Opiate substitution in Hungary

Trends, challanges and barriers.

Trends, challanges and barriers.
 

The Parliamentary Committee on Drug Affairs held a meeting last week in Budapest, the main item on the agenda was the situation of opiate substitution treatment in Hungary. Dr. József Csorba, head of the Drug Addiction Centre of the Nyírő Gyula Hospital in Budapest presented recent trends and figures to the MPs and experts of the Committee. He estimated that there are approximately 10.000 opiate addicts in the country, most of them did not enter any forms of treatment. He refered to a 2006 study made by the Research Institute on Drug Studies (ELTE University) among injecting drug users in Budapest. This study showed that according to IDUs substitution treatment is the least accessible form of treatment in the capital. Only 700-800 clients are on methadone substitution in the whole country. There are 9 methadone clinics in Hungary, 4 in Budapest, the others operate in the towns of Miskolc, Gyula, Szeged, Veszprém and Pécs. The Western region of Hungary is still not covered by any service, patients from that part of the country very rarely can afford the time and money to enter substitution treatment somewhere else. Dr. Csorba emphasized that there are many reasons why there was no progress in scaling up substitution treatment in the last couple of years. Even if the Hungarian national drug strategy approves opiate substitution as an integral part of the harm reduction pillar, the annual governmental budget spent on substitution – estimated to be 21.000.000 HUF (approximately 81.000 Euro) – is not enough to scale up existing services. A major barrier is the funding system of the Health Insurance Company (Hungary has a single-insurance health care model), which does not provide the adeqate priority for substitution. There a so called „performance-volume limit” (TVK), a regulation in Hungary according to which the number of newly registered clients must not exceed 95% of the previous year's number. Another barrier is the lack of professionals in the field: addiction care is not an attractive carrier for young medical doctors, many of the psychiatrists who work as addiction specialists are still suspicious about substitution because they do not accept the principles of harm reduction. Dr. Csorba mentioned as a promising sign for change that after years of negotiations a new substitution medicine was introduced to Hungary this year, Suboxone, which contains buprenorphine and naloxon at a ratio of 4:1. Recently there are 19 patients participating in a clinical trial of Suboxone at his clinic and there are more people at other treatment sites. Suboxone, which has a reputation of having less potency for abuse and overdose, may improve the general acceptance of substitution in Hungary.

Most Committee members were supportive to substitution treatment and urged the scaling up of these services. However, some experts of the Committee – who were invited by conservative opposition parties – criticized Dr. Csorba’s presentation as „one-sided” and „distorted”. They said substitution treatment is absorbing clients from abstinence-based therapeutical and rehabilitation centres. Katalin Szomor, an expert appointed by the Hungarian Democratic Forum (MDF) even claimed that methadone can have harmful effects on the outcomes of antiretroviral treatment for IDUs living with HIV/AIDS. Other experts, like Peter Sarosi from the Hungarian Civil Liberties Union (HCLU) rebuted these allegiations, pointing out that all relevant international organizations and recommendations prove the positive relationship between adherence of ARV treatment and substitution therapy, for example WHO and UNAIDS. Ms. Szomor could not deny this fact so she murmured that „UNAIDS is a political organization” and not a scientific one. (After the meeting HCLU made up a literature review on the issue of substitution treatment and adherence to ARV, which will be published in the Hungarian journal Addiktológia.)

Substitution treatment is still not available in prisons. According to Dr. Katalin Heylmann, chief health commissioner of the Hungarian Prison Administration, who made a presention for the Committee on services in prisons, this is due to security reasons: correctional officiers are concerned about the risks of storing methadone in prisons. She claimed that prisoners can access substitution treatment if they ask for it, but only those who were already registered clients of a community treatment site. In these cases the prison administration can arrange a daily transfer of these clients to the community centre to get their doses at the site. However, Peter Sarosi from HCLU questioned if this system really works in reality. According to reports of clients of NGOs, prison medical staff usually provides them with other, less effective medications, and they cannot continue substitution treatment after entering prisons. Dr. Csorba also confirmed this information. Experts of the Committee pointed out that substitution treatment in prison settings is highly effective and poses no dangers to prison security according to international organizations and documents, for example a recent status paper of WHO. HCLU and the Hungarian Harm Reduction Association recommended to change the legislation on prison health care to explicitly approve and promote substitution in prisons. It is also a major issue of concern that the number of HIV and HCV tests decreased rapidly among prisoners after mandatory drug testing was abolished in 2003 (after a succesful campaigne of HCLU). Ms. Szomor accused HCLU to be responsible for this decrease. Sarosi replied that the solution is not mandatory testing and segregation of people living with HIV/AIDS, but the initiation of cooperation with civil society to improve education and motivation among prisoners. Dr. Heylmann agreed and mentioned that recently they approached profit and non-profit organizations to scale up voluntary testing and counselling in prisons.  

Peter Sarosi