Bosnia and Herzegovina

The addictions in Bosnia and Herzegovina still have the same trend of increasing as one of the consequences of recent war.

Methadone treatment was first opened in Bosnia and Herzegovina in 1989. During the war time this system was destroyed, and it is renewed in 2002.

Methadone detoxification programs exist only in Sarajevo for the whole state, while methadone maintenance exist in Sarajevo, Mostar, Zenica, Sanski Most, Bihac and Doboj.

The treatment is performed only in Sarajevo according to the EUROMETH guidelines, and this center currently has 176 clients. This all means that there is expansion of the program at the state level, and the causes for that are different. One is the increase in the number of addicts, and secondly there are more addicts who wish to have treatment.

In city of Tuzla there are some attempts to implement the treatment with Buprenorphine, but this program is still not operational. The reason why we don't use the antagonist is because of the high costs of the treatment, and because these medications are not on the positive list of our Ministry, which means that patients must pay the full cost.

Recently at the state level new law about the drug abuse reduction is been adopted, but unfortunately we still don't have unique strategy of prevention. There are preventive programs in certain regions, cantons and they are implemented base on the economic power of the community that made it.

In general, among youth, there is more and more interest for psychostimulants and alcohol beside opiates and this is a consequence of black market availability.

Nermana Mehic-Basara, M.D.

Bulgaria

Overview
Bulgaria is a country situated in the southeast part of Europe over a territory of 111.000 sq. km. The population at present is close to 8 million.

The drug problem started to increase rapidly since the early 90's. The estimated number of heroin addicts is 25,000 - 30,000, over 70 % are positive for Hepatitis C, the incidence of HIV among heroin users is very low.

History
The first MMP in Bulgaria opened on November 15, 1995 and in two years increased to 200 patients. Although for a period of 8 years, it remained the only one in the country.

As a result of sustained professional efforts to promote and develop methadone maintenance treatment as a central component of the national treatment system, the national policy was reconsidered. Four new programs opened in 2003 and 2004 and the Bulgarian Methadone Treatment Association was established.

The N. of treatment slots reached 770 by the end of 2005.

Treatment models
There is a variety of services and treatment philosophy, from low-threshold substitution to comprehensive treatment and high-quality therapy oriented programs.

Training and qualification requirements
All chief doctors of MMP are psychiatrists with specialized training in addictions and methadone maintenance treatment.

Trends
Increased professional and public interest for the last 2 years.
Five new programs expected to open in 2006.

Submitted by Dr. Alexander Kantchelov, M.D.

Mexico


Three primary organizations provide medication assisted treatment to the opioid dependent using methadone. Additionally, several solo practitioners operate within their private practices.

International coordination of treatment for temporary and permanent patient participation can be accessed through the following providers using the current AATOD guest medication protocol.

Current Status
Efforts initiated in 1990 with the Mexican Department of Health culminated in 1994 with the opening of clinics in the border cities of Tijuana and Mexicali in the State of Baja California. These were the first clinics using methadone to treat the opioid dependent in Latin America.

Twelve (12) years of struggle has realized the development of over 22 clinics throughout seven (7) states and the Federal Department of Mexico City currently serving over 2,500 patients. The clinics operate on a fee for service basis only; are separately owned and administered; offer an array of primary and ancillary medical services; and network cooperatively through MATOD, the Mexican Association for the Treatment of Opioid Dependent.

Basic Services Available:

* Addiction Assessment
* Primary Medical
* Psychiatric Consultation
* Therapeutic Counseling
* Anti-Doping
* Pain Management (Intractable)
* Suboxone/Subutex (Buprenorphine) - on demand

Development Problems
The initial development problem consisted first of the principle of
pre-emptive response to the anticipated epidemic of heroin addiction. Therein followed the problems of education, awareness, acceptance and the lack of objective data, governing regulations and the prevailing bias for the importation of methadone for medical use. After overcoming these initial problems it was mutually agreed by the pioneering providers and the Department of Health that the protocols would follow the existing guidelines of the U.S. Food and Drug Administration.

History
The 1970s and the 1980s experienced the transport of heroin from Latin America over and around Mexico into the United States, relieving Mexico of the ready availability of heroin. The late 1980s and early 1990s evidenced the introduction of heroin from the U.S. into the Mexican border communities thus beginning the current instability.

The 1990's advent of the Mexican narco-cartels' has resulted in the
marketing along expanding transportation routes, spreading its availability to the broader population. This expanding market is anticipated to reach epidemic proportions with its historically documented impacted.

Submitted by:
Mexican Association for the Treatment of Opioid Dependency (MATOD)
Emilia Figueroa, M.D.
Galen E. Rogers, M.S.

Sweden

I was the leader of a National Swedish Methadone Programme for 23 years (1966-1989). We had a yearly retention rate of 80-100% (mean 90%) and a vocational rehabilitation rate of 70 -84%. When I retired in 1989, this programme was split between 4 regions and in 1990, the National Board of Health altered the treatment goal and sent out instructions recommending short-term treatment, instead of the earlier long-term treatment policy. This resulted in a rapid rise in mortality rates among Swedish heroin addicts and a drop in vocational rehabilitation. The new short-term treatment was not specified as a defined number of years or months, but repressive elements were introduced and patients are expelled from treatment on various pretexts (for instance if they had positive urine tests). Methadone doses were reduced as a punishment for not being in time at the methadone clinic (between 9-10 a.m. patients receive their full dose; between 10 and noon they receive half the dose and those who show up later get no dose). All patients have to deliver urine samples under supervision, even patients who are working and self-supporting since decades. I am presently trying to achieve a debate around this sad development and if possible a return to our earlier policy.

Submitted by Lars Gunne, M.D.