necessary.
- One is still physically addicted to opiates as long as they are on buprenorphine.
- Just like any other type of medication, buprenorphine too can have side effects.
- Buprenorphine, like heroin, is a potent drug and can be very dangerous if not used properly.
- It is very important not to use buprenorphine together with sedatives such as alcohol and sleeping pills (Vulbegal, Hipnocedon), because this combination can have an overdose effect.
When used together with heroin, methadone or other opiates, buprenorphine can cause withdrawal symptoms.
"Atrapos" Adolescence/Young Adult Unit of Athens
OKANA's Unit for Adolescents "Atrapos" is a'drug-free' treatment programme addressed to:
- adolescents up to 24 years of age who use drugs experimentally, occasionally or systematically
- families of adolescents using drugs and their greater settings
The main pursuit of "Atrapos" is to attract adolescents, to intervene in time to make occasional users discontinue use, and to provide psychosocial support, training and treatment to addicted adolescents and their families. Units for adolescents are also addressed to experts and professionals working with young people, in an effort to keep them informed and raise their awareness, as well as to schools, sports venues etc. in the greater community that have to do with adolescents and substance use cases with a view to creating partnership networks. The treatment approach shared by "Atrapos" is based on the systemic and family therapy, together with elements of the behaviouristic model and the therapeutic community model.
"Atrapos" consists in the Advisory Services stage, the Treatment Programme stage and the Social Reintegration stage.
- Information on drug use effects and how to deal with them
- Psychological support and awareness raising among adolescents about discontinuing use
- Preparing adolescents for the treatment programme
The Treatment Programme:
- Individual and group meetings of adolescents aimed at their personal development, making them adopt a new, creative way of life free from substance use (fostering skills for more effective problem solving, for creating healthy relationships, for improving communication in the family, for boosting self-esteem, and for assuming one's personal responsibilities)
- Creative group activities (artistic, recreational, sports activities etc.) helping adolescents learn to creatively coexist with others, communicate, share and express their feelings.
- Standing by adolescents, in their effort to go down a new path
- Bringing them back in touch with their studies or work and keeping them away from trouble with the law
- Career guidance counselling
- Supporting them in their effort to find a job.
Parents of adolescents who have joined the programme receive the following support throughout the treatment process:
- They are kept informed about the addiction problem and how to deal with it
- They are assisted in their role as parents in order to be able to stand by their adolescent children in their effort to discontinue use
- They receive counselling and support in order to better manage family crises, and to re-establish communication and ties within the family, so that adolescents are helped in gradually distancing themselves from the family setting to become independent
- They can participate in group meetings with other parents aimed for mutual support, and exchange of experiences and concerns.
Parents whose children are not in the programme also receive counselling and support so that they are informed, helped to change their attitude to drug use, and trained, so to speak, in order to motivate their addicted family member to seek help.
"Atrapos" Adolescents/Young Adult Unit of Athens
9, Varvaki St., 11474 Αthens, Τel.: (+30)210 6420453, 6448796, Fax: (+30)210 6429689, e-mail: firstname.lastname@example.org
The Treatment Services Network of Patra "Gefyra"
OKANA's first drug-free programme was the Treatment Services Network of Patra in 1998. This network is addressed to persons aged 18-40 who are addicted to psychoactive substances with no major psychiatric symptoms. It is based on the systemic approach, and on the therapeutic community & self-help group model.
The Treatment Services Network of Patra is a programme which is:
- Systemic: all family members and other major stakeholders participate in the treatment process
- Multi-phase: the treatment process consists in several phases
- Drug-free: 'Gefyra' community members and Social Awareness Programme participants abstain from psychoactive substance use
- Voluntary: programme participation is up to the interested person to decide
- Open and residential: clients living in the greater Patra area spend the night at home, but those living far away stay at the Residential Section/Hostel of the "Gefyra" Community
The Treatment Services Network includes the following:
1. Advisory Services
2. The "Gefyra" Therapeutic Community
3. A Social Awareness Programme
4. A Residential Section - Hostel
5. A Family Programme
1. Advisory Services:
This is the first Network Unit to be contacted by an addict. Average stay ranges from two to three months. Advisory Services aim to:
- Do awareness raising and counselling in order for addicts to discontinue use
- Make them join "Gefyra"
- Encourage their families to participate in the programme so that:
- they can persuade their addicted member to seek help from the Network, if they have not done so yet
- they can support and stand by their addicted member in the context of the treatment process
- Change the use-related behaviours of addicts and their families
- Provide community education and do awareness raising among users
2. The "Gefyra" Therapeutic Community (Open and Residential Section)
Eligible adults include those who have completed the Advisory Services Programme, have proved themselves to be off psychoactive substances, and have made clear that they wish to continue their treatment throughout the subsequent stages of the treatment services network.
"Gefyra" aims to:
- Consolidate the disentanglement from use of its members and their families
- Develop their self-knowledge, improve their self-esteem and self-image
- Develop and strengthen workable family relationships
- Develop client accountability
- Develop their skills, get them to find out about health issues and how to take care of themselves, enable them to face up to problems and difficulties, and help them build healthy relationships
- Stimulate learning
- Assist with pending court cases and legal matters
- Generate a sense of belonging in "Gefyra" and in the greater community.
3. "Gefyra" Residential Section/Hostel
The "Gefyra" Residential Section (Hostel) gives "Gefyra" and Social Awareness Programme members whose families live in remote areas in the Peloponnese, Nafpaktia and the Ionian Islands the possibility to stay in Partra. In this way it is possible to cater to people from the greater Patra area. In addition, staying at the hostel prepares members for an independent way of life once they complete the programme.
4. Social Awareness Programme
The Social Awareness Programme is for clients who have completed the "Gefyra" stage and wish to pursue their treatment.
The Social Awareness Programme aims to:
- Further consolidate abstinence and the mindset of non-use
- Bring about gradual social participation
- Offer career guidance and facilitate employment
- Provide consolidation, empowerment, new knowledge and skills, and help create new, healthy relationships
- Consolidate the clients' self-maintenance and problem solution potential.
The Social Awareness Programme consists in three separate stages of 10 to 14 months in total. A turning point in the treatment stage of the Social Awareness Programme is client involvement in the provision of Advisory Services.
5. Family Programme
This involves a user's family and relatives.
The Family Programme aims to:
- Persuade the user's family to join the Detoxification Programme together with the user
- Forge partnership and alliance ties with the treatment programme
- Change the family attitude to use
- Support the client's true coming of age and gradual independence
- Create clearly defined and frank family relationships.
The Family Programme progresses in parallel with the treatment programme. In addition, Family Programme participants are involved in awareness raising activities targeting prejudice against former users and treatment programmes. At the same time, parents of users are encouraged to join the programme.
Treatment Services Network of Patra "Gefyra"
185, Al. Ipsilantou St., 26225 Patra, Tel.: (+30)2610-279795 Fax: (+30)2610-621955, e-mail: email@example.com
The Multiple Intervention Programme in Rethymno
The Multiple Intervention Programme was established in June 2012 in its current status. Previously there were two types of "drug free"treatment services provided by OKANA in Rethymno, an adolescent treatment unit and an alcohol treatment unit for adults. Today, OKANA's Multiple Intervention Programme is a "drug free" non –residential treatment programme addressed to drug and alcohol users of all ages and their families. The members of the programme receive support to deal with drug and alcohol addiction and related problems through psycho-social and psychiatric interventions.
The Multiple Intervention Programme provides for:
- Motivation for abstinence from substance use, individual counseling and prevention of relapse
- Individual, family and couple therapy
- Psychiatric support
The Multiple Intervention Programme together with the Substitution Treatment Unit constitute the local network of OKANA's support services in Rethymno.
MULTIPLE INTERVENTION PROGRAMME: 2 Kaffatou str., 74100 Rethymno, Crete, tel.: (+)3028310-21200; fax: (+) 3028310-21201; email: firstname.lastname@example.org
The Treatment Service Network of Chania
The Treatment Service Network of Chania includes:
An Adolescents Medical Unit which aims at preventing and dealing with addiction (drugs, alcohol, internet etc) and provides for:
- Information on drug use issues and how to deal with them
- Personalized interventions
- Psychological support for adolescences and their families
- Individual and family psychotherapy sessions
Furthermore, the Unit aims at raising awareness among specialists that are in contact with adolescents, in order to create a supportive environment.
An Adults Alcohol Treatment Unit which aims at mental and physical discontinue use of adult alcohol users through psychotherapy as the main therapeutic method. It also aims at therapeutic interventions in families by giving the chance to the relatives to take part in the psychotherapeutic procedure.
Both units are staffed by specialized doctors (psychiatrist and psychiatrist specialized in children and adolescents), psychologists and nurses.
Adolescents Medical Unit and Adults Alcohol Treatment Unit:
11 Iroon Politechniou str., 73100, Chania, tel: +3028213-44225, +3028213-44248
The 'Athena' Treatment Programme
'ATHENA', a 'drug-free' Treatment Programme, is the fruit of partnership between OKANA and the Psychiatric Clinic of the University of Athens. It started off in 1998 as the successor of the Special Outpatient Clinic for Drug Addicts run by the Psychiatric Clinic of the University of Athens since 1988.
'ATHENA' is addressed to drug and alcohol users aged more than 18 years, as well as to their families and relatives.
'ATHENA' provides the following services:
- medical services: basic health care, psychiatric care
- psychological services: individual counselling, relapse prevention
- psychotherapy: individual, group and family therapy
- social services: post-treatment care
- other activities: training of professionals, research
'Athena' Treatment Programme, 20, Xenias st., 11528, Athens, tel.: (+30)210 7757692, fax: (+30)210 7753240
Self-Help Promotion Programme
The 'Self-Help Promotion Programme' started in February 2001, as a joint effort between the Aristotle University of Thessaloniki and OKANA. This programme aims to promote self-help for those who want to face up to their addiction problem, to differentiate between the traditional health professionals' role and their being trained in new roles, and to research into the self-help potential in dealing with psychosocial problems.
These objectives are to be attained by means of:
- a self-help data base
- an Internet web page
- self-help for addicts and their parents
- support for members of self-help groups(Νarcotics Anonymous - ΝΑ, Alcoholics Anonymous – ΑΑ)
- social networking consisting in civil society organisations sharing a similar philosophy
- promoting self-help in the general public
Self-Help Promotion Programme, 10, Mitropoleos St., 546 25 Thessaloniki, Τel.: (+30)2310 500477, Fax: +32310 500478