Actie-Onderzoek over de aflevering van methadon in de publieke officina in België

Onderzoeksproject DR/15 (Onderzoeksactie DR)

• Documentatie

Beschrijving :

1. Elements of the June 2002-October 2003 study

In the first phase of the study the role of the pharmacist in complement to the doctor’s in the dispensation of opiate substitutes has been highlighted. Pharmacists are indeed a forgotten intervention in most evaluations of patients and doctors relations, The study is the first attempt to appreciate the global situation of methadone substitution in Belgium with a methodology helping the drawing of a representative sample of patients on a national level. Community pharmacists were instrumental in answering a general quantitative questionnaire on the importance of methadone delivery, and were also asked to evaluate the situation of individual patients supervised in their pharmacy.

Although 800 community pharmacists answered the general questionnaire, 300 pharmacists evaluated a total of 1200 patients in October 2002. A first follow-up (not published yet) of more than 700 patients was realized in June 2003. Furthermore, pharmacists handed out lengthy self-administered questionnaires to their patients and 400 answers were collected.

The study’s first report has been published as a .pdf file by the Belgian Scientific Policy Department on their website:

http://www.belspo.be/belspo/home/publ/rappdrug1_fr.stm


2. November 2003-October 2004 research program

2.1. Continuation of the patient’s evaluation

New participants and a recall to former ones will help increase data collection and the sample of evaluated cases.
A new self-evaluation by patients besides another follow-up at 18 months will help increase knowledge on the present situation of methadone maintained patients and psychosocial dimensions of their evolution in treatment. The follow-up will also provide new clues on retention in methadone maintenance comparing treatment in specialized centers and more than half of the total of patients taken charge of in office based medicine.

To evaluate the effects of the data collection method (questionnaires included in a copy of a normally well read specialized monthly for community pharmacists), a telephone survey on a sample of pharmacists who did not participate will be launched. If required, the method to be further used will then be corrected.

2.2. Study of Psychotropic substances use and health conditions of the adult 18-60 year old Belgian population

In Belgium a constant difficulty of existing data on drug users or patients is the lack of comparison of their specific characteristics with observations in the general population of the same age. What is "normal" or at least to be expected is always considered implicit and relative risks are never checked thoroughly.

Widening the scope of the investigation, a General Population survey through Community Pharmacists (C.Phs) has been planned and carried out in February-March 2004. A sample of 300 C.Phs has been provided with 3000 questionnaires to be distributed among their 18-60 year old clients (“active” adults). The first aim is to enable a comparison with Methadone Maintenance (MM) patients.
Such a comparison, lacking in Belgium, will thus fulfill a need, not only to delineate social and personal specificities of MM patients, but also to compare their relations with doctors and pharmacists to the experience of other patients with a chronic disease.

On the other hand we have been lead to enrich the content of the questionnaire not to limit it to the purpose of a strict comparison with MM patients. The study should indeed become on its own a Health and Substance use survey in the General adult population.
Instruments used in the survey were chosen among the most valid ones in the scientific literature. A perusal of available instruments in both French and Dutch provided only one positive result on the measurement of perceived Health.
The SF-36 was chosen as a very sharp tool to measure Health and a one-year license was purchased. This self-administered instrument provides 8 perceived health dimensions. These dimensions are:
1. Physical Functioning
2. Role-Physical
3. Bodily Pain.
4. General Health
5. Vitality.
6. Social Functioning
7. Role-Emotional
8. Mental Health.

The first 4 dimensions constitute a cluster summarizing Physical Health and the next four a Mental Health cluster. This powerful instrument is used for a little more than a decade in thousands of publications. It enables to compare any sub-group to norms for the general population in many countries, except…in Belgium. If our sample through community pharmacies can be regarded as a representative sample of Belgian adult population, then this study will set “standards” for Belgium. The interest of this instrument is thus clear for future health studies. Any studied group in the Belgian population could then be compared to the norms produced in this study. The SF-36 is thus available in French and Dutch. Translations have been validated in a sample of angina patients in Belgium (Razavi. D, Gandek.B, 1998). In 1998, a special issue of the Journal of Clinical Epidemiology has been indeed fully devoted to this topic of translations of the SF-36.

With a license for 2004 and the interest for a production of Belgian standards, we felt the need to use the instrument for MM patients. This specific sub-study will test the variation of the gap with scores in the general population (corrected by age) according to length of treatment, with the hypothesis that there exists a positive relation of a gap reduction with length of treatment. More globally variations with standards will be analyzed in the light of results in the general population according to drug use and dependence to several substances.

Besides Health measures, substance use will be investigated with reliable instruments, such as Fagerströhm for tobacco, MAST or measures of Frequency/Quantity for alcohol, DAST for drug use. If these scales are well known internationally (although never used in Belgium in a national sample) some original creations will also be presented. In particular a measure of dimensions of cannabis and tobacco end of use. Indeed we believe that the focus should once be put on how people stop the use of “recreational” drugs such as tobacco and cannabis.
Also for the first time in Belgium, a benzodiazepines dependence scale will be used. This Australian instrument (Baillie A.J., Mattick R.P., 1996) is given its first French and Dutch translation.
Inspired by Prochaska’s stages of change theory (Prochaska J.O., et al., 1988; 1992), a measure of defining at which stage of change the alcohol and cannabis user can be located is included...Finally a Therapeutic Alliance scale, defined as the Gordian knot in opiate substitution in the first part of the study, will be compared to the results of this general population study, in particular concerning respondents suffering from a chronic disease...

Continuation of data collection and follow-up of MM patients will benefit from the extension of the study toward the general population. It will help to answer some questions on the specific aspects of opiate use effects on health and methadone substitution medium or long term effects on the patients well being.
The density of instruments used in the survey and the focus on some new aspects of drug use process or cycle let us hope to shed some new light on addictive behaviors in Belgian adult population.


References

Baillie A.J., Mattick R.P., The Benzodiazepine Dependence Questionnaire: Development, reliability and validity.(1996). Brit J Psychiat. 169(3), 276-281.

Prochaska J. O., DiClemente C. C., & Norcross J. C. (1992). In search of how people change. American Psychologist, 47, 1102-1114.

Prochaska J. O., Velicer W. F., DiClemente C. C., & Fava J. L. (1988). Measuring processes of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology, 56, 520-528.

Razavi D., Gandek B. Testing Dutch and French translations of the SF-36 Health Survey among Belgian Angina Patients. (1998). J.Clin.Epidemiol. 51( 11), 975-981.

Ware J.E., Kosinski M., Gandek B. SF-36 Health Survey. Manual and Interpretation Guide. (June 2003). QualityMetric Inc.