1. Croatian Society for Addiction
Assessment of Drug Treatment in Croatia - results from CATS (Croatian Addiction Treatment Survey) and its implication on new national Drug Policy strategy
Zrinka Ćavar, child and adolescent psychiatrist
Teaching Institute for Public Health dr. Andrija Štampar
Department for mental health and addiction prevention
Croatian Society for Addiction

2. Background- the Croatian model of addiction treatment
law and strategy to Fight Drugs (1996)
hybrid model in primary-care settings - OMT licenced phyisicians (60) of county public health institutes and general practitioners (1200)
dividing diagnostic assessment and psychosocial treatment (PST) from providing OMT in primary-care settings
implemented quality standards and treatment guidelines (pharmacotherapy, PST, harm reduction)
EBT interventions- OMT ( 1991 methadone, 2007 buprenorphine, buprenorphine–naloxone) + PST
one of the highest MAT coverage in EU (65%)
more then 6000 people received MAT in 2017 (53% buprenorphine or buprenorphine/naloxone , 47% methadone)
treatment costs - fully covered by the social insurance system

3. Background- Croatian Addiction (Opioid) Treatment Survey (CATS)
timely snapshot of current treatment practices across Croatia from the perspectives of opioid-dependent patients, users of psychoactive substances and the physicians who treat them
data will help to
identify barriers to success through the key markers
provide insight as to whether current treatment system is successfully achieving the basic harm-reduction goals and/or setting patients up for recovery
inform policy making around the desired structure, process and outcomes of the treatment system necessary to achieve the desired state of recovery
we report part of findings from the project involving the combined analysis of survey data from 646 participants

4. Metodology
the methodology and questionnaire instruments in this study were adapted from a survey which was designed in Germany (IMPROVE), and to date have been applied in more national and international surveys (EQUATOR, INSIGHT)
the present survey was conducted in 2016 through three months
aimed numbers of participants were 60 licenced physicians in primary-care settings, 400 of patients and 400 users of psychoactive substances
participation was voluntary and randomly, all participants provided informed consent prior to participating and did not receive money/voucher to take part in the survey
inclusion criteria for participants
physicians - having in care for at least 5 people with opioid dependence and having at least 2 years of experience in treating
patients - receiving OMT at the present or earlier
users of psychoactive substances - using at least 6 months at least one of the PASs mentioned in the questionnaire

5. Results- profil of respondents (646)
Patients (379)
the mean age 38y, y
82% male
69% SSQ, 21% no SSQ, 10% HSQ
51% single, 49% married/cohabiting, 8% divorced/ widowed
46% rates of unemployment
Users (237)
the mean age 37y, y
76% male
62% SSQ, 21% no SSQ, 17% HSQ
47% single, 53% married/cohabiting, 9% divorced/widowed
52% rates of unemployment
Physicians (30)
the mean age 51y, 29-69y
67% male
65,4% psychiatrists, 26,9% others specialists, 8% GPs
12y (3 -20y) practicing and prescribing OMT
80% public health, 20% hospitals
the mean number of patients per physician 98 ( )

6. Results- quality of care
patient requests for, and awareness of, specific opioid pharmacotherapies
65% of patients asking for a specific OMT, 91% receiving
59% of physicians offered their patients the choice of substitution therapy
levels of awareness
patients: 66-93% of methadone, 57% of mono-buprenorphine, 44% of buprenorphine–naloxone, 30% of psychosocial treatment, 26% of naltrexone
users: 86% of methadone and mono-buprenorphine, 81% of buprenorphine– naloxone, 42% of naltrexone
sources of information regarding treatment options for opioid dependence
83% of users reported well informed of OMT medication options
for 65% of users and 40% of patients - other drug users/friends
for 40% of users and 20% of patients – drug support centres/ physicians

7. Results- quality of care
use of specific opioid pharmacotherapies
patients: 54% methadone, 25% buprenorphine, 20% buprenorphine– naloxone, 0,3% naltrexone
users: 64% methadone, 17% buprenorphine, 11% buprenorphine/naloxone, 0,8% SROM
physicians: 44% methadone, 32% buprenorphine, 24% buprenorphine–naloxone, 10% SROM, 4% naltrexone
time on current OMT: the mean length of time on current OMT - 74 months (SD=64,05), 6 y (1-12y)
levels of dosing supervision
59% low level of dosing supervision (17% unlimited, 42% often but not unlimited therapy)
41% high level of dosing supervision (9% daily, 32% perodically on weekends, vacation or holidays)

8. Results- quality of care
compliance: medication diversion and misuse
45% of patients and 56% of users ever having sold/given their OMT medication !
more then 30% of patients/users reported ever having misused their OMT medication (at maximum 29% ever having injected and 21% ever having snorted) !
patients: 29% injected methadone liquid, 16% injected methadone tablets or buprenorphine, 7% injected buprenorphine- naloxone, 21% snorted buprenorphine, 16% snorted buprenorphine- naloxone
users: 32% injected methadone liquid, 19% injected methadone tablets, 14% injected buprenorphine, 5% injected buprenorphine- naloxone, 13% snorted buprenorphine, 5% snorted buprenorphine- naloxone
73% of physicians reported that giving/selling and 60% that misusing of OMT was a serious problem in their geographic area

9. Results- quality of care
prescribing practice
84% of patients were in the maintenance program (SD = 16.72)
induction phase dose on the first day
40 mg (28%) or 50 mg (28%) of methadone !
4 mg (30%), 8 mg (27%) or 6 mg (23%) of buprenorphine or buprenorphine/naloxone!
stabilization phase
methadone maintenance daily dose days (SD = 6.69)
buprenorphine and buprenorphine/naloxone daily dose days (SD = 18.33) !
maintenance daily dose
methadone tbl 62mg (SD=23), liq 77mg (SD=29)
buprenorphine 12mg (SD=4) and buprenorphine/naloxone 11mg (SD=3)

10. Results- quality of care
psychosocial treatment (PST)
10% currently receiving
22% have ever received
30% had heard about PST before entering the treatment
30% reported that PST is part of treatment
physicians reported 7% of patients received only PST
patient satisfaction with OMT medications
78% of patients being satisfied
physicians satisfaction with quality
90% of the physicians reported the high quality of care for opiate addicted persons

11. Results- clinic outcomes
number of previous OMT episodes
the mean length of time current OMT - 6 years (1-12y)
the average patient/user – 3 times had been in treatment
compliance outcomes
45% ever having diverted, more then 30 % ever having misused OMT
use of illicit opioids by patients
42% of patients continued to use illicit opiates
19% regularly (daily, weekly)
23% rarely (1–2 times per month/per year
reasons for misuse/use:
52/39% want to get high occasionally
other reasons 29% (curiosity, influence of friends, learned behavior, faster way)/24% (aches, stress, bad feeelings)
21% use because of missed appointments
14/16% drug treatment doesn’t control cravings
5% if misused they could have sold part of medication

12. Results- public-health-related outcomes
use of illicit drugs by users (51% of them are OMT patients)
98% of users use illicit opioids
85% regularly (daily, weekly)
13% rarely (1–2 times per month/per year)
last six months: 68% marijuana, 57% alcohol, 56% heroin, 54% opiate analgesics, 35% cocaine, 33% others (substitution/other therapy)
current use: 47% marijuana, 38% alcohol, 35% heroin, 18% cocaine…
use of diverted medications by users
30% methadone liquid, 25% methadone tablets, 15% mono- buprenorphine, 8% buprenorphine– naloxone
25% benzodiazepines, 17% opiate analgesics, 1% SROM

13. Results- public-health-related outcomes
health and comorbidities
51% of users (99% of patients) medical treatment of addiction
70% of users (57% of patients) medical treatment of somatic/psychiatric comorbidity
BBV
0,8% of users (0,5% of patients) HIV infection treatment (country 0,5%)
15% of users (9% of patients) HCV infection treatment (country 40%)
29% of users (24% of patients) depression treatment
medical treatment of somatic comorbidities
users/patients: 12% treatment of other conditions such as hypertension, hyperlipidemia, diabetes, gastritis, thyroid disease, 8/6% treatment of respiratory diseases, 6/5% treatment of cardiovascular diseases – misuse !

14. Results- public-health-related outcomes
prison episodes
48%, on average 3 years and 2 times
75% were in OMT before entering prison, and of these, 71% continued OMT in prison
employment
48% of patients (28% full time), 40% of users (16% full time)
30% of patients were looking for employment (recovered?) !
retired- 6% of patients and users
students- 2% of users and 1% of patients

15. Conclusions about current treatment system
good accessibility and retention
cost-effective- successfully achieving the basic harm-reduction goals and setting majority (more then 60%) patients up for recovery
high quality of process of treatment (available EBT interventions)
Barriers to success:
a public stigma about of persons with mental disorders (recovery!)
variations in the quality of treatment across country mostly for methadone OMT and PST with negative public health impact (for part of patients too low a level of methadone dosing supervision, too much non - compliance (diversion and misuse), too much users use (misuse) diverted OMT)
minority (20-40%) of patients still have been in harm reduction program with OMT medication (non- compliance, continue to use illicit opiates and other drugs, more somatic/psychiatric comorbidities)
low national level of employment rate for that age group (30% of patients reported have looking for employment)

16. Recommendations for policy making
anti stigma programs - change stereotypes about opiate addicted persons and possibility for recovery by healthcare professionals
optimising quality of treatment
balance between control and patient flexibility
implementation of measures for prevention, evaluation and therapeutic response to diversion and misuse
national methadone guidelines lack clarity – there is need for Clinical protocol
optimising prescribing practice (induction, daily doses) and supervision
providing more PST interventions
more patients education about OMT options, diversion and misuse
more abuse-deterrent formulations of OMT medications
need for standardized mandatory and continuous training of physicians with better linkages between different treatment services (GP and lycenced physicians)
optimising outcomes
additional support is necessary to achieve recovery for % of patients who are now in harm reduction program with OMT