Methadone maintenance programme, Sofia

by Philip G. Lazarov & Roumen S. Sedefov

There has been an on-going controversy throughout the world as to whether methadone should be used in the treatment of opiate addiction as a long-term pharmacological treatment or as a short-term medical intervention to help addicts attain an opiate-free state. This brief article describes a five month experience of the first Methadone Maintenance Programme in Sofia. It reflects our deep belief that long-term pharmacological treatment combined with variable psycho-social, behavioural, psychiatric (when needed), etc., interventions in the framework of highly structured and highly intensive programmes can effectively meet the needs of each individual patient/client.

We view addiction as a bio-psycho-social process that not only handicaps an individual’s functioning, but also impairs the development of cohesive family and community relationships. Treatment and risk reduction involve systematically changing attitudes and behaviours. This includes combinations of pharmacological treatment, education, counselling, client advocacy, evaluation, etc. Ideally, patients/clients obtain the skills they need to assume control over their addiction and in the process bring the various parts of their lives into balance.

Epidemiological situation

Illegal drug use evolved later in Bulgaria than in many Western European countries. An important reason for this was the political situation and the relative isolation of Bulgarian youth from the international mainstream. In the late 1980s and early 1990s, the first real epidemic of heroin use and addiction occurred. The prevalence increased rapidly, mainly in the capital city, Sofia. As prevalence increased, the social profile of those involved began to change, including not only individuals who, in Western society could be described as "middle class", but also young people from more socially deprived and marginal groups of society. This unfavorable trend and the first 4 cases of HIV infection diagnosed amongst the injecting drug users led to the decision that programmes involving hard-core drug users had to be introduced in addition to the traditional drug-free treatment programmes.

Description of the Methadone Maintenance Programme - Sofia

The Methadone Maintenance Programme - Sofia started thanks to financial support from the British government. The programme started on 1 September 1995 when the intentionally established commission of psychiatrists from the National Centre for Addiction (NCA) began to select possible candidates for the programme. At the same time an outreach letter was distributed amongst the drug using population explaining the aims of the programme and some of the requirements for admission. Being the first programme of this type in Bulgaria, it was decided that the criteria used for admission would be very strict: severe heroin dependence (using the criteria of ICD-10); mainly by injecting; at least 21 years of age; more than 3 years of drug use; more than 3 proven failed treatment attempts; no pending law suits, etc. All candidates were put on a waiting list, while females were given some priority, until reaching 25% of the total number. As a pilot high threshold programme the total number of patients/clients admitted was limited to 30 people, but the enormous interest and social resonance led to the inclusion of 42 patients/clients. At present the waiting list consists of more than 60 people, fulfilling the criteria for admission.The structure of the programme is based on the adapted phases-of-treatment model suggested by Moolchan and Hoffman (1994), including four main phases: intensive stabilization; commitment and rehabilitation phase; medical maintenance phase and the methadone tapering phase.

The intensive stabilization phase intends to achieve the methadone dose (varying between 40 and 150 mg.) and general medical stability, it lasts 1 to 3 months and includes a minimum of one individual counselling session, two group counselling sessions per week, and urine testing every two weeks.

The commitment and rehabilitation phase is intended to achieve commitment to the treatment process and bio-psycho-social balance and functioning. It lasts 6 to 9 months and includes one individual and one group counselling session per month, and a minimum of one urine test every month.

The medical maintenance phase is intended to achieve social integration while maintaining personal balance and physiological stability. The contracts of the patients/clients with the programme are minimal but at least one urine test is performed every month. This phase could be termless or could progress into the methadone tapering phase which is intended for gradual discontinuation of the use of methadone while maintaining bio-psycho-social stability. The patients/clients can go back and forth from one phase to another depending on the compliance with the programme rules. A twenty-one-day detoxification period is provided for those subjected to administrative discharge or in cases of any emergency.

Preliminary results

Up until now the drop out rate has been less than 10% which is considered extremely low. Improvement of the overall health and employment status is obvious. The use of illicit drugs and in particular injecting, decreased significantly. This could be due to the high motivation of the patients/clients (registered at admission to the programme), the enthusiasm of the staff or the programme design itself. The evaluation component of the treatment process and outcome is under development. None of our patients/clients tested positive for HIV but the Hepatitis C and B rate seems to be quite high, 75% and 33%, respectively. The testing for HIV was offered after individual counselling and was strictly confidential.

Conclusion

Methadone Maintenance Programme - Sofia is a worth-while effort. It is extremely well accepted by the drug users, their families, professionals and official institutions. Being a pilot project MMP-Sofia is too important not to be rigorously evaluated. Analysis of the evaluation data will be the basis for further development and improvement of methadone maintenance treatment and for establishing it as one of the main treatment modalities for heroin users in Bulgaria.

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