A-Clinic Foundation Seminar-Lisbon 2017 Associação Ares do Pinhal Mobile Outreach Programme – Lisbon* MOP-L * funded by SICAD-Ministry of Health (80%) and the Lisbon Municipality (20%)
A-Clinic FoundationSeminar-Lisbon 2017
Associação Ares do Pinhal
Mobile Outreach Programme – Lisbon*
MOP-L
* funded by SICAD-Ministry of Health (80%) and the Lisbon Municipality (20%)
ASSOCIAÇÃO ARES DO PINHAL (NGO)
• Ares do Pinhal is a nonprofit NGO for social inclusion which has worked since 1986 with
severe drug users starting with a Therapeutic Community (TC) for residential long-term
treatment (12-18 months)
• Since then Ares do Pinhal has established a therapeutic apartment for social
reintegration (1990), a vocational school for community educators (1991), two more TC´s
(1992 and 1995) and a Mobile Outreach Programme in the city of Lisbon (MOP-L) for health
and social support of severe opioid drug users (2001)
MOP - Lisbon
In 1998 Ares do Pinhal was invited by the municipality of Lisbon to
manage an outreach harm reduction project within the urban
regeneration of a run-down and drug trafficking neighbourhood
(Casal Ventoso)MOP - Lisbon
Our start in Drug Addiction Harm Reduction Approach
URBAN INTERVENTION PLAN OF CASAL VENTOSO
In the nineties ±6000 drug users moved every day to Casal Ventoso to buy all
kind of illicit drugs (mostly heroine at that time)
±400 severe drug users lived in the vacant plots of the neighbourhood in
improvised shelters
Sharing of drug comsumption paraphernalia was common.
MOP - Lisbon
URBAN INTERVENTION PLAN OF CASAL VENTOSO
MOP - Lisbon
• Address the drug users who lived in improvised shelters in the vacant plots of the neighbourhood to
accommodate them in a temporary reception centre located near to the area
• Provide this population with basic health, food, hygiene, clothing, social care and acess to a Low
Threshold Methadone Programme by a multidisciplinary team working in a set of containers located
near to the area
• Referral to conventional outpatient (treatment centres) and inpatient clinics (Detox, CT)
URBAN INTERVENTION PLAN OF CASAL VENTOSO
OUR GOALS
1998-2000 (N=558)
HIV 340 (61%); HCV 441 (79%); TB 75 (14%) PWID (80%)
Never sought treatment before (90%)
MOP - Lisbon
URBAN INTERVENTION PLAN OF CASAL VENTOSO
URBAN INTERVENTION PLAN OF CASAL VENTOSO
➢ In 2001 the urban regeneration project was completed by the municipality
➢ However this intervention revealed that severe drug users have great dificulty in
acessing the conventional drug addiction treatment facilities and even more the health
and social public services
MOP - Lisbon
URBAN INTERVENTION PLAN OF CASAL VENTOSO
SEVERE DRUG USERS
Key issues to take into account
• Completely unaware of their health condition
• Repeated and compulsive self-administration of drugs of abuse become their
way of life and their purpose in life
• Deep sense of mistrust in health professionals and conventional health
services
MOP - Lisbon
URBAN INTERVENTION PLAN OF CASAL VENTOSO
The following slides shows how far some PWID are prepared to go
MOP - Lisbon
MOP - Lisbon
MOP - Lisbon
Urban Intervention Plan of Casal Ventoso
• What we saw and experienced in the late nineties in Casal Ventoso showed us the
need to reshape some established paradigms within the drug addiction treatment
perspective and rethink the approach to severe drug users
MOP - Lisbon
Paradigms
Drug Addiction Treatment Approach
Wait for the drug user
Wait for drug user motivation
Main goal → Stop drug(s) use
Drug Addiction Harm Reduction Approach
Go out and be closer to the drug users
Address all drug users
Main goal → Safer use of drug(s)
Transition to Outreach Work – 2001
Main guidelines
• Go out and be closer to the drug users – Facilities should be near the
drug users spots and/or easy to get to
• Address all drug users - Meet them in their territories in order to give
them safer drug use conditions (e.g. exchange of needles and syringes,
pipes or any other comsumption paraphrenalia) and become someone with whom
they can talk
• Main goal → safer use of drugs - To show that our aim does not concern
their use of drugs but the personal health problems and social impairment
they cause
MOP - Lisbon
Transition to Outreach Work - 2001
MOP - Lisbon
Mobile Outreach Programme – Lisbon*
MOP-L
*funded by SICAD - Ministry of Health (80%) and the Lisbon Municipality (20%).
The MOP-L has started in 2001 with the following principles
• A drug user centred harm reduction programme that uses mobile units for medical and
psychosocial care within the ambit of a low threshold methadone programme* in the city of
Lisbon
• To reach opioid drug users (with polydrug use or not) who, that for whatever reason, do not
access conventional drug addiction treatment centres or other health and social services.
*Low threshold methadone programmes do not demand abstinence of drugs of abuse (licit or illicit)MOP – L
Mobile Outreach Programme – Lisbon
• MOP-L is frequented every day by approximately 1200 heroin users (85% men and
15% women; Mage = 45,40, SDage = 8.09), many of whom are polysubstance users
(Cocaine; Alcohol; BZD)
MOP - Lisbon
Mobile Outreach Programme – Lisbon
• Users are mostly engaged in high-risk behaviours and many present personal disorganization,
physical impairment or disease, psychiatric disease, psychological vulnerability and social
exclusion
• A significant part of them are PWID
HIV 14%
HCV 55%
HIV+HCV 11%
PWID ±20%
Homeless ± 10%
(January 2017)MOP - Lisbon
Mobile Outreach Programme – Lisbon
What We(try to)Do
MOP - Lisbon
Mobile Outreach Programme – Lisbon
MOP - Lisbon
UserCentredCare
Low Threshold MethadoneProgramme
Judicial support
Social support
Referral Drug
addiction treatment centers
Health care
Mobile Outreach Programme – Lisbon
How we(try to)do it
MOP - Lisbon
Mobile Outreach Programme – Lisbon
Main aspects
Low threshold methadone programme, health care and psychosocial support
• Ease of access (proximity to problematic neighbourhoods or transport interfaces)
• Prompt response to any request for admission (if indicated)
• Simplified admission procedures
• Main concern toward abstinence symptoms and craving
• Abstinence of drugs use is not required
MOP - Lisbon
Mobile Outreach Programme – Lisbon
Patient´s Admission and Follow up In Programme
➢ The admission in programme is granted directly by the psychosocial professionals and the nurses in the
mobile units with an interview in order to assess clients physical and social situation and a urine
analysis for opiates (women also do urine analysis for pregnancy)
➢ Patients are informed of the services provided and the programme’s operating rules and sign anagreement form
➢ Unless otherwise indicated, methadone substitution programme will start at that moment
➢ Taking of methadone is on-site and in Directly Observed Therapy (DOT) and individual dosages follows
medical guidelines
MOP - Lisbon
Mobile Outreach Programme – Lisbon
Patient´s Admission and Follow-up In Programme
• In a short period of time he/she will be assigned a case manager who start the follow-up by being aware
of the major problems and/or needs of the user (health, social, judicial, etc.). Then step by step the
case manager will try to create the best achievable helping relationship
• Within the first month of the programme, patients are tested for transmissible diseases (HIV,
Hepatitis, Syphilis) in the MU´s and do an X-Ray (TB) in an X-RAY mobile unit which stops near the MU
spots twice a month
• While in programme users have access to regular medical and psychosocial assessments
MOP - Lisbon
Low threshold methadone programme
Methadone - basic principles
Pharmacokinetics
Methadone ≠ Heroine
• Methadone and Heroine are opioid substances but they are very different in
pharmacokinetics terms
Psychoactive substances
Pharmacokinetics issues of psychoactive substances of abuse in the brain
Quick onset of action
• The quicker the onset of action the higher the effect (e.g. IV > Oral)
• The quicker the onset of action the shorter the action (e.g. crack > cocaine > heroine)
• The quicker the ups and downs the more addictive the effect (the ups and downs have
a crucial role on the neurobiological changes underlying the origin of addiction)
Disfunção neurobiologica => Euforia e sintomas de privação são alternados (1)
Estado clinico
Euforia
Normal
Sintomasdeprivação
Heroína
10 -8
Co
nce
ntr
ação
pla
smat
ica
(M)
Doses de heroína
I
0
I
4I8
I12
I16
I20
I24
-710
-610
(1) Dole V.P., Nyswander M. Pharmacological treatment of narcotic addiction. NIDA Res. Monogr. 1982 ; 43 : 5-9.
ADICÇÃONEUROBIOLOGIA e MEDICAMENTOS
Your Brain on Drugs
1-2 Min 3-4 5-6
6-7 7-8 8-9
9-10 10-20 20-30
Methadone
Pharmacokinetics
• Full agonist of mu opioid receptors
• Long half-life ( ˃ 25 hours )
• Distributed into lipid stores (mainly in the liver) “Accumulation process”
• Delayed onset and offset of action ( “no peaks”) low reward effect (⇩abuseliability )
(1) Dole V .P., Nyswander M. Pharmacological treatment of narcotic addiction. NIDA Res. Monogr. 1982 ; 43 : 5-9.
Estado clinico
Euforia
Normal
Sintomas de privação
TRATAMENTO DE SUBSTITUIÇÃO(
10-8
Co
nce
ntr
ação
pla
smat
ica
(M)
Dose terapêuticasubstituição
I
0I4
I8
I12
I16
I
20I
24
-710
-610
Heures
Estabilização neurobiológica=> Supressão dos sintomas de privação(1)
Mobile Outreach Programme – Lisbon
Safe use of Methadone
Short practical guidelines
• Maximum dose in admission - 20-30 mg
• Slow increase of doses in the first two weeks (induction phase) – MOP-L → 30-35-40-45-45-50-50...
(preventing sedation and respiratory depression due to the accumulation process / delayed development of
tolerence)
• Risk of overdose occurs basically during the first week of the induction phase
• After achievement of sustainable tolerance methadone remains very safe
• Doses should be adjusted to patient needs (main goal no craving)
• Awareness of drug interactions, medical or psychological comorbidity, individual genetic factors, etc..
Mobile Outreach Programme – Lisbon
Safe use of Methadone
Short practical guidelines
Methadone has no relevant toxicity to the body
Is not nephrotoxic (renal impairment does not require changes of doses)
Is not hepatotoxic (chronic liver disease does not require changes of doses)
Questionable cardiotoxicity (high doses ˃ 150mg: prolongation of the QTc interval?)
Methadone Programmes
• Reduce HIV and Hepatitis B/C risk behaviours
• Reduce risk of overdoses
• Increase compliance to health care and social support
• Reduce crime
Low Threshold Methadone Programmes
Distinctive aspects from Methadone Maintenance Treatments
• Abstinence of drug use is not required
• Main concern toward abstinence symptoms and craving safer use of drug(s)
Mobile Outreach Programme – Lisbon
• 2 “Methadone” Mobile Units (MU1;MU2) operating every
day in five strategic spots in the city of Lisbon and
with fixed schedules twice a day (morning and afternoon)
in each spot
• 1 Support car backing MOP and patients needs
• 1 Mobile Office (MO) for medical support operating side
by side with the MU´s four days a week and covering all
spots and schedules of each spot (mornings and
afternoons)
• 1 Backup office for clinical meetings, clinical
supervision, programme procedures, communication work
with the health and social public network and
administrative workMOP - Lisbon
Logistics
Mobile Outreach Programme – Lisbon
StaffThe staff is multidisciplinary: medical doctors, psychosocial professionals(psychologists and social workers), nurses, community educators andadministrative staff
• Psychosocial professionals – Work in the back office and on a shift
schedule beside the MU´s. Each of them must cover all spots and all
schedules of the MU´s during the week
• Nurses – Fixed workplace in the MU´s
• Community educators – MU´s and support car
• Medical doctors – MO and Backup office for medical evaluations andappointments
• Administrative staff – Backup officeMOP - Lisbon
Mobile Outreach Programme – Lisbon
Outreach Logistics
• 2 “Methadone”* Mobile Units operating every day in five strategic spots in the city of Lisbon
with fixed schedules twice a day (morning and afternoon) in each spot
* Low Threshold Methadone Programme
MOP - Lisbon
Mobile Outreach Programme – Lisbon
Outreach Mobile Units (MU1/MU2) schedule
MorningSta. Apolónia 08:30 -10:00 Bela Vista 10:30 -12:30
AfternoonLumiar 14:30 -16:00 Bela Vista 16:30 -17:30 Sta. Apolónia 18:00 -19:30
Weekends and holidays Sta. Apolónia 08:30 -09:45 Bela Vista 10:15 -12:00 Lumiar 12:30 -13:30
MorningAv. Ceuta 08:30 -09:30 Lumiar 10:00 -11:30 P. Espanha 12:00 -13:30
Afternoon Av. Ceuta 15:30 -17:00
P. Espanha 17:30 às 19:30
Weekends and holidaysAv. Ceuta 08:30 -10:30 P. Espanha 11:00 -13:30
MOP - Lisbon
MOP - Lisbon
Mobile Outreach Programme – Lisbon
• Administration and monitoring of medical drugs (methadone*; antiHIV; antiHCV*;
anti-TB*; antibiotics; antipsychotics; antidepressives, contraceptive
injection, etc.)
*Directly Observed Treatment (DOT)
• Blood Sampling for HIV, Hepatites B/C and Syphilis
MOP - Lisbon
Mobile Units
Key Tasks
Mobile Outreach Programme – Lisbon
• To teach safe injection practices to PWID
• Needles and Syringes Exchange or other comsumption paraphrenalia,
distribuition of condoms and harm reduction awareness
MOP - Lisbon
Mobile Units
Key tasks
Mobile Outreach Programme – Lisbon
• General coordination of the methadone programme
• Physical and mental evaluations
• Harm reduction practices for safer use of drugs
• Evaluation of patients who have been hospitalized
• Conseling about bloodbourne/infectious diseases
• Medical evaluation on demand
• Evaluation of demanding changes of methadone doses
• Evaluation of medical drugs interactions
• Supervision of clinical cases with the staff
MOP - Lisbon
Mobile Office
MEDICAL DOCTORS – Key Tasks
Mobile Outreach Programme – Lisbon
MU´s and Backoffice
PSYCHOSOCIAL PROFESSIONALS / Case Managers
Evaluation and follow-up of the user needs in personal and social life
➢Health issues
➢Social issues
➢Justice issues
➢Referral issues
MOP - Lisbon
Psychosocial support in close communication with drug addiction,health and social services of the community network
Mobile Outreach Programme – Lisbon
Mobile Units and Backoffice
Psychosocial Professionals/Case Managers
Some key tasks
• Building a trustworthy relationship (to be and to talk with the user as many time aspossible)
• To try hard to know as well as possible the major health problems and/or needs of the
user and help the users to be aware and to take care of themselves
• Follow-up of the medical cares in which users are envolved
• Understand the needs and respect the priorities of the users (e.g. we can not ask a user
to attend an appointment during his time of consumption)
MOP - Lisbon
Mobile Outreach Programme – Lisbon
Mobile Units and Backoffice
Psychosocial Professionals/Case Managers
Some key tasks
• Harm reduction awareness
• To develop peer work with some drug users (e.g. help in needles and syringes
exchange in open air shooting spots)
• Network, network, network…to open doors in health care and social public
services
Mobile Outreach Programme-Lisbon
Harm reduction approach
To be close
To be patient
To be persistente
To like what you do
THANK YOU
Have a nice stay in Lisbon
MOP - Lisbon
[email protected]@aresdopinhal.pt