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Final Report UNODC assessment of drug abuse treatment services in Albania Draft 16/07/2012 James Bell Introduction The

e objective of this assignment is to assess the national capacities on drug treatment and in particular Methadone Maintenance Treatment (MMT) and to provide recommendations on increased accessibility on MMT services in Albania. 1. Background 1.1 Drug problems in Albania In the two decades since the collapse of communism, Albania has gone through a period of rapid social change. With limited resources, it faces the task of developing the infrastructure and services of a modern social democracy. Albania devotes just over 3% of GDP to provision of health services. The remainder of health expenditure, approximately twice the government contribution, comes from private payments for care and medicines. In the 1990s (and possibly still), Albania served as a hub for distribution through Europe of heroin from Afghanistan, cocaine from South America. The combination of factors - heroin entering the country, and rapid social change - contributed to a sharp rise in heroin and cannabis use in Albania in the 1990s. Police believe the increase in heroin use has slowed, and they believe that the number of heroin users has now stabilised. They report that there was a heroin shortage in 2010. However, there is now an established culture of heroin use in many Albanian cities. International experience is that this will be very difficult, if not impossible, to eradicate (Strang, 2012). Problem drug users (PDU) are defined by the EMCDDA as intravenous users or longduration or regular users of opiates, cocaine and/or amphetamines. Ecstasy and cannabis users are not included in this category. A recent estimate is that there were 45005000 PDU in Albania in 2009 (EMCDDA, 2012). This figure is an estimate, based on the country experts opinion. Accurate statistics are not readily available. In 2009, among those entering treatment 48.3 % use intravenously, 36.6 % sniff, 10.8 % inhale. Drugs used are opiates (mostly heroin) in 68.2 %, cocaine 5.8 % and THC 0.9 %. Heroin is the primary drug for 83% of polydrug users (EMCDDA, 2012) International studies have estimated that age-adjusted mortality among heroin users is high, 13% per annum. Among younger heroin users, overdose is the commonest cause of death, with suicide and violence also contributing to mortality [Hulse, 1999; Darke, 2002). Rates of heroin overdose are a useful public health indicator of the prevalence of heroin addiction in the community. At this time in Albania, there is no systematic data on heroin overdose fatalities, making it difficult to track trends in heroin use. The injecting of street drugs, and sharing of needles, is a major route of transmission of blood-borne viruses (BBV), notably Hepatitis C and HIV, and as addicts and former addicts age, deaths due to liver disease, AIDS, and a variety of medical conditions, become more common. As of 2008 there was a low prevalence of HIV among IDU in Albania, with injecting drug use contributing 1% of national cases. The prevalence of HBSAg positive injecting drug users was 10-20% (compared to 8% in general population) (EMCDDA 2009). Prevalence of HCV positivity was 29% (Drug treatment systems overview).

In 2011 the Behavioural and Biological Surveillance Study was conducted among injecting drug users in Tirana (BIO-BSS, 2011). Two previous rounds of this study were conducted, in 2005 and 2008, providing some indication of changes over time. This study used a modified snowball technique, and interviewed 200 people. The 2011 report found that the median age at first injection was 21 years, with about 18.5% of IDU estimated to have injected before the age of 19. 43.5 % of the population injected drugs multiple times daily. The most commonly used injectable and non-injectable drugs in the past month were heroin (93.2%), diazepam (33.4%), marijuana (48%), and cocaine (30%). In total 32 % of respondents were younger than 25. Slightly more than one third of respondents (35.4%) reported never having received any treatment for their drug addiction (compared with 64% in 2008). 28.4% reported currently being in treatment in 2011, more than twice the number of those in 2008 (10.8%). The limitation of these data is that the sampling technique is susceptible to bias, and the figures do not provide a reliable indicator of prevalence of problems nor of demand for treatment. However, the high proportion of young heroin users suggests that recruitment to heroin addiction has continued in recent years. Legal statistics provide some evidence of the impact of drug misuse on the criminal justice system. In 2009 647 drug cases were registered, 568 offenders were prosecuted. These represent 5 % of all offences (13,100) and 4.7% of offenders (11,989) registered in Albania. 16 were women. 392 drug offenders were aged between 19 and 35 years; almost all (380) were unemployed. Around 30% (113) of drug offenders had prior offences (EMCDDA, 2012). 1.2 Drug Treatment in Albania In the 1990s there was some experience of opioid substitution treatment (OST) in Albania, when for a few years there was a program involving prescription of short-acting injectables. This was not successful, with escalating doses, threats of violence, and the development of a black market. Memory of this negative experience may have contributed to reluctance of psychiatry services to become involved in OST, and possibly to some lasting professional resistance to substitute prescribing. Methadone maintenance treatment (MMT) was implemented in 2005 by the NGO Aksion Plus, funded by the Soros Foundation. The programmes continuity (2008 onwards) as a free-of-charge service was ensured by the financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM); two centres in Vlora and Shkodra are partially supported by UNICEF and EU projects. The local government is providing in kind contribution and human resources such as counsellors from HIV Voluntary Testing and Counselling (VCT) centres. As of 2012, there were 5 centres run by Aksion Plus established in other cities outside Tirana. In 2009 a service was developed in Clinical Toxicology Service (CTS) (now renamed Clinical Toxicology and Addiction Service). The CTS is a public drug treatment service. It has 20 beds, treats detoxification and overdoses. There is also an outpatient clinic. Treatment is not free of charge, neither is it covered by medical insurance. 75% of treatments are ambulatory, mostly short term therapy and detoxification, with numerous relapses(EMCDDA, 2012). Patients bring their prescription to pharmacies, and collect medication (for which they pay), and which is taken without supervision. The statistical reporting of activity from the CTS is not easy to understand. According to the WHO-SAIMS report, in 2010 101 patients received in-patient treatment for narcotics

problems in the Clinical Toxicology Service. The average length of stay in the clinic was 7.4 days, with a bed occupancy rate estimated at about 50%. In the same year, 148 patients were hospitalized for alcohol problems in the Toxicology Service. 671 drug users were treated on an ambulatory basis. The total number of occasions of service for these drug users was 1,452 in 2010 (an average of 2.2 visits per patient, suggesting fairly poorlysustained treatment). There is a not-for-profit, residential rehabilitation facility located a short distance outside Tirana, the Emanuel Centre. In 2010, 77 persons received residential service in Emanuel Centre. Admissions for drug-dependent individuals are intended to be for 3-6 months. GPs are not involved in the treatment of drug users. However, the CTS in the last 2 years has provided training to around 300 GPs, and it is envisaged that GPs will play an increasing role in the future. There is a needle and syringe program (NSP) is administered by an NGO, Stop Aids, which currently has ~150 regular clients picking up needles and syringes in Tirana. The NSP includes outreach workers distributing near heroin dealing hot spots. There are 21 prisons in Albania, the largest with 900 inmates. In 2010, there were 4689 prisoners, although the official capacity was for 3,480. No reliable statistics are available but its estimated 270 drug users are incarcerated or on probation. Every prison has a doctor (several in large prisons). Separate services manage drug addiction and mental health. Distressed patients are likely to receive diazepam. More attention is paid to psychosocial aspects than to medication. There are no Prisons department protocols for the assessment and management of drug dependent prisoners. Training for health staff is provided by IPH, and UNODC delivers treatment packages. Aksion Plus also supports limited provision of methadone to some prisons, in order to continue treatment of patients who have been incarcerated. This has been done in accordance with an agreement with the Ministry of Justice. In general, imprisoned patients are tapered off methadone, although in the case of some prisoners with serious mental health problems, Aksion recommends to prison authorities that methadone is continued indefinitely. When people are first arrested, they are held in pre-detention or in police commissariat for up to 72 hours before transfer to the prison system. Aksion Plus also provides some methadone to arrested patients in pre-detention, although there appears to be no written protocol or official arrangements under which this is done. 2. Treatment of heroin addiction The objectives of long-term management are reduced risk of death and disease, improvement in mental health and outlook, and restoration of impaired social role. These objectives are most likely to be achieved if patients stop or markedly reduce their use of street heroin and other drugs. In suppressing use of street heroin, pharmacological maintenance treatment is more effective than short-term treatment or no treatment (Mattick, 2009). Methadone is a long-term treatment, and the duration of treatment is a linear predictor of outcome longer treatment produces better results.

Experience from other countries is that private funding of treatment for heroin addiction has potential problems. When drug users pay for treatment they are deterred from participating, and when they do participate, there is a risk that they will divert a proportion of prescribed medication in order to defray treatment costs. This compromises the effectiveness and reputation of treatment, and the safety of the community. Treatment of drug dependence at no cost or minimal cost to the consumer is an investment in better outcomes. 2.1 Methadone treatment In addition to being a treatment of individuals, methadone is a cost effective societal strategy for reducing drug related harm. Methadone treatment attracts and retains in treatment more heroin users than drug-free approaches (Mattick, 2009). The result of suppression of heroin use is a reduction in the risk of death as a result of entry to treatment, the protective effect lasting while people remain in treatment (Clausen, 2009); in conjunction with availability of clean needles and syringes, a reduction in risk of blood-borne virus transmission (Turner, 2011), reduction in involvement in crime, and subjective improvement in quality of life. However, while these reassuring data support MT as an effective intervention in reducing the harm associated with heroin addiction, methadone as delivered in practice often deviates from models of treatment demonstrated to be effective, and may fall short of delivering the benefits predicted from research studies. Despite widespread lip service paid to evidence-based practice, there has been a long and persisting tradition in Addictions of divergent, idiosyncratic and ineffective approaches to delivering treatment. Lack of clear objectives of treatment, punitive or exploitative clinicians, can detract from the effectiveness of treatment. Most importantly, low dose MMT is common, and reduces effectiveness. Doses of methadone 30-50mg/day block withdrawal for 24 hours in the majority of dependent heroin users, but these doses are not adequate for effective maintenance treatment. People maintained on low doses of methadone usually continue injecting heroin. By increasing the daily methadone dose, patients tolerance to opioids is progressively increased, and high tolerance attenuates the individuals response to injected heroin, tending to extinguish the habit. High dose MMT (60-100mg/day) is more effective than lower doses (Faggiano, 2003). Programs need a clear focus on recovery from drug dependence, for which the first step is stopping heroin use. Practitioners need to advise patients to accept adequate doses, as many patients are content to remain on low doses - enough methadone to abolish withdrawal, but not enough to block the reinforcing effects of injected heroin. Response to persisting drug misuse needs to be accepting and non-judgemental. An accepting, concerned response is more effective than punitive and demeaning responses. Patients need to be encouraged to explore their ambivalence about heroin use, and encouraged to accept higher methadone dose if they persist in heroin use. Regular monitoring of response to treatment, including urine toxicology, is an important element of treatment. The implication of these observations is that there are minimal conditions for effective methadone treatment protocols, policies and procedures, access to supervised doses, regular clinical monitoring and urine toxicology, and staff supported in providing nonjudgmental, empathic and supportive care.

2.2 Buprenorphine treatment Buprenorphine is an alternative pharmaceutical to methadone, of similar effectiveness as methadone. Buprenorphine is associated with a significantly lower risk of overdose deaths than is methadone. The potential importance of buprenorphine is that the availability of a drug with lower risk of overdose has permitted the development of a new model of maintenance treatment, Office-Based Opioid treatment (OBOT). In France and the US, methadone is delivered in highly-structured and regulated treatment programs, with most doses taken under direct observation, but high-dose buprenorphine is delivered by prescription, from office-based settings, without supervised administration. In addition to providing less institutionalized, more acceptable treatment to consumers, less problem of people congregating around clinics, the critical advantage of treatment without direct of observation of dosing is cost, as the expense of daily observed treatment is a major cost factor in delivering treatment. This is particularly relevant in developing countries, in many of which there has been a rapid increase in opioid addiction, and where buprenorphine treatment can be provided at low cost (Ruger, 2012). 2.3 Diversion All forms of substitution treatment carry the risk that prescribed medication will be diverted either misused by the patient for whom it is prescribed (injected rather than swallowed), sold to others, or simply not taken. Missing several doses of methadone allows the patient to use heroin and experience the full effect (whereas with daily supervised dosing, the effect of injected heroin is diminished). This is not simply a theoretical risk. The evaluation published by Aksion Plus noted that after dispensing takeaways for a holiday period, the majority of patients returned toxicology tests indicating heroin use. Diversion of medication prescribed for management of addiction is an inevitable concomitant of such treatment; as prescribing increases in a jurisdiction, diversion increases. Effective measures to reduce diversion include the administration of doses under direct observation, restricting unsupervised doses to people who meet criteria of stability; and dispensing take-home methadone in dilute form, reducing the likelihood it will be injected. 2.4 Other components of OST Opioid maintenance treatment is a pharmacological treatment, based on ensuring an adequate dose is taken daily; but it is not only a pharmacological treatment. People who have lost control of their drug use and their lives need structure and support, and freedom from the compulsion to use heroin is often merely a first step. Many heroin users have significant mental health, physical health and social adjustment problems predating their addiction, and impeding their recovery. Since its inception, methadone treatment has included counselling as part of care. However, a recent Cochrane review of psychosocial treatments as an adjunct to methadone treatment found that such interventions did not improve outcomes in terms of retention, nonprescribed opioid use, psychiatric symptoms, compliance or depression (Amato, 2011). Clinical experience is that while patients often request counselling, services are often not utilized. A reasonable compromise is that counselling should be available, not necessarily on site, but at least by referral. While formal counselling does not appear to be a critical ingredient of treatment, the quality of the relationship between patient and clinic staff is important. Establishing a therapeutic relationship requires structure - clearly defined protocols, program rules, mutual expectations between therapist and patient, and agreed objectives of treatment. Monitoring

of drug use (including use of urine testing), minimizing risk, monitoring side-effects and mental and physical health, form the basic structure of treatment, and the context in which the therapeutic alliance can develop. In acute care settings the doctor-patient relationship involves the patient being a passive recipient of care. In chronic care contexts, particularly in dealing regularly with patients with disorders of motivation, the therapeutic relationship is a partnership. General practitioners are often skilled in working in such long-term therapeutic relationships, but doctors and nurses trained in acute care settings require supervised experience in chronic care to acquire the necessary experience and skill. Treatment services delivering MMT do not exist in isolation. It is desirable to have collaboration with primary and secondary health care services, such that doctors, pharmacists and nurses who may come to be involved in treating patients have a basic knowledge of methadone treatment. There need to be agreements with police, such that police do not harass patients in the vicinity of the clinic, and that when patients are detained they may get access to methadone in order that they are not sick when facing court. There need to be agreements with prison services so that incarcerated patients can be managed humanely. There need to be professional relationships with other Addictions services, so that patients receive consistent, clear advice, and do not experience competition and conflicting messages from differing services. 2.5 Leadership and management Studies from the US and Australia have found that clinical leadership from an experienced and committed person is a critical element in determining the effectiveness of a methadone clinic. Without such committed leadership, there is a tendency for staff to drift into repetitive and unthinking interactions with patients, and for treatment to lose its focus. 3. Current provision of treatment in Tirana 3.1 Aksion Plus According to its website, Aksion Plus operates an accessible, non-judgemental programme using a target maintenance dose of 80mg/day of methadone, performing regular urine tests, with almost all doses supervised. The service has a commitment to supportive relationships with clients, and involvement of families. Aksion Plus dispenses methadone to about 200 patients daily in Tirana, and has opened 5 satellite clinics in other cities. In 2010, it was dosing around 295 patients daily. Aksion has recently experienced a crisis a shortage of methadone. It meant that patients had several weeks without methadone, and following emergency funding, patients are currently receiving lower doses of methadone. The centre now has assured funding for two more years, from the GFATM. Aksion Plus also works with police custody, and doses patients in some cells. An MOU between Aksion Plus and the Ministry of Justice, General Administration of Prisons, was signed in 2006, under which Aksion Plus provides methadone treatment for arrestees and prisoners. It works with 2 prisons the doctor assesses patient in prison, has Aksion protocol, and writes a note, it is delivered to Aksion who supply methadone to be administered in gaol. The methadone is for tapering during sentences, unless the patient has serious mental health issues when Aksion recommends maintenance.

A parent was interviewed. She attended Aksion Plus daily to collect her sons methadone, apparently a practice followed by several parents. She praised the treatment at Aksion. Her greatest concern over the Centre related to the presence of several drug dealers among the clientele. She was reluctant to elaborate further. She expressed considerable negativity towards CTS, where her son had received treatment previously. Her concern related to the cost of prescribed methadone. Consumers interviewed said heroin and cannabis were plentiful in Tirana. They claimed that 90% of people on methadone were using heroin while in treatment, partly because drug dealers were present. They reported that there had been a reduction in urine testing, a marked reduction prescribed doses, and that the treatment now is not what it was some years ago. In particular, they commented that regular urine testing had been helpful, but was now being performed infrequently. The patients said they felt that contact with other drug users was problematic, and impeded recovery, and thought that receipt of more takeaway doses would help them. The Needle and Syringe Program representative reported that more than 50% of the 150 regular clients of the NSP are on methadone. This is consistent with international experience that use of low doses is associated with high prevalence of heroin use among people in treatment. It is arguable that it is better to treat 100 patients with 80mg/day (meaning almost all are receiving effective treatment) than to give 200 patients 40mg/day, meaning very few are receiving effective treatment and persisting heroin use is common. I visited Aksion Plus unannounced at 8am to observe whether congregating and possible drug dealing were taking place. However, there was no sign of a crowd gathering. By 8.30 am dispensing was underway and the system appeared to be working smoothly. There was no obvious sign of drug dealing around the premises. The issue confronting Aksion Plus concerns sustainability. In response to insecurity over funding, the director of Aksion Plus has adopted strategies to secure support. He has two years of funding, and sees the way forward as being to obtain funding from local councils. He reported that he sees his role as encouraging people to ask for their rights. He asks patients and parents to advocate, seeks to have meetings with local officials, trying to argue the case for MT. This is how, despite limited funding, he has established a number of satellite centres. Comment The achievement of Aksion in bringing methadone treatment to Albania has been recognised and admired by all respondents interviewed. Aksion Plus has good premises, in a good location, and has a good therapeutic ethos. Patient and staff interaction appears professional, warm and courteous. The director has provided impressive leadership and commitment. However, the recent methadone shortage was a disaster which has probably destabilized many patients. In the short-term, Aksion Plus needs to repair the damage done by the recent methadone shortage, as there are currently problems in service delivery. It was not possible to assess the claims from consumers about drug dealing around the clinic. This may occur, but it may also be exaggerated by patients trying to pressure the clinic to provide take-home doses or trying to pressure parents into coming to the clinic to collect methadone for them.

The medium to long term issue is that Aksion Plus is under-resourced. Continuing uncertainty over long-term viability has led the organisation to focus on survival strategies. It is built around one persons drive and commitment, and in the medium to long term this is not sustainable. 3.2 Clinical toxicology Service Clinical Toxicology and Addictions Service (until recently Clinical Toxicology Service) comprises a 20 bed in-patient unit, plus offices and an outpatient service. Staffing is 3 toxicologists/addictionologists, a visiting psychiatrist, a psychologist, a social worker, and a growing number of nurses. There are 2 (possibly 3) trainees undertaking 3 year training in toxicology and addictions. The unit has limited drug budget, and usually charges patients for medication. For the last 12 months the unit has received in total only 600 X 40mg methadone tablets (provided by global fund) and has no budget to purchase more. As a result, the CTS cannot do maintenance, and the use of methadone is restricted to 3 week detoxification. In-patient phase of treatment lasts 10-14 days. The statistical for the years 2007-2010, report supplied by the CTS, says 94% of patients selfreferred. 71% of PDUs were dependent on heroin, and 80% were unemployed. Numbers being treated diminished sharply in 2010. No subsequent statistics were available. The director said that approximately 1/3 of the work of the unit is Addiction. On the day I visited, there were 6 in-patients in the ward 3 self-poisoning (1 with organophosphates, one swallowed acid, one pills); and 3 PDUs, 2 undergoing planned heroin withdrawal, and one recovering from a heroin overdose. All 3 heroin users were male, all were recently released from custody. The two undergoing detox had recurrent previous detoxes. Family members were at the bedside of 2 of the three heroin users. The ethos was that of a hospital acute medical ward, authoritarian rather than empathic. Asked what he thought was the greatest barrier to implementation of the Albanian Drug Strategy, the director said lack of political engagement/commitment, and resulting lack of funds and direction. He affirmed the need for a harm minimization framework, and for solid partnerships with NGOs, which he sees as currently stand alone services, not part of a network. Although CTS hopes to establish an Alcohol Abstinence Club, it has not done so yet. There are no self-help groups in Albania. EMCDDA has provided funding to develop an electronic patient record for Addictions Services, and this will facilitate standardised data collection. It was not possible to establish how far this process has been taken, to whom the money was provided, nor how it has been spent.

The CTS not inconsiderable resources appear substantially devoted to in-patient treatment. Even were it often full and on the days it was visited, it was 2/3 empty - 3 toxicologists, 2 trainees and a visiting psychiatrist, a social worker and a psychologist, as well as full complement of nurses, represents a substantial investment in acute care. Managing overdoses is the original role of the service, and remains an essential role. This model of acute care is very different to the treatment paradigm of managing chronic diseases, which is the appropriate paradigm in treating drug dependence.

The CTS remit has been broadened to deal with Addiction, and the staff needs to be exposed to other settings, particularly if they are to play a key role in future service delivery. The inpatient followed by aftercare medical model, while it may have a limited place in responding to alcohol problems, is not the appropriate model of care for responding to heroin addiction. In-patient detoxification from opioids is neither necessary (ambulatory withdrawal is safe and effective) nor sufficient (relapse after detoxification is usual, and detoxification is associated with an increased risk of death). Providing in-patient detoxification from heroin when resources are insufficient to support methadone maintenance represents an inappropriate allocation of scarce resources. A hospital based setting is physically not a good location for numbers of patients to attend daily for supervised methadone. Other elements of the hospital will be unhappy if a large number of drug users attend daily for dispensing. It seems far preferable to continue to provide the bulk of Tirana methadone services from the Aksion Plus building. It may be more appropriate to focus on providing more specialised assessment and management of patients with psychiatric morbidity, physical illness, and of patients dependent on multiple drugs in the CTS ambulatory clinic. Trainees do not receive experience in methadone treatment or community based treatment. If this is to be the unit which leads in professional education, development of protocols, and delivery of MMT, staff will need to gain the experience working in community settings. 4. Albanian National Anti-Drug Strategy 2012-2016 An expert group has developed a drug policy for Albania, and this policy has been endorsed by the government. The Drug Strategy 2012-2016 sets out a framework for funding expanded services. It proposes a leadership role for the CTS, the roll-out of a network of multidisciplinary hospital clinics across the country, and in time the education and involvement of GPs in delivering treatment. The policy and action plans will be funded by the state budget and the other donors. International agencies have led in establishing harm reduction services for drug users, for which the Albanian Health system will need to progressively assume responsibility. However, the treasury has not approved a budget. Given multiple demands throughout the health sector, and the current fiscal austerity, it seems unrealistic and suboptimal use of resources to move from small provision of treatment to a national roll-out of hospital-based, specialist centres. The drug strategy and accompanying proposed budget, make clear that responsibility for responding to drug problems is being handed to the Clinical Toxicology Service (CTS). The draft budget reinforces the very medical orientation of the CTS, with items such as ventilators (draft budget line item 1.2). It is essential that any final budget clearly distinguishes between funding to reduce drug-related harm (through methadone and buprenorphine treatment, counselling, detoxification) from costs of running an acute toxicology service. It is specifically stated in the policy document (section 9.3.1) that providing access to methadone treatment will be one element in the CTS role. However, the performance indicators for the CTS make no specific mention of MT. The Drug Policy envisages a medical leadership, teaching, research and service delivery role for the CTS. The objectives of the CTS include providing undergraduate and postgraduate

training in Addictions, development of protocols and guidelines, and collaborate internationally on research. It will develop a national database system, collecting medical and psychological data from all services for clients with drug-related problems. The policy envisages limited scope for involvement of GPs in the immediate future. Physicians in primary heath care service are allowed to give prescriptions for some psychotropic medicaments, but they have to wait for the initial recommendation of a specialist on the medicament, before they could proceed with the treatment. Looking to the future, were buprenorphine available, primary care based prescribing of buprenorphine might provide a low cost public-health intervention. Essential before introducing such an approach would be the availability of training for GPs, and a database monitoring drug-related mortality. 4.1 Concerns There are 3 concerns about the strategy: 4.1.1 Financial The ambitious program laid out in the Drug Strategy seems, if anything, overambitious in an under-resourced public health sector during a period of austerity. It represents a statement of intention or a wish-list but it is a strategy unlikely to be implemented in the foreseeable future, given the resources required 4.1.2 Human resources The experience, knowledge and skills to implement the strategy are not yet available and need to built over time. Plans for guidelines, training and accreditation for specialists, training for GPs in identification and referral, establishment of national monitoring systems and research capability will take many years of sustained resources, and pursuing these objectives should not be at the expense of ensuring current services are sustainable and are able to grow to facilitate access. Priorities The strategy is hospital based, and the critical need in responding to heroin users who make up the great majority of PDUs is the development and support of a network of methadone community clinics. Rolling out a number of hospital-based units is not the most effective use of resources for expanding access to effective addiction treatment. The medium-term priority is provision of a stable methadone program, which can serve as a training site to develop the skills and knowledge to serve future progressive expansion.


5. Critical Issues in expanding access to treatment

5.1 Funding
The critical question is how to allocate scarce resources to obtain the best public health outcomes. Drug dependent patients are disproportionately from the poorer elements of society, and reliance on privately funded treatment and privately purchased medications reduces access to treatment, and potentially creates serious risks of feeding a black market. OST coverage by MoH, such that methadone is a reimbursed medication, is essential to the delivery of sustainable, accessible treatment.

When funding is allocated to support expanded access to treatment, there need to be mechanisms in place to ensure that funding directed to taking on state responsibility for MT is devoted to MT, and not diverted into expensive, acute-care hospital based services which are less cost-effective. 5.2 Workforce development The consolidation and expansion of MMT (and of other Addiction services) in Albania will require staff gaining experience and skills across a range of Addictions treatments. In principle, this approach laid out in the strategic plan of commissioning a specialist service to provide leadership, guidelines, training, research and evaluation is a sound one, designed to set treatment of drug addiction on a sustainable, long term basis. It is a model used in Australian when it established a national Campaign Against Drug Abuse in 1985, and allocated funding to establish the National Drug and Alcohol Research Centre, to develop guidelines, undertake training and research, and advise government on policy. However, it took many years before the National Centre was able to perform this role, as its own researchers were for the most part initially unfamiliar with the Addictions field. In the early years it was practitioners delivering treatment who actually led in the development of guidelines, training programs and research. Health care is not learned from a book, but from the experience of delivering treatment and reconciling that experience with theory. Eventually, there is likely to be a place for office-based treatment, but an essential step towards this is to ensure there is training available to be delivered by practitioners with good experience of working in community clinic settings. There are currently 3 trainees in toxicology addiction working in CTS, and for these young doctors to provide medical leadership in Addictions in the future, it is critical to ensure that there training is comprehensive. The curriculum for toxicology/addiction training should include the experience of doing 1 or 2 sessions per week, for a minimum of 3 months (preferably 6 months) in a community methadone clinic. Only by working with patients, and with a team, over months will doctors gain the requisite experience to go on and become future trainers. Their methadone experience should include not just writing prescriptions, but assessing new patients, personally case-managing a number of patients (setting dose, monitoring treatment, participating in multidisciplinary case reviews), and undertaking a clinical audit or reviewing protocols). Similarly, it is essential to train a cohort of nurses with experience dispensing and managing a caseload of OST clients. Aksion Plus is the setting in which health professionals can receive training in MT. 5.3 Service development It is better to start with a regulated system and move towards a more liberal one as more experience is gained, than to begin with a liberal program which risks giving OST a bad reputation (as occurred in the 1990s in Albania). Heroin supply is plentiful in Albania, and persisting use of heroin during methadone treatment (and relapse after drug free treatment) is common. In considering the need for a sustainable and effective harm reduction service, it needs to be anticipated that most dispensing will be supervised to ensure compliance. The widespread use of supervision minimizes risks of diversion and misuse. Such structured treatment costs more, and delivers better outcomes. Clinic operating hours should be designed to accommodate employed patients, and the practice of

having family members collect methadone for patients should be minimized, as it detracts from the monitoring of patients, and may place inappropriate pressure on family members. 5.4 Partnership The concrete, resource neutral first step is to establish a meaningful partnership. There need to be professional relationships between Addictions services, so that patients receive consistent, clear advice, and do not experience competition and conflicting messages. This needs to be based on a formal partnership describing the roles and responsibilities of the services.

5.5 Political engagement

Several respondents commented that there is no clear political or bureaucratic responsibility or leadership on the issue of expanding access to treatment. A previous review (SAIMS, 2011) noted the lack of central coordination of drug policy (P25).The committee charged with responsibility for drugs has been inactive. Several respondents expressed concern that without clearly identified government or bureaucratic leadership, implementation of the Drug Strategy 2012 will be problematic. However, divisions and competition between services make government role more difficult. When services have differing objectives, different beliefs about what is effective, and different treatment approaches, patients, families and government receive contradictory messages. Governments are not experts in treatment, and the role of the bureaucracy in managing resources can be assisted by consistent, evidence-based messages from professionals in the field. It is up to clinicians to provide clear advice to government otherwise governments have to choose between competing services, leading to perceptions of favouritism. Therefore, while political support for treatment is needed, and bureaucratic oversight of how resources are used is essential, it is clinicians who need to provide leadership in service development. 5.6 Promoting collaboration and transparency There needs to be a disinterested third party not a service provider - to commission and monitor services and facilitate the development of a partnership between Aksion Plus and CTS. Whatever funding is allocated to development of services for drug users, there needs to be transparency and accountability to ensure that funding goes to providing the most useful services. The logical body to perform both these roles is the Institute for Public Health (IPH), which has public health expertise, but no direct vested interest in treatment delivery. IPH can monitor implementation of a partnership, arbitrate on disputes, and report back to MoH to ensure transparent allocation of resources (specifically, staffing and medication). Continued annual funding for treatment of addiction should be contingent on reporting from IPH that funding has been allocated in accordance with agreements.

6. Proposals
1. The critical issue in provision of services for drug users is sustainable and adequate resourcing. Inadequate funding and insecurities over funding are compromising delivery of MT in Albania. International agencies have led in establishing harm reduction services for drug users, for which the Albanian Health system will need to assume responsibility. Investment in treatment of problem drug users is costeffective a public health investment which should substantially be met by the state, as without a state budget, no expansion of treatment capacity is going to be sustainable. Methadone is an inexpensive drug. The first necessary condition for sustaining (let alone expanding) access to methadone treatment is funding from Albanian Ministry of Health to purchase methadone supplies. Whether regulatory or legislative change is necessary, this is required to ensure methadone is reimbursable medication, and that government will supply medication for treatment programs. 2. The Albanian Drug Strategy envisages allocation of resources to expand drug treatment capacity. It will be critical to ensure that funding for drug treatment is clearly identified, that the broad objectives of funding are agreed, and that services in receipt of funding are accountable. For this to occur, there need to be agreed treatment priorities, and agreed reporting of activity, outcomes and expenditure. Continued funding of clinical services needs to be subject to meeting these requirements. 3. There should be a formal partnership between the two treatment providers, Aksion Plus and CTS. A committee comprising the directors of Aksion Plus, CTS, and a senior representative of the IPH, will oversee the partnership. The IPH will have responsibility for the commissioning of services, receiving statistical reports from the clinical services, and reporting back to MoH. Continued MoH funding of clinical services should be dependent on evaluation by IPH. 4. The committee will set priorities for development of services, with IPH arbitrating disputes. It is recommended that funding priorities are (1) place existing services on a sustainable basis through a commitment to funding methadone (2) progressive establishment of further methadone dispensing capacity as needed, and (3) training of primary care practitioners (4) hospital based-based clinics as trained workforce permits. 5. The partnership between CTS and Aksion Plus has three objectives: promoting access for patients to adequately-resourced treatment developing a skilled and experienced workforce as a basis for sustainability and expansion developing quality collection of clinical and management data, and reporting relating to activity, outcomes and expenditure 6. To meet these objectives, the partnership should include specific measures: Medical and nursing staff employed by CTS work part of their time in Aksion Plus. This will ensure adequate staffing of Aksion plus, and will provide training and experience in community treatment for CTS staff who will have future leadership roles in Addiction services. There needs to be strategic planning based on availability of resources. The committee should reach agreement, reviewed every 6 months, on numbers in treatment (and therefore on volume of methadone required, staff numbers and facilities required) The two services will develop and use a shared patient database (minimum data set, as specified by EMCDDA) and electronic patient record, allowing systematic data collection. Responsibility for choice of data base and implementation should lie with IPH

Sessional counselling, or social work support from CTS staff members be provided to clientele of AKsion Plus, at Aksion Plus. Patients presenting to CTS for opioid detoxification will be referred to Aksion Plus for ambulatory detoxification, rather than the current, unsupervised ambulatory detoxification provided through CTS. Only in exceptional circumstances should patients be admitted for in-patient opioid detoxification, as this is not a cost-effective modality of treatment. 7. Workforce development. Sustainability and expansion of services depends on an experienced workforce. Bringing in overseas expertise to train people is of limited value, and is is most likely to be beneficial when such training is provided to people who already have some experience working with PDUs, as they are more likely to be able to learn once they can relate to the issues being discussed. Specific training issues are A curriculum specifying training to be recognised as a specialist in Addiction medicine needs to be developed, specifying the range and extent of experience, knowledge and skills. A key element in such a curriculum is a minimum experience of MT - trainees should spend 3 months doing 2 sessions per week in a methadone clinic, not simply signing prescriptions, nor merely doing health checks, but, undertaking assessment of new patients, personally managing a caseload, and participating in case review meetings. Such experience will equip doctors for the anticipated future implementation of OBOT in Albania. Trainees would benefit from a range of teaching and supervision Similar experience (a prolonged, 2-3 sessions per week placement) should be offered to nursing staff from CTS. In addition to dispensing the nurses will manage a small caseload. 8. Aksion Plus has led in the development of agreements with police and prisons, and the partnership should continue this work, in developing formalised agreements with police and prison services to ensure methadone-maintained patients are not harassed, and can receive continuity of care if detained.

Documents referred to EMCDDA report on Albania SAIMS Report on Prevention and Treatment Systems for drug-related health disorders in Albania 2011 Section from R9 GFATM REPORT EVALUATION OF THE COMMUNITY BASED METHADONE PROGRAM FOR OPIATE USERS IN TIRANA, July 2007 Aksion statistics 2010 Aksion website Anti-drug strategy 2012-2016, plus draft budget accompanying anti-drug strategy Drug treatment systems overview no author, undated

Behavioural and Biological Surveillance Study among injecting drug users Report 2011 (Stop Aids)
Ensuring relevant authorities act to contain the HIV/TB/Hepatitis C epidemics among drug users and in prison settings in Albania, Serbia and the FYR of Macedonia: Assessment of policy and training needs in Albania REPORT UNODC 2012

Interviews conducted
Mr. Pellumb Pipero, Director of Health Policies at MoH Arian Boci, NGO STOP AIDS and national partner in this project Representatives from the Prisons Administration - Rosalba, health unit Mr Roland Bani, National Coordinator on HIV/AIDS, IPH Dr Eduard Kakarriqi, Head of Epidemiology Department at IPH

Dr. Alban Ylli, Institute of Public Health Rosealba Reci, Health Service at the General Directorate of Prisons Administration
Mr Genci Mucollari, Aksion Plus Consumers and family members at Aksion Plus Consumers at CTS Dr Zhini Sulaj and staff, CTS

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