© Borgis - New Medicine 4/2012, s. 131-141
*József Rácz1, 2, 3, Ferenc Márványkövi1, 2, Katalin Melles1, Zsolt Petke2, 4, Viktória Vadász3, István Vingender4
Methadon maintenance treatment programs in Hungary: Treatment, Harm Reduction and Social Control
1Eotvos University, Institute of Psychology, Budapest, Hungary
Director of Institute: Dr Zsolt Demetrovics, PhD
2Department of Addiction Medicine, Semmelweis University, Faculty of Health Sciences, Budapest, Hungary
Dean of Faculty: Dr Judit Mészáros, PhD
3Blue Point Drug Counselling and Outpatient Centre, Budapest, Hungary
Director: Prof. Dr Jozsef Racz, PhD, DSc
4Doctoral School, Semmelweis University, Faculty of Health Sciences, Budapest, Hungary
Program coordinator: Prof. Dr István Szabolcs, PhD, DSc
5Semmelweis University, Department of Social Sciences, Faculty of Health Sciences, Budapest, Hungary
Dean of Faculty: Dr Judit Mészáros, PhD
There are three drug policy strategies for methadone maintenance treatment programmes: treatment, harm reduction and social control. In this study we examine the Hungarian methadone maintenance treatment programme. Our objective is to arrive at recommendation that can also be applied to other countries in Central and Eastern Europe, where these types of treatment do not currently exist. Patients and experts from all eight Hungarian clinics performing maintenance treatments were included in the research. The patients’ group was made up of 150 individuals, and the group of experts consisted of two professionals from each of the treatment facilities.
On the basis of our research observations we recommend the “opening up” of the maintenance system, as well as an approach that accords with the principles of treatment and harm reduction. These conclusions can be applied to other countries in the region, which had similar historical, political and professional policy factors in the past.
In this study we evaluate the national methadone maintenance treatment (MMT) programme of Hungary, a member of the European Union situated in central Europe (with a population of 10 million). Our main objective is to examine to what extent the Hungarian National Guidelines for MMT (1) are kept. Another aim of the paper is to explore to what extent clients of the programme are satisfied with the treatment and whether their treatment needs have been met properly. On the basis of the results, we will briefly make an attempt to determine whether the harm reduction paradigm is successfully being carried out in MMT in Hungary. The relevance of this study can be explained by the fact that MMTs, apart from a few exceptions, in the Central and Eastern European regions are less common and have a shorter operation history in comparison with Western European and overseas countries, whereas risky behaviours associated with intravenous use are relatively common in the Central and Eastern European regions (2-6). Another relevance of the study is that apart from one evaluation project (7), the Hungarian MMT had not been evaluated before.
Across the Eurasian region, all but five countries and territories have some form of Opioid Substitution Therapy (OST) provision. Programmes will soon begin operating in Tajikistan and Kosovo, but in Russia, Turkmenistan, Kosovo and Uzbekistan (where a pilot OST site was shut down in June 2009) OST is not available. Even in regions where programmes exist, OST is accessible to less than 5% of opioid users, with some exceptions in Croatia, Slovenia, Hungary and the Czech Republic. In Eastern Europe and Central Asia, only 1% of people who inject drugs are reported to be receiving OST and OST programmes have generally remained at the pilot stage rather than systematically scale up (8).
The experience gained from our study can also be used in these countries where HIV infection related to intravenous heroin use has reached an extremely high rate (in contrast to Hungary where HIV infection among injecting drug users are less than 1% (9)). The connection between HIV and injecting drug use are studied widely (e.g. 6, 10-15).
A EuroHIV (2007) report stated that “n many western and central European countries, HIV prevalence is low and the proportion of new HIV diagnoses reported among IDU is <10% and decreasing” (16, p. 12). Furthermore, “n some countries in the East, the HIV epidemic started to spread intensively more than a decade ago, and large and increasing numbers of new HIV diagnoses in several countries may reflect possible continuing transmission of HIV in this population, especially among younger IDU. In the East, increasing heterosexual HIV transmission partly is attributed to IDU partners” (16, p. 13).
Regarding HCV infection, in Hungary this rate in Budapest (the capital of Hungary with a population of two million residents) is around 35%, while elsewhere in the country it is under 20% (6, 17-23).
In the following section we will take a brief look at three different drug policy paradigms that are applied in MMTs worldwide.
Medical Treatment – Brain Disease Model
According to proponents of the medical treatment – brain disease model MMT is a medical treatment (24-27) and/or addiction is a brain disease (28, 29). The understanding of drug dependence as a “chronic disease” is represented most markedly by McLellan et al. (30). The summaries and international recommendations cited in what follows interpret MMT within the context of the medical disease model and the treatment paradigm (31-35).
In those countries where MMT is considered a medical treatment, programmes have high threshold (36) as the admission criteria are strict. In Norway for example, the programmes are the part of the general health care and social services. The strict rules did not prevent the quick spread of the programme, or the inclusion of heroin users in Norway (36).
Harm Reduction as a Public Health Model
The Harm Reduction (HR) model is only slightly different from the treatment model. The literature on HR emphasizes different areas of drug use and its consequences in relation to MMT. The difference is slight in many cases because the same authors or international organizations employ both the “treatment” and the HR terms for MMT (or for other substitution therapies). Despite this, for didactic reasons, we strive to separate the two models from one another as much as possible.
Single (1995), who defines harm reduction as programmes “which attempt to reduce the harm associated with use, without the user giving up his or her use at the present time” and explicitly points out that “conceiving of harm reduction in this way means that abstinence-oriented programs would not be considered harm-reduction measures” (37). The objective of the HR model is not achieving abstinence outside of methadone, but the reduction of individual and social harm related to heroin use (primarily infectious diseases, criminal behaviour, use of needles and drug mortality, etc.).
MMT (or more precisely opioid substitution therapy, OST) is one of the main forms of intervention for HR (8, 38). The experts of the European Monitoring Centre on Drugs and Drug Addiction place MMT within the context of HR, or the “new” public health approach (39). The Joint United Nations Programme on HIV/AIDS WHO, UNODC, & UNAIDS (2009) consider substitution therapies to be a “core set of HR” (40).
European programmes, and in particular the Dutch or Swiss maintenance programmes, are of this type (36, 39, 41). The programme presented by Millson et al. (2007) operates in Canada, within a needle exchange programme. The majority of the patients are recruited from amongst the visitors to the needle exchange programme, for whom this is a step “forward” towards more intensive programmes with a higher threshold. Sweden for example has moved from the restrictive (“high threshold”) model to a more tolerant (low threshold, public health) model, increasing the number of participants in MMT (and in buprenorphine treatment) (42). This has resulted in better retention and the reduction of certain kinds of harm related to heroin use.
Trautmann et al. (2007) reviewed the Slovenian methadone maintenance treatment system. This study is the closest to our study in terms of both the approach and the method, and because, like Hungary, Slovenia is a post-socialist country in central Europe (43). The aspects that they examined were related, in part, to the professional, political and ideological background of methadone treatment, they also characterized the treatment system and studied patient’s satisfaction in relation to methadone programmes. At the end of the research the authors did not emphasize the critical elements of the therapeutic system, but instead formulated recommendations on how it could be operated more effectively.
MMT as Social Control
In Keane (2009), MMT is analyzed, in a Foucaultian manner, as a regulatory technology that aims to create productive and obedient subjects. According to Keane, “[w]e can emphasise the social control of drug users through MMT” (44). This train of thought is expanded upon by Saris’s (2008) Irish example, where MMT is a part of governance, primarily for socially excluded populations (the author also examines how these populations construct a political or psychiatric drug discourse) (45). On the basis of street ethnographic studies, Bourgois concludes that:
[MMT] is an expression of the competition of contradictory discourses: the criminalizing and healthiest versions of biopower that dominate in law enforcement, and popular culture, versus the ‘addiction-is-a-disease’ model that prevails in the biomedical establishment and emphasizes the pharmacological control of bodies. This contradiction is reflected in the imposition by the legislature of repressive legal regulations that discourage high dosage prescriptions of methadone despite the emphatic consensus of federally-funded drug researchers that the biggest problem with most methadone clinics is the inadequately low doses they administer (70).
MMT in Hungary
According to the Hungarian national drug strategies in 2009 and in 2000 (46, 47), MMT is primarily a HR, low threshold service, while according to the methodological policies developed by the profession (1, 48) it counts as treatment. While there is not a sharp differentiation between these two approaches, the two documents (the National Drug Strategy and the guidelines developed by the College on Addictions, 2009) define MMT as a different drug policy tool. The first methadone treatment in Hungary was initiated in 1987, but it only became professionally and politically accepted in 2001 (49).
Participants in Substitution Treatment in Hungary
Following an initial increase in the number of patients, after 2005 their number did not increase; the financing system reached the boundaries of its capacity (tab. 2). Suboxone substitution treatment, an alternative to methadone, began in 2007. It has several traits that make it preferable to methadone (50). In 2009 a total of 638 patients were given MMT, while another 354 patients received a combined buprenorphine+naloxone therapy (20). A total of 57% of patients were treated at a single centre in the capital (20). MMT can only be offered in special outpatient centres that deal with alcohol and drug dependency. Methadone can only be prescribed by a psychiatrist or a doctor that specializes in addiction medicine (this latter qualification is generally acquired by psychiatrists). MMT is free, whereas buprenorphine-naloxone therapy represents a significant expense for patients – at Hungarian prices – and therefore cannot reach those that need it most (20).
Between 2003 and 2006 the number of patients participating in substitution treatment increased by 343%, and the 2006 figure then fell to 79% in 2008 (see table 1). Budapest has the greatest proportion of patients participating in MMT. In Budapest, there are two centres, the biggest is the the Nyírő Gyula Hospital Outpatient centre. This centre also collects and records the patients treated throughout the country (called National Methadone Register), using (since 2006) the Treatment Demand Indicator (TDI) (51).
Table 1. Participants in methadone substitution treatment.
| ||Budapest||Outside Budapest||Total|
|2003||249 (Annual average)||0||249|
|2004||N.A.||N.A.||377 (Annual average)*|
*80% from Budapest.
The Ministry of Health’s Guidelines for MMT on methadone treatment and the objectives of harm reduction drug strategy
These guidelines for MMT (1, 48) outline the diagnosis and treatment indication considerations necessary for methadone treatment (and thus for MMT too), as well as the features facilities must be qualified in providing MMT. The guidelines for MMT provide the registration of patients, the dose of methadone that can be given out (60-120 mg/day) and the amount that can be given out (and taken home). It also provides the other medical, health care and psychosocial services, as well as after-care. We have already mentioned the general objectives of the national drug strategies in 2009 and in 2000 as they relate to HR (46, 47).
Aim of the study
Our research objectives were as follows:
1. To examine to which extent the treatment principles laid down in the guidelines for MMT (48) are being successfully carried out in practice, and the extent to which the expectations related to HR are being met (on the basis of the National Drug Strategy, 2000-2009, 2009-2018 developed by the Ministry of Youth and Sports (2001); and Ministry of Social and Labour Affairs (2010).
2. To examine to what extent clients of theMMT are satisfied with the programme.
Material and methods
The data survey that we performed concerns two different target groups. The first group is the patients currently participating in a methadone maintenance treatment programme, the second is the directors of the programmes or the staff that provide methadone. A single data survey was given to both target groups.
The inclusion criteria for the patients were that they must be older than 18 and must fulfil the quotas for inclusion in the sample group. We determined the framework for the sample of patients on the basis of the substitution data for 2008. This contained the information on the proportions of patients on methadone maintenance in the national treatment locations in 2008, and the ratio of men to women at the given treatment locations. The examiners at the given treatment locations selected the patients at random. Of all the treatment locations, patients from three locations in the capital and five locations from elsewhere in the country were included in the sample group (tab. 2).
Table 2. The distribution of individuals included in the sample according to their treatment location and gender.
|Treatment location||Male||Female||Total |
|Budapest, Nyírő Gyula Hospital||59||19||78|
|Soroksár Methadone Centre||18||5||23|
|Miskolc Outpatient centre||13||1||14|
|Pécs Outpatient centre||2||1||3|
|Szeged Outpatient centre||13||5||18|
|Veszprém Outpatient centre||2||1||3|
|All treatment locations||115||35||150|
Note: Interviews were conducted with two professionals from each of the treatment locations listed in this table.
During the course of study, 150 patients were included in the sample group and a data survey was performed on 16 directors or professionals that provided methadone. Interviews took place at the treatment locations. Before beginning the survey we pilot tested the patient questionnaire with five clients. Following this, the questionnaires for both the patients and the professionals started at the beginning of August 2009 and concluded at the end of November 2009. We performed the analysis of the results with the aid of SPSS. The ethics permit was issued by the Joint Psychological Research Ethics Committee (chairman: Dr. Gergely Csibra).
The research we performed through the questioning of the target groups was carried out with the aid of two questionnaires. When developing the questionnaires (for the patients and the professionals) we used the “Evaluation of Self and Treatment” questionnaire (TCU Methadone Outpatient Form) (52) and the questionnaires used in the study by Trautmann et al. (2007) as a basis.
1. The patient’s satisfaction questionnaire (hereafter the patient’s questionnaire) was made up of 16 pages of questions, which took approximately 40-50 minutes to answer. The main sections of the patient’s questionnaire were: accessibility; the amount of and the frequency with which the methadone provided was used; the conditions of take-home methadone; rule violations through the failure to use it; attitudes to the staff providing methadone; information and sanctions related to following the protocol; and the health, social and psychosocial changes experienced by the patients.
2. The interview of the professionals was a 21 page questionnaire, which took approximately 60-90 minutes to complete. During the course of the questioning, the professional evaluated the programme. The main sections of the professional’s questionnaire were: description and characteristics of the organization; the content characteristics of the service; the professional staff; criteria of success; and knowledge of the guidelines for MMT.
During the course of the interviews, the patients were asked to provide their TDI code to avoid duplication of interviews (53). The TDI identification number (a number generated using the patient’s name and birth date) made the survey data anonymous insofar as it does not identify the individual. The examiners participating in the research were practicing social workers.
The Major Socio-demographic Characteristics of the Sample (see table 3)
Table 3. The socio-demographic characteristics of the sample (N = 150), in percentages.
| ||Number of Cases||Percentage|
|18-29 years old||40||26.7|
|30-39 years old||80||53.3|
|40-49 years old||25||16.7|
|50+ years old||5||3.3|
|Living with parents||40||26.7|
|Raising children alone||4||2.7|
|Living with a partner (as a couple)||40||26.7|
|Living with a partner and children||18||12|
|Living with friends||5||3.3|
|In an institute (prison, clinic) ||0||0|
|Regularly employed ||45||30|
|Highest educational degree|
|Did not attend/did not complete eight years of primary schooling ||2||1.3|
|Primary school diploma||47||31.3|
|Secondary school diploma||89||59.3|
|Citizen of an EU member country||0||0|
The major socio-demographic characteristics were as follows. The sample group comprised of 76.7% males and 23.3% females. The average age in the sample was 33.8 years old. The largest group in the sample (26.7%) lived with parents or a companion (as a couple). The next largest groups were those living alone (24%) and those living with a companion and children (12%). The overwhelming majority in the sample (92%) lived in stable conditions. Every individual in the sample was a Hungarian citizen. A total of 40% stated that they were unemployed, while 30% had regular employment. A total of 14% were economically inactive, and another 14% had some other employment status. The majority (59.3%) had a secondary school diploma, while 31.3% had finished primary school and 6% had a higher educational degree.
Drug Use Characteristics
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