Opioid Substitution Therapy

Opioid substitution therapy (OST)
OST is available in many forms; the most commonly used are methadone and/or buprenorphine.

Opioid substitution is a treatment for drug dependence which reduces the likelihood of relapsing to injection and can be considered an effective HIV prevention strategy.

Drug dependence and HIV infections are not isolated problems, with one capable of influencing the progression of the other. There is a variety of treatment modalities for drug dependence, including drug-free residential therapy, outpatient counselling-based treatment, and medication-assisted substitution and detoxification for opioid dependence.

Effective treatment options using evidence-based counselling approaches for dependence on cocaine and amphetamine-type stimulants (ATS) should also be offered. Medication-assisted therapy for cocaine and ATS dependence may be of benefit, although substitution therapy for non-opioid dependence is much less developed and generally unavailable outside of research protocols.

Given the chronic and relapsing nature of substance dependence, detoxification alone is seldom effective in producing long-term and sustained change.

Treatment of drug dependence, in particular through OST, provides many benefits in the prevention and treatment of HIV/AIDS by:
- improving access to HIV care and treatment as well as general healthcare
- retaining active drug users in treatment
- reducing the transmission of HIV, viral hepatitis and bacterial infections
- decreasing the need for hospitalisation
- improving and facilitating adherence and follow up of patients on ART
- reducing illicit opioid use
- reducing criminal activity
- decreasing deaths due to overdose
- cutting down on behaviours with a high risk of HIV transmission
- improving social integration

The benefits of substitution therapy programmes can be maximised by:
- prescribing methadone or buprenorphine in doses that effectively prevent craving and reduce drug use
- orientating programmes towards maintenance rather than abstinence
- offering counselling, assessment and treatment for psychiatric co-morbidity and social problems
- using evidence-based strategies such as motivational interviewing or contingency management to assist patients in reducing the use of additional drugs
- ensuring ready access to services, including convenient geographical location and opening hours, and affordable cost

Where substitution therapy is available, consideration should be given to offering HIV/AIDS medical care and dispensing ART at the same site from which drug substitution therapy is dispensed.

This approach can:
- achieve maximal levels of treatment supervision and improve adherence
- reduce the risk of developing ARV drug resistance
- facilitate the management of interactions between methadone and HIV/AIDS medications
- provide the opportunity to administer DAART to patients attending daily to receive methadone (a second “take-home” ARV dose is usually needed)

Source: WHO

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