Выступление Мартина Коймана на IV съезде Независимой наркологической гильдии об истории внедрения заместительной терапии в Голландии, а также некоторые полезные соображения о плюсах и минусах ОЗТ и реабилитации зависимых.

1. Methadone and Drug FreeMethadone and Drug Free
Therapeutic CommunitiesTherapeutic Communities
Limitations and OutcomesLimitations and Outcomes
Moscow, 4 December 2015Moscow, 4 December 2015
Martien KooymanMartien Kooyman M.D., Ph.D.M.D., Ph.D.

5. orientation
methadone detox day centre
project 4
T.C.
Emiliehoeve
T.C.
Mistral
T.C.
Triple-Ex
re-entry

7. ““PPerhaps the limitations of medicalerhaps the limitations of medical
treatment for complex medical-socialtreatment for complex medical-social
problems were not sufficientlyproblems were not sufficiently
stressed. No medicine canstressed. No medicine can
rehabilitate persons. But to succeedrehabilitate persons. But to succeed
in bringing disadvantaged addicts to ain bringing disadvantaged addicts to a
productive way of life, a treatmentproductive way of life, a treatment
program must enable its patients toprogram must enable its patients to
feel pride and hope in acceptingfeel pride and hope in accepting
responsabilityresponsability””

8. Heroin addiction is a symptom of an
underlying psychological and/or social
problem.
Substitution with methadone does not
solve these underlying problems

9. Definition of addictionDefinition of addiction
Addiction is a self-continuing harmfulAddiction is a self-continuing harmful
process resulting from the loss ofprocess resulting from the loss of
control over adaptive behaviour whichcontrol over adaptive behaviour which
then itself becomes a problemthen itself becomes a problem

10. Definition of addiction
Addiction is a dependency disorder from which
recovery is possible

11. Calling addiction a chronic relapsing disease
gives practicioners an excuse for failing treatment
and creates a lack of motivation among addicts
and primary care physicians

17. 50% of heroin addicts were
involved in criminal behaviour
before they used their first drug

18. Because heroin use is illegal, serious
secondary problems exist.
It is questionable if prohibition solves
more problems than it produces

19. Drug addicts are aDrug addicts are a
nuisance to others, sonuisance to others, so
- force them to give up drugs- force them to give up drugs
- lock them up- lock them up
- supply free drugs- supply free drugs
- shoot them- shoot them

20. All addicts should be reached by treatment

21. All addicts should be given methadone

23. Profits from methadone and crime

24. Drug Related Deaths in Scotland Linked to
Methadone
year Total Number
of Addict
Deaths
Total Number
of Methadone
Related Deaths
% of Total
Deaths linked to
Methadone
2004 356 80 22
2005 336 72 21
2006 421 97 23
2007 455 114 26
2008 54 169 29
2009 545 173 32
2010 485 174 35
2011 584 275 47
2012 581 237 40
www.drugmisuseresearch.org
Centre for Drug

25. 2007 National Treatment Agency Client Survey
England n=12,398
Drug Happy with Use Like to Reduce
Use
Like to Stop
Using
Heroin 11.4 8.1 80.5
Methadone 36.5 12.9 50.7
Crack Cocaine 16.3 10.5 73.2
Amphetamines 27.5 11.4 61.0
Cannabis 64.2 14.7 21.1
Alcohol 53.6 21.2 25.2
Benzodiazepines 50.4 12.7 36.9
Centre for Drug Misuse Research
Scotland

26. Only methadone substitution
programmes with sanctions regarding
illegal drug use have positive effects on
criminality

27. Qualities of methadone programsQualities of methadone programs
- Methadone maintenance makes clientsMethadone maintenance makes clients
no longer dependent on black marketno longer dependent on black market
- Structured methadone programs canStructured methadone programs can
improve re-socializationimprove re-socialization
- Methadone can be a first step towardsMethadone can be a first step towards
further treatmentfurther treatment
- Structured methadone programs are cost-Structured methadone programs are cost-
effectiveeffective

28. Limitations of methadone programsLimitations of methadone programs
- Methadone can only be used for heroinMethadone can only be used for heroin
addictsaddicts
- Availability of methadone postpones theAvailability of methadone postpones the
decision to stop using and entering a drugdecision to stop using and entering a drug
free programfree program
- Harm reduction programs without furtherHarm reduction programs without further
rehabilitation are expensiverehabilitation are expensive

29. Unintended harm caused by methadoneUnintended harm caused by methadone
- Deaths in combination with alcoholDeaths in combination with alcohol
- Sudden deaths through heart arrhytmiasSudden deaths through heart arrhytmias
(doses higher than 100 mg)(doses higher than 100 mg)
- Availability of methadone postpones theAvailability of methadone postpones the
decision to stop using and entering a drugdecision to stop using and entering a drug
free programfree program
- Life longe Methadone programs withoutLife longe Methadone programs without
further rehabilitation are expensivefurther rehabilitation are expensive
- Selling of methadone to othersSelling of methadone to others

30. Contra indications for methadoneContra indications for methadone
prescriptionprescription
- Heavy alcohol useHeavy alcohol use
- Below 21 yearsBelow 21 years
- Continuing use of opiods or other nonContinuing use of opiods or other non
prescribed drugsprescribed drugs
- No prior detoxification attemptNo prior detoxification attempt

32. СамопомощьСамопомощь
ВзаимопомощьВзаимопомощь
Ответственное отношениеОтветственное отношение

33. Значимость ролевых поведенческих моделей,Значимость ролевых поведенческих моделей,
реализуемых более старшими резидентами иреализуемых более старшими резидентами и
штатными сотрудниками,штатными сотрудниками,
имеющими опыт аддиктивности в прошломимеющими опыт аддиктивности в прошлом
The importance of role models of older residentsThe importance of role models of older residents
and ex addicts in the staffand ex addicts in the staff

34. Только ТЫ САМ можешь сделать это,Только ТЫ САМ можешь сделать это,
но ты не сможешь сделать это ОДИН, безно ты не сможешь сделать это ОДИН, без
поддержкиподдержки
You alone can do itYou alone can do it
but you can not do it alonebut you can not do it alone

35. Медицинская модельМедицинская модель
Medical ModelMedical Model
врачврач
doctordoctor
пациентпациент
patientpatient
Врач несет ответственность за лечениеВрач несет ответственность за лечение
The doctor is responsible for the treatmentThe doctor is responsible for the treatment
Пациент не отвечает за свое заболеваниеПациент не отвечает за свое заболевание
The patient is not responsible for the diseaseThe patient is not responsible for the disease

36. George De Leon
Собственность
Наш дом
Ownership
Our House

37. Все виды деятельности, которые выполняютсяВсе виды деятельности, которые выполняются
в Терапевтическом Сообществе, включаяв Терапевтическом Сообществе, включая уборку,уборку,
приготовление пищи,приготовление пищи,
организационные вопросы – являются терапиейорганизационные вопросы – являются терапией
AAll T.C. activities includingll T.C. activities including
cleaning, cooking andcleaning, cooking and
administration areadministration are
therapytherapy

39. Обучение умению
помогать самому себе
с помощью других людей
learning to help yourself
with the help of others

40. ГОВОРИ О ТОМ,ЧТО ЧУВСТВУЕШЬ,
И
ПРОЧУВСТВУЙ ТО, О ЧЕМ ГОВОРИШЬ
say what you feel
and feel what you say

41. «Группы столкновений»
Encounter groups

43. Отношение к гневу
юмор
angry concern
humor

44. В Терапевтическом СообществеВ Терапевтическом Сообществе
участникиучастники
могут обрестимогут обрести самоощущение,самоощущение,
благодаря которому получают возможностьблагодаря которому получают возможность использовать своииспользовать свои
собственные внутренниесобственные внутренние ресурсы,ресурсы,
находясь при этомнаходясь при этом
в безопасной и стимулирующей средев безопасной и стимулирующей среде
и следуя здоровому образу жизнии следуя здоровому образу жизни
In the therapeutic communityIn the therapeutic community
residents can find a sense of self from which they can use their ownresidents can find a sense of self from which they can use their own
power in a safe and stimulating environment promoting a heathy life

45. Терапевтическое Сообщество дает людям с разрушеннойТерапевтическое Сообщество дает людям с разрушенной
идентичностьюидентичностью
шанс на преодоление своего страхашанс на преодоление своего страха
близких контактов и отверженностиблизких контактов и отверженности посредством коррекциипосредством коррекции
состояния эмоциональной сферы и повышения самооценки,состояния эмоциональной сферы и повышения самооценки,
делая их способнымиделая их способными выстраивать стабильные отношениявыстраивать стабильные отношения
The therapeutic community gives people wth a failure identityThe therapeutic community gives people wth a failure identity
a possibility to overcome their feara possibility to overcome their fear
of closeness and rejection through corrective emotional experiences and increase their selfof closeness and rejection through corrective emotional experiences and increase their self
esteem enabeling them to have stable relationshipsesteem enabeling them to have stable relationships

46. Терапевтическое сообществоТерапевтическое сообщество являетсяявляется
терапевтическим по сути.терапевтическим по сути.
Сообщество – это метод.Сообщество – это метод.
The therapeutic community isThe therapeutic community is
therapeutic in itselftherapeutic in itself
The community is the methodThe community is the method

48. Criteria for successCriteria for success
- no use of hard drugs- no use of hard drugs
- no alcohol problems- no alcohol problems
- less than once a week cannabis,- less than once a week cannabis,
tranquillizerstranquillizers or sleeping pills usedor sleeping pills used
- no drug related arrests or convictions- no drug related arrests or convictions
- no treatment for addiction- no treatment for addiction
- no admission to a psychiatric hospital- no admission to a psychiatric hospital

49. EH
N= 172
ES
N= 47
NA
N= 62
N
Success
85 20 10
% 49,4 42,6 16,1
Success half year before interview ofSuccess half year before interview of
all clients two years out of programall clients two years out of program
with follow-upwith follow-up

53. Вовлеченность родителей в работу (ВР) позволяет
добиться более продолжительного пребывания на
программе (БПП) и делает ее более
результативной и успешной (РУ)
Parent participation (PP) is related to longer time in the
programme (TIP) and gives therefore more successful
outcome (SO)
ВР
PP
БПП
longer TIP РУ
more SO

54. Triple ExTriple Ex
- ex-addict- ex-addict
- ex-unemployed- ex-unemployed
- ex-prisoner- ex-prisoner

56. Relapse after Triple-Ex
(FU of 116 ex-clients (76%) after average 2 years)
No relapse: 41%
< 1 month: 3%
1-3 months: 7%
3-6 months: 4%
> 6 months: 45%
period of drug useperiod of drug use
after Triple-Exafter Triple-Ex
91% received after care

57. Social integration after Triple-ExSocial integration after Triple-Ex
(FU of 116 ex-clients (76%) after average 2 years)
Dominant social situationDominant social situation
- study- study 7%7%
- job (part/full-time)job (part/full-time) 47%47%
- unemployedunemployed 31%31%
- disabillity allowancedisabillity allowance 4%4%
- residential treatmentresidential treatment
or prisonor prison 11%11%

58. Social integration after Triple-ExSocial integration after Triple-Ex
(FU of 116 ex-clients (76%) after average 2 years)
Crime after dischargeCrime after discharge
Arrests after dischargeArrests after discharge (before admission)(before admission)
dealing drugsdealing drugs 8%8% (55%)(55%)
stealingstealing 36%36% (92%)(92%)
violenceviolence 14%14% (49%)(49%)
Month before interviewMonth before interview
illegal activitiesillegal activities 17%17%
detention, prison 19%detention, prison 19%

59. 5 year follow-up Donovan Prison
Program - Amity TC California
0
10
20
30
40
50
60
70
80
90
% Gearresteerd
83
86
42
Contr gr Gev. TG Gev. TG+ nazorg TG
(Prendergast, c.s., 2004)

60. EH
N= costs benefits
a year 1,500,000
after care 300,000
in-/out 60
in treatment 30 1,200,000
success yr 1 20 800,000
success yr 2 18 720,000
success yr 3 16 640,000
success yr 4 12 480,000
long success 12 1,440,000
total 1,800,000 5,280,000
C-B ratio 2.9
total before 50,000
after 10,000 (success)
long = 7 yr
Cost-Benefit Ratio Emiliehoeve TCCost-Benefit Ratio Emiliehoeve TC

61. Benefits each per yearBenefits each per year
EmiliehoeveEmiliehoeve 3,5 million Euro3,5 million Euro
Triple-ExTriple-Ex 3,5 million Euro3,5 million Euro

62. Longer term success
4 year follow-
up of
Treatment
Leavers
2005/06
(n= 41,475)
NDTM
S
CJS:
Prison &
Commun
ity
Drug
Test
Did not
re-
present
54%
46%

63. What constitutes successful treatment? (present)

64. Contra indication for TherapeuticContra indication for Therapeutic
communitiescommunities
- Non drug related psychosisNon drug related psychosis
- (Need double diagnosis TC or psychiatric(Need double diagnosis TC or psychiatric
clinic)clinic)

65. Qualities of drug free T.C.’sQualities of drug free T.C.’s
- T.C.’s can treat clients addicted to any drugsT.C.’s can treat clients addicted to any drugs
- 30% of all admissions have a successful long term30% of all admissions have a successful long term
outcomeoutcome
- Longer time spent in the program improvesLonger time spent in the program improves
outcome successoutcome success
- Parent participation improves successful outcomeParent participation improves successful outcome
- Treatment in a T.C. can be an alternative for prisonTreatment in a T.C. can be an alternative for prison
- Treatment in a T.C. is cost-effectiveTreatment in a T.C. is cost-effective

66. Limitations of drug free T.C.’sLimitations of drug free T.C.’s
- Highly structured programs are notHighly structured programs are not
popular with the addicts and helperspopular with the addicts and helpers
- High drop-out rate in first monthsHigh drop-out rate in first months
- Not all addicts can sustain the pressure ofNot all addicts can sustain the pressure of
a T.C.a T.C.

67. Minimun Standards of drug free T.C.’sMinimun Standards of drug free T.C.’s
- Basic rules:Basic rules:
No Drugs No Alcohol No Violence or Threat of ViolenceNo Drugs No Alcohol No Violence or Threat of Violence
Breaking can lead to dischargeBreaking can lead to discharge
-- A job structureA job structure
-- Groups on behavior here and nowGroups on behavior here and now
- Consequences for negative behaviorConsequences for negative behavior
- Clear procedures for admission andClear procedures for admission and dischargedischarge
- Meetings for parents and relativesMeetings for parents and relatives
- Develop a staement on the philosophy of the programDevelop a staement on the philosophy of the program
- Protection from negative use of powerProtection from negative use of power

68. Best Practices of drug free T.C.’sBest Practices of drug free T.C.’s
- Specific groups: (, extended groups (marathons, thematicSpecific groups: (, extended groups (marathons, thematic
groups, separate groups for females and males,groups, separate groups for females and males,
mindfulness, peer groups, (dynamic) meditations,mindfulness, peer groups, (dynamic) meditations,
psychodrama, bonding groupspsychodrama, bonding groups
- Family therapyFamily therapy
- Sport, outward bound activitiesSport, outward bound activities
- Education classesEducation classes
- CreativityCreativity
- Separate re-entry program and after care- Separate re-entry program and after care
- Training and adequate supervision for staffTraining and adequate supervision for staff
- Accountability to an external or community boardAccountability to an external or community board
- Evaluation of the programEvaluation of the program
- AA and NA meetings- AA and NA meetings

69. Harm reduction is not treatment.
Treatment is harm reduction

70. Treatment in any form will never solve
the total drug problem

71. Treatment is cost effective and
part of the solutoion

72. Thank you