This document summarizes global access to opioid substitution therapy (OST) and how drug policies can improve availability. It finds that while OST is effective in treating opioid dependence and reducing harms like HIV transmission, availability remains limited in many regions. The document advocates expanding OST provision and removing legal barriers to improve health outcomes and public safety internationally.

1. International access and availability
of OST and how drug policy can
improve this
Dr John Roche
INTERNATIONAL DOCTORS FOR HEALTHIER DRUG POLICIES

2. Overview
• What is the problem?
• What is OST?
• What is the evidence?
• Global access
• How to improve access

3. Key problems caused by heroin
• Overdose
– Leads to respiratory depression and death
• Problems associated with IV use
– Leads to spread of BBV – HIV, Hep C
– Abscesses, DVT, endocarditis etc
• Dependence
– Leads to withdrawal symptoms and need for further
use – funds criminal networks, crime to support habit
• Direct health effects
– Constipation, nausea, sedation

4. Basic Principles
• Opioid use can lead to tolerance and
withdrawal symptoms
• NIDA estimate 23% of people who use heroin
become dependent
• To avoid or stop withdrawal symptoms further
opioid use is required
• Opioid substitution aims to prevent need for
heroin

5. What is OST?
• Opioid substitution treatment (OST) is a type of
treatment for those with heroin dependence.
• It includes the prescribing and administration of a
pharmaceutical opioid as a ‘substitute’ for illicit
opioids, in the context of care-planned treatment
with psychosocial and recovery interventions,
and regular review.
• The same medicines (methadone and
buprenorphine) are used in both detoxification
and substitution regimens.
• Advisory Council on the Misuse of Drugs

6. OST in the UK
• According to UK clinical guidelines OST is designed to:
– Reduce or prevent withdrawals that typically lead to
further use of illicit heroin
– Provide an opportunity to stabilise drug intake and lifestyle
while breaking with illicit drug use and associated
unhealthy risky behaviours (including injecting)
– Promote a process of change in drug taking and risk
behaviours
– Help maintain contact and offer an opportunity for
therapeutic work with a patient or client
• Advisory Council on the Misuse of Drugs

7. WHO/UNODC/UNAIDS 2004
• Substitution
maintenance therapy is
a critical component of
community-based
approaches in the
management of opioid
dependence and the
prevention of HIV
infection among
injecting drug users
(IDUs)

10. Eurasian Harm Reduction Network
(2012)

11. OST: Why do it?
• Individual
– Improve health, reduce risk of overdose, access to
health/social care
• Society
– Reduce transmission of Hep C, HIV
– Reduce crime to fund drugs
– Reduce money going to criminal networks

12. World Drug Report 2014
• We have seen that
countries that have
adequately invested in
harm reduction services
have lowered
remarkably HIV
transmission among
people who inject
drugs.
• Yury Fedotov, Executive
Director, UNODC

14. • Injecting drug use reported in 158 countries
• Estimated global number of:
– IVDU is 8.9-22.4 million
– IVDU with HIV is 0.9-4.8 million
• UNAIDS (2011): 50% reduction in incidence of
HIV in IVDU by 2015
– Incidence (2010) 110,000 (2013) 98,000
• 10% reduction

15. Global State of Harm Reduction

16. Global State of Harm Reduction

23. Continent Number of
Countries
Harm
reduction
in national
policy
Needle
exchange
programmes
OST
operational
Drug
consumption
rooms
Asia 19 19 17 15 0
Eurasia 29 26 29 26 0
Western
Europe
21 20 19 21 6
Caribbean 3 1 2 1 0
Latin
America
6 6 6 2 0
N America 2 2 2 2 1
Oceania 2 2 2 2 1
Middle East
& N Africa
11 7 8 5 0
Sub-Saharan
Africa
8 5 5 5 0
Total 101 88 90 79 8

24. Global State of OST
• Methadone, buprenorphine most common
• More available in high income countries
• 43 countries provide OST in prisons
• Since 2012:
– Only 2 countries (Burkina Faso and Turkey) have
newly implemented OST
– Bahrain provides OST in rehabilitation
– 25 countries increased provision
– 5 countries decreased provision

25. Asia

26. Asia
• OST provision has continued to be scaled up in
several Asian countries, with an estimated
297,000 people who inject drugs accessing these
services.
• Between 2012 and 2014, Bangladesh increased
from 1 site to 3 sites, India from 72 to 145 sites,
Malaysia from 674 to 811 sites, Myanmar from
10 to 18 sites, Nepal from 3 to 12 sites, China
from 738 to 763 sites, Vietnam from 41 to 80
sites and Indonesia from 74 to 85 sites.

27. Asia
• As with NSPs, OST provision in Asia is hindered
by legal and policy barriers that restrict or
prohibit its implementation and scale up. For
example, in Malaysia, recent punitive
enforcement and coercive action means that
people who inject drugs have reduced trust in
OST programmes, and therefore underuse
them because of fear of arrest.

28. Eurasia

29. Eurasia
• Since 2012, a number of countries have removed
barriers, facilitating access and improving the quality of
OST programmes.
• In Latvia, new regulations to legalise OST provision
resulted in a 28% increase in patients in 2012.
• In Bulgaria, buprenorphine was approved for the
treatment of HIV-positive or high-risk people under 18
years, enabling OST to become accessible to this age
group.
• Ukraine also removed a number of barriers, including a
weakening of age restrictions for legal minors, which
resulted in expanded access.

30. Eurasia
• According to the UNAIDS representative in
Ukraine, Crimea’s OST provision was
considered an example of best practice.
• Among the 800 people formerly enrolled in
OST in Crimea, 38% were living with HIV and
50% of them were receiving antiretroviral
therapy (ART).

31. AIDS Epidemic in Russia
• Almost 60% of those with HIV in Russia are
injecting drug users and a further group are the
sexual partners of the drug users.
• The HIV virus has spread via contaminated
needles and syringes.
• Yet in Russia methadone is banned. The World
Health Organization may see the synthetic opiate
as essential in combating heroin dependence, but
in Russia anyone caught using it or distributing it
can face up to 20 years in prison.

32. AIDS Epidemic in Russia
• About 1 million people live with HIV today in Russia and the rate of
infection is rising. 88,000 new HIV infections in 2013.

33. Western Europe

34. Western Europe
• In most of Europe, HIV rates among people who inject
drugs appear to be stable or declining as a result of
early scale up of harm reduction measures.
• However, recent severe outbreaks of HIV among
people who inject drugs in Greece and Romania
prompted the European Centre for Disease Prevention
and Control (ECDC) and the European Monitoring
Centre for Drugs and Drug Addiction (EMCDDA) to
undertake a risk assessment in 2013.
• They concluded that five countries in Western Europe
are of concern for HIV risk: Estonia, Greece, Latvia,
Lithuania and Romania.

35. Western Europe
• Over half of opioid users in Europe access OST,
with an estimated 734,000 receiving OST in
2012 – a slight rise compared to 2011.
• The most significant increase in OST between
2011 and 2012 was in Turkey, which saw an
increase of 250% from 8,000 to 28,656,
followed by Greece, which saw an increase of
45% to 9,878.

36. Caribbean

37. Caribbean
• Puerto Rico remains the only territory in the
Caribbean providing OST.
• However, the first OST pilot has now been
approved in the Dominican Republic and
should be in place towards the end of 2014.

38. Latin America

39. Latin America
• Opioid use is thought be rare in Latin America.
• At present, Mexico and Colombia are the only
countries in the region that provide OST to
people who inject drugs and/or use opiates,
with approximately 18.6% of opiate users
receiving OST in Mexico.

40. North America

41. North America
• OST is available in both countries, although
access is by no means universal.
• Over 2,418 licensed facilities provide OST across
the USA.
• The most recent available data indicate that in
the USA in 2009 there were 640,000 individuals
on buprenorphine or buprenorphine–naloxone
combination for maintenance therapy (up from
96,000 in 2005) and 266,818 on methadone (up
from 236,836 in 2005).

42. Oceania

43. Oceania
• Approximately 102,040 people inject drugs in
Australia and New Zealand combined, a
decrease of approximately 70,000 on figures
from 2012.
• HIV prevalence among them is relatively low
(1.2% and 0.2% respectively).
• Hepatitis C (HCV) rates have remained high, at
54% and 50% respectively.

44. Oceania
• Although OST provision is high in Australia,
there has been little change since 2012.
• In New Zealand, current levels of OST
provision are unclear, but in 2009 it was
estimated that approximately 4,600
individuals were receiving OST, predominantly
in methadone form.

45. Middle East and North Africa

46. Middle East and North Africa
• An estimated 626,000 people inject drugs in
MENA (range 335,000–1,635,000), with injecting
drug use appearing as the primary mode of
transmission of HIV in Bahrain, Iran and Libya.
• With 80% of the global opium production
occurring in Afghanistan, and the price of heroin
markedly lower than in other parts of the world,
the geographical location of many of the
surrounding territories means that injecting drug
use remains high.

47. Middle East and North Africa
• Six MENA countries provide OST to different degrees:
Bahrain, Iran, Israel, Lebanon, Morocco and United Arab
Emirates.
• In some countries such as Bahrain and the United Arab
Emirates, OST is only available through detoxification and
rehabilitation facilities, with people who inject drugs being
reached through post-rehabilitation or prison programmes.
• In other countries, OST provision is not based on punitive
measures or rehabilitative/detoxification programmes e.g.
Iran, where OST is offered to people who inject drugs in
4,275 centres, 4,038 of which are privately operated. This
represents an increase of 902 sites since 2012.

48. Sub-Saharan Africa

49. Sub-Saharan Africa
• An estimated 23.5 million people are living with
HIV in sub-Saharan Africa, representing 69% of
the global HIV burden.
• In 2012, 75% of all new HIV infections globally
occurred in the region.
• Although reliable information on injecting drug
use in sub-Saharan Africa is very limited,
estimates suggest that there may be 1,020,000
people who inject drugs, with an extremely wide
range of between 300,000 and 6,240,000, of
which 5 to 10% are thought to be living with HIV.

50. Sub-Saharan Africa
• OST remains largely unavailable throughout
Sub-Saharan Africa, with the exception of
Mauritius, where over 6,000 people access
services, and newly initiated programmes in
Tanzania.

51. Policy
• World drug trade $320 billion (UN, 2013)
– 0.9% Global GDP
• Over $100 billion spent on drug control and
enforcement
• $160 million on harm reduction
– IHRA campaign to redirect 10% of drug control
budget to harm reduction by 2020

52. 10 by 20 Campaign
• Advocate for a new focus on
harm reduction in the global drug
policy regime, and for increased
harm reduction funding to ensure
that HIV targets can be met.
• Endorse a rebalancing of funding
that prioritizes health, human
rights and harm reduction, by
reallocating funds from
ineffective punitive responses.
• Ensure that health, human rights
and harm reduction are central
pillars in the high-level debate
and in the lead up to the 2016
UNGASS on Drugs.

53. References
• United Nations Office on Drugs and Crime, World Drug
Report 2014 (United Nations publication, Sales No.
E.14.XI.7)
• Global Commission on HIV and the Law: Risk, Rights and
Health (UNDP, 2012)
• Eurasian Harm Reduction Network (2012)
pag.aids2012.org/PAGMaterial/PPT/1377_2717/final.pptx
• Substitution maintenance therapy in the management of
opioid dependence and HIV/AIDS prevention : position
paper / World Health Organization, United Nations Office
on Drugs and Crime, UNAIDS (2004)
• The Global State of Harm Reduction 2014 (Harm Reduction
International, 2014)

54. Thank you