Managing opioid dependence treatment and controlling for HIV incidence among injecting drug users in Greece: a case study of optimism in the face of adversity


The Addiction readership may be interested in an example of how, even in the face of adversity, it is possible to make advances in service provision. A grim picture of the state of public health in Greece has been painted over the past 2 years since the start of the fiscal crisis and the implementation of severe austerity measures [1, 2]. However, not all is doom and gloom. A case in point is shown by the 2012 Annual Report of the European Monitoring Center for Drugs and Drug Addiction (EMCDDA) [3] and the report of the European Center for Disease Control (ECDC) assessing the risk of HIV in Greece on behalf of the European Commission [4], which recognize the work of the Organization Against Drugs (OKANA) in rapidly developing ‘appropriate, effective, and efficient responses’ to control HIV/AIDS among people who inject drugs (PWID).

PWID have played a major role in the explosion of HIV incidence in Greece (+1250% in 2011 versus 2010), mainly in Athens [5]. Of the available responses to preventing or controlling for HIV incidence among PWID, the World Health Organization (WHO) [6] highlights a combination of approaches, including the distribution of clean needles and syringes and access to opioid substitution treatment (OST).

Under both headings, the country was lagging behind what was required: in early 2010, OST coverage was at a low 21%, and more than 5500 opioid dependents were waiting to receive treatment for (on average) 7.6 years in Athens and 4.4 years in Thessaloniki. The needle and syringe programme (NSP) was also underperforming: at seven syringes per PWID per year, it ranged far behind the guidelines of 200 syringes.

Taking the challenge head on, within just over 12 months OKANA overcame organized and persistent resistance from local communities to open up access to OST for PWID in 33 additional centres in general hospitals across the country, increasing coverage from 21 to 40%. This also halved the ‘waiting-list of shame’ to receive treatment in Athens (to 3.6 years) and almost eradicated the list in Thessaloniki, despite the severe budget cut that necessitated managing double the patients with half the budget (8060 patients in 2012 at an average per patient annual cost of €3200 versus 4771 patients in 2009 at an average per patient annual cost of €10 600). With another four centres planned to open within 2013 in Athens, PWID will now be able to access OST within 1–4 months from applying, equitably, across the country.

OKANA also implemented a substantial, sevenfold increase in NSP coverage to reach approximately 45 syringes per person per year in 2012, and is taking immediate steps to meeting the 200 syringes target in 2013, optimizing the existing infrastructure.

In the face of all adversity and funding shortcomings, in almost a year OKANA achieved what was deemed impossible for almost a decade: it doubled access to OST care in a geographically equitable and cost-effective manner and increased access to NSP programmes exponentially in a country plagued by fiscal crisis. This was made possible through the development of a decentralized network of additional units that operated within general hospitals across the country, thus (a) optimizing available resources and (b) de-stigmatizing access to OST. This choice respected and safeguarded the right to treatment of patients suffering from opioid dependence and helped to control for the spread of HIV among PWID, providing an almost unique example of positive public health outcomes and also a reason for optimism in a country desperately in search of politically robust, scientifically evidence-based and patient-friendly responses to its mounting health and fiscal challenges.

Declarations of interest