In 2023, within the framework of the Regional Project “Sustainability of Services for Key Populations in the Eastern Europe and Central Asia Region” (SoS_project 2.0), implemented by a consortium of organizations led by the Alliance for Public Health in partnership with the CO “100% Life”, with the financial support of the Global Fund, EHRA issued 5 sub-grants for community-led monitoring in Kazakhstan, Kyrgyzstan, Moldova, Georgia and Tajikistan. All community organizations that received funding chose to monitor the Opioid Agonist Treatment (OAT) program.
TAJIKISTAN
In Tajikistan, the initiative group Intihob, with the support of SPIN PLUS, investigated the impact of the lack of substitution therapy on patients’ lives and adherence to treatment. The goal of advocacy is to start and scale up the provision of take home medication. According to the existing protocol for the provision of OAT, such a possibility exists, but in practice it is not implemented.
The method of data collection was qualitative interviews. A total of 25 people were interviewed: 15 people from two sites in Dushanbe, 5 people from Vahdat and 5 people from Kulob.
Problems identified:
1. The complexity of transport links and daily transportation costs, especially considering that most patients do not work due to the requirement to provide a certificate from narcology for employment.
2. Frequent abuse of pharmacy drugs among patients
3. Lack of psychological support for program participants
4. Negative attitudes from OAT program staff, lack of places to communicate after receiving therapy, harassment from medical staff and residents of nearby houses
5. Lack of access to therapy in the pre-trial detention center during the investigation even for patients who were in the program prior to arrest.
6. Failure to use the procedure for dispensing take-home methadone to stable patients according to the existing protocol
Recommendations:
1. Develop a mechanism for dispensing and monitoring medications to continue self-administration at home
2. Set up mobile clinics and review legislation for the flexible application of OAT
3. Advocate for the dispensing of buprenorphine as an OAT drug
4. Consider the issue of issuing prescription for OAT medication due to the lack of narcologists
MOLDOVA
In Moldova, PULS Communitar also studied the impact of the limited availability of take-home substitution therapy on patients’ lives and adherence to treatment.
The goal of the advocacy is to establish and scale up take-home OAT. According to the existing protocol on the provision of OAT, such possibility exists, but in practice, as in Tajikistan, it is almost not used. The method of data collection was focus groups.
In total, 9 focus groups were conducted, based on the fact that today the geography of OAT covers 8 localities (Balti, Orhei, Chisinau (2), Ungheni, Falesti, Comrat, Cahul, Edinet) and 9 sites. Focus groups with OAT participants were distributed depending on the place of treatment. The number of focus group participants ranged from 3 to 10 people. A total of 77 program participants were interviewed.
Problems identified:
1. Physical accessibility and geographical distance
Methadone is available on 9 sites, while buprenorphine is available only on 4 in the cities of Chisinau, Orhei and Balti. In a number of cities, including Edinet, Cahul, Comrat, Falesti and Ungheni, only methadone is provided.
Access to OAT sites in Moldova is problematic, especially for those living in rural areas. Existing site schedules often do not meet the needs of patients. Addiction doctors may informally extend their hours of operation to meet the needs of patients. However, the inability to dispense take-home doses for biased reasons and non-compliance with established treatment protocols complicate the re-socialization of patients.
2. Acceptability and availability of treatment to maintain adherence:
In some regions, such as Ungheni and Comrat, patients report the use of diluted methadone, which can negatively affect the effectiveness of treatment.
At present, access to the OAT programme is only possible through specialist narcological services, but the shortage of addiction doctors, counsellors, social assistants and psychologists in OAT centers creates obstacles to the provision of comprehensive support to patients, complicating an individualized approach to treatment and monitoring of its effectiveness.
Patients with OAT often do not have full information about the principles and mechanisms of the treatment program, as well as the possibilities of appealing violations and protecting their rights.
Addiction therapists sometimes avoid communicating with patients, and the study also found that there are no dedicated facilities for the provision of psychosocial services at OAT sites, which creates serious obstacles to effective treatment. The low level of programme coverage and the lack of a waiting queue procedure are also challenges that reduce the effectiveness and accessibility of OAT.
3. Accessibility and respect for human rights, confidentiality:
Serious breaches of confidentiality, such as video surveillance and the presence of security guards, have been identified. Participants in the program also expressed concerns about the availability and transfer of their personal and medical data to third parties without their consent, which undermines patient trust and can negatively affect the effectiveness of treatment. Examples of such violations are given in the analyses of the OAT sites in Ungheni and Chisinau.
Recommendations:
1. Expanding access to treatment:
· Mandatory introduction of both methadone and buprenorphine at all OAT sites to ensure greater choice of medications and a personalized approach to treatment.
· Expansion of the opening hours of the OAT sites, including weekends and non-working hours, for the convenience of patients.
· Inclusion of OAT in the standard set of primary care services and distribution of medication though pharmacies to increase accessibility.
· Cooperation with private medical institutions and revision of legislation to improve the quality of services and expand the geography of access.
· Further research and implementation of innovative methods, such as remote treatment through video surveillance (VADO), is recommended to remove these barriers and increase access to treatment.
2. Improving the quality and effectiveness of treatment:
· Standardize treatment protocols and regularly evaluate healthcare professionals to ensure compliance with standards and treatment efficacy. It is necessary to ensure strict adherence to protocols and standards at all stages of treatment, taking into account the individual approach and benefit of patients. This includes reviewing and, if necessary, adjusting the methods of provision/administration of drugs that would preserve pharmacological properties
· Implement individualized treatment plans and reduce the time spent in the program before dispensing medications to two months to increase patient adherence and improve their quality of life.
· Support for people with opioid use disorders, as outlined in the National Clinical Protocol, should be two-pronged: include both pharmacological and psychosocial care. Psychosocial counseling should take place in a safe environment, be geographically accessible and ensure complete confidentiality.
· In order to guarantee full-fledged medical and social support, the offices of OAT should be provided with appropriate personnel: a narcologist, a peer counselor, a social assistant, a psychologist. The presence of such specialists will not only ensure an individualized approach to treatment, but will also establish mechanisms for robust monitoring of compliance with standards and protocols.
· It is necessary to stop the practice of dispensing drugs through the window and review the current procedures in order to optimize them. It is recommended to switch to a drug dispensing model similar to the dispensing regimens for the treatment of tuberculosis and HIV (ARV therapy).
3. Establishment of monitoring and feedback mechanisms:
· Implementation of systems for tracking and monitoring compliance with treatment protocols to improve the quality and efficiency of services.
· Establish systems for collecting and analysing patient feedback to identify and address possible problems with the availability and quality of services.
· Creation of a centralized body to coordinate and monitor the OAT program with the inclusion of additional evaluation indicators, such as the level of patient satisfaction and the success of their re-socialization, for more targeted and effective work.
· It is recommended to strengthen the mechanism for quality control of pharmacovigilance drugs on all OAT sites.
· It is necessary to conduct information training sessions that would familiarize patients with their basic rights and obligations, as well as with the mechanisms and steps to be taken in case of violation of these rights. Create and implement a unified tool for feedback on human rights violations.
· It is necessary to introduce a clear and understandable schedule of the doctor’s work, accessible to all patients. In addition, each patient should be provided with an individualized treatment plan, which will be regularly updated and agreed upon with the patient.
· It is necessary to conduct a due diligence of current video surveillance practices to determine their legality. It is recommended to reconsider the need for the presence of security guards or their interaction with patients so as not to violate the principles of confidentiality and respect for the individual.
· It is recommended that police continue to be trained on the Guidelines for Their Involvement in HIV Prevention and Control, taking into account access to OAT, to clarify their roles and limitations within the OAT programme.
· In order to build trust in the program and ensure the confidentiality of patient data, it is necessary to audit the current confidentiality measures and, if necessary, strengthen them.
· Given the high mobility of patients, who often move from one medical center to another or temporarily stop treatment, it is necessary to introduce an electronic accounting system.
· Strengthen the role of the Republican Narcological Dispensary as a coordinating unit.
GEORGIA
In Georgia, the community organization Rubikoni studied the impact the limited availability of take-home OAT medication on patients’ lives and adherence to treatment through patient diaries. The goal of advocacy is to get OAT drugs to be distributed. According to the existing protocol on the provision of OAT, such a possibility exists, but in practice, as in Moldova and Tajikistan, it is practically not used.
A total of ten people were selected to keep diaries. Every day, for two weeks, OAT participants described all the topics related to the program, told what path and how they had to go to get the mrdication, expressed their attitude to additional services, and focused on the positive and negative aspects of substitution therapy.
Problems identified:
1. The main problem identified in the study is the limited geographical availability of the program for most patients, especially for residents of remote regions. Also problematic is the requirement of daily visits to the institution, which makes it difficult to find a job and affects the quality of life of patients. These factors lead to the next problem – queues that gather every morning at the doors of the program.
2. Another problem is the attitude of the staff towards the patients and the quality of the doctors’ performance of their duties. Most patients do not have constant contact with the doctor, and the decision to reduce the dose of the medication is made by the patient himself.
3. Most OAT participants are not aware of the additional services provided by non-governmental organizations.
4. An important aspect of psychosocial support for participants in the substitution therapy program is the work of a psychologist. However, none of the 10 participants in the study used the services of a psychologist.
Recommendations:
1. Expand the geographical availability of services
2. Revise state dispensing laws, including allowing multiple daily doses
3. Ensure the availability of psychological services
4. Conduct information campaigns among beneficiaries about available additional services to improve the effectiveness of substitution therapy.
5. Revise government restrictions for OAT participants, including the right to work and driver’s licenses.
6. Work to reduce the stigma around OAT in society.
7. Conduct regular trainings and seminars to improve the skills of the staff of the OAT centers
8. Reduce the risk of breach of patient privacy.
9. Adapt the infrastructure of OAT centres for people with disabilities and people with children
10. Assist in the employment process for patients in the program
KAZAKHSTAN
The PUD Kazakhstan Forum, a community organization, also assessed the impact of the lack of take-home OAT on patients’ lives and adherence to treatment. The goal of advocacy is to ensure the dispensing of take-home OAT medication and ensure the continuity of treatment. For many years, the community of people who use drugs in Kazakhstan has been pushing for the provision of take-home therapy and its availability in hospitals and places of detention.
The study was conducted using semi-structured interviews in 7 cities: Temirtau, Ust-Kamenogorsk, Uralsk, Kostanay, Rudny, Lisakovsk, Pavlodar. A total of 21 interviews were collected, the duration of which ranged from 40 to 60 minutes.
Problems identified:
1. Participants mention the hurdles they overcame before deciding to enroll into OAT. This may be due to doubts about ensuring continued access to the medication by the state. 14 people out of 21 respondents discontinued treatment due to interruptions in the supply of the medication at the state level.
2. In the country, medical care is provided free of charge to persons attached to a medical institution. Attachment is carried out on the basis of an application, with an identity card and registration at the place of residence. Among people living with drug dependence, there is a lack of registration and identity documents. This makes access to OAT difficult.
3. The waiting time from the moment of application to inclusion in the OAT ranges from 1 day to 9 months.
4. Before starting to take the medication, all participants sign an agreement on participation in OAT. Out of 21 participants in the study, only 5 had the text of the contract in hand.
5. In different cities, the travel time to the OAT site takes from 60 to 90 minutes one way.
6. The opening hours of sites in the country are limited, as a rule, they are determined from 8 to 10 am. Participants express a desire to have a permanent job, but face problems in finding or maintaining the work due to the timing of the OAT appointment.
7. Unsuitability of OAT centers for people with disabilities. Climbing several floors causes difficulties for people with physical problems or illnesses.
8. According to the clinical protocol of OAT, the combination of psychosocial and pharmacological care leads to higher rates of treatment completion and a lower relapse rate during follow-up. Most study participants do not have information about available psychosocial care in the program. They did not seek additional medical or social services.
9. Most of the participants have health problems and need inpatient treatment, but face difficulties in obtaining the necessary treatment due to the lack of access to methadone outside the dispensing site.
Recommendations:
1. Improvement of the working conditions of the OAT:
· Standardization of the mechanism for the dispensing of OAT for self-administration, home delivery and hospitalization.
· Consideration of expanding the choice of medications, including buprenorphine.
· Prevention of interruptions that may adversely affect motivation to participate in OAT.
2. Taking into account regional characteristics and patient needs:
· Changing site working hours to meet the needs of more patients.
· Placement of drug dispensing rooms in more accessible and convenient places.
· Creation of separate entrances and consultation rooms to provide greater privacy and personal space for patients.
3. Development of a system of OAT performance indicators:
· Inclusion of the assessment of the quality of life of patients in the system of indicators of the effectiveness of OAT.
· Regularly gather feedback to identify patient needs and improve care.
4. Provide clear, easy-to-understand and accessible information about OAT, its objectives, procedures and benefits.
5. Improving the quality of medical care and non-medical support within the framework of OAT:
· Ensuring access to hepatitis C treatment:
· Issuance of referrals for necessary laboratory tests for OAT patients at high risk of infection
· Prescription for additional medications, tailored to individual needs and chronic illnesses.
· Establishing trusting relationships with patients through the work of psychologists in OAT cneters to reduce anxiety and increase motivation for treatment.
· Introduction of screening for depression and anxiety, followed by prescribed medication if necessary.
· Increased coordination between physicians and dispensers for more effective referral
· Revising the conditions for the delivery of biological samples, ensuring confidentiality and respect for the human dignity of patients.
· Implementation of peer-to-peer counseling to strengthen collaboration and trust between patients and professionals.
· Develop family support programs to help patients cope with challenges and improve communication with loved ones.
6. Amendments to regulatory legal acts to abolish mandatory narcological registration, which contributes to unemployment and problems with resocialization of patients.
7. Collaboration with relevant NGOs to represent the interests of OAT patients and people who use psychoactive substances.
8. Organizing activities at various levels to reduce stigma and discrimination against OAT patients.
KYRGYZSTAN
Peer-to-Peer (Peer-to-Peer), a community organization in Kyrgyzstan, surveyed client satisfaction with the opioid agonist treatment program and collected examples of countries where OAT medication is dispensed through pharmacies. The goal of advocacy is to expand the range of medicines, dispense methadone in tablet form and the ability to receive prescription therapy in pharmacies.
The survey by the method of structured interviews was conducted on 4 OAT sites in Bishkek. A total of 30 men and 8 women were interviewed.
Findings:
1. Monitoring the safety of an existing OAT program for patients and factors affecting safety:
· 52.6% of respondents consider OAT sites to be safe.
· 100% of the monitoring participants expressed a desire to remove drug user registration to increase the safety of participation in the program.
· 7.89% of respondents spoke about the fear of the police.
· 50% of participants mentioned issuing prescriptions through a private doctor as a safer way, but only 34.21% found it attractive due to financial constraints.
· 86.8% find it inconvenient to come to the site every day for a dose of methadone.
· Encounters with stigma and discrimination on or near the OAT website were described by 52.6% of respondents, with the main stigma and discrimination coming from the police (55.2%).
2. Monitoring of satisfaction with OAT services and factors contributing to program improvement:
· Acquaintances (73.7%) are the main source of information about the programme, followed by non-governmental organizations
· A third of the participants (33.3%) had previously left the program due to tiredness from daily visits to the site or due to the use of other drugs without medical prescription.
· Almost half of the respondents (57.89%) rated the work of the OAT sites as satisfactory, but 42.10% expressed dissatisfaction.
· Most people get take-home methadone for 4-5 days (52.63%), which is considered more convenient.
· The majority of respondents (73.7%) expressed a desire to have a choice between methadone and buprenorphine. Some respondents also expressed interest in the tablet form of methadone.
Recommendations:
1. In cooperation with the Republican Center for Psychiatry and Narcology (RCPN), attract funding for the creation of peer-to-peer counselor and social worker positions on each OAT site.
2. Together with the RCPN, advocate for the inclusion of the purchase of methadone tablets and buprenorphine in the state budget within the framework of the State Guarantee Program, similar to the procurement of methadone at present.
4. Together with the RCPN, develop a Concept for the expansion of OAT through the dispensing of methadone through pharmacies on prescription and the introduction of methadone tablets to improve availability
5. Abolish the practice of “drug user registration” for OAT participants.
6. Implement digital tools, such as Telegram bots and mailing lists, for OAT participants, covering overdoses, rights, and other relevant issues, including information about methadone and buprenorphine.
7. Organize training activities for organizations from the OAT community and participants, based on the experience of other countries, with a focus on naloxone and buprenorphine.
