Heroin Addiction and Related Clinical Problems September 2012

116 Pages·2012·2.12 MB·English

ISSN 1592-1638
Vol. 14 • N. 3 • September 2012
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eriodico trimestrale - Sped. in ut. tirb. di Pisa n.5 del 9-3-200
PA
the official journal of
World Federation
for the
Treatment of
Opiod Dependence
Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS)
E-mail: [email protected] - Web: www.aucns.org
Being instituted in Viareggio in 1994, AU-CNS is as a no-profit association aiming to promote the spreading of scientific knowledge and its
application upon issues of mental illness and substance abuse. AU-CNS is involved into research and teaching activities, and the organiza-
tion of seminars, conferences and public debates with either scientific or popular audience targets. Among these, the most remarkable are
the National Conference of Addictive Diseases, taking place in Italy every two years, The European Opiate Addiction Treatment Association
Conference taking place in different European towns every two years, and a Europad satellite meeting within the American Opioid Treatment
Association Conference (AATOD) in the USA, every 18 months. AU-CNS directly cooperates with national and international associations on
the basis of common purposes and fields of interests, and runs an editing activity comprising psychiatry and substance abuse textbooks, and
the official magazine of Europad-Wftod ”Heroin Addiction and Related Clinical Problems”.
Officers: President: Icro Maremmani (Pisa, Italy, EU); Scientific Director: Alessandro Tagliamonte (Siena, Italy, EU);
General Secretary – Treasurer: Marilena Guareschi (Pietrasanta, Italy, EU)
European Opiate Addiction Treatment Association (EUROPAD)
E-mail: [email protected] - Web: www.europad.org
EUROPAD (formerly EUMA) was founded in Geneva (Switzerland) on September 26, 1994. It is, and shall remain, independent of political
parties and of any government. EUROPAD exists to improve the lives of opiate misusers and their families and to reduce the impact of illicit
drug use on society as a whole. The Association works to develop opiate addiction treatment in Europe but also aims to make a major contri-
bution to the knowledge of, and attitudes to, addiction treatment worldwide. EUROPAD aims to (a) promote the development and acceptance
of Agonist Opioid Therapy, (b) encourage collaborative research into effective addiction treatment, (c) provide a forum for the communica-
tion of research results and best practice, d) encourage contact between individuals and groups within treatment services, (e) co-operate in the
development of effective public policy.
Officers: President: Icro Maremmani (Pisa, Italy, EU); Vice-President: Marc Reisinger (Brussels, Belgium, EU);
General Secretary: Andrej Kastelic (Ljubljana, Slovenia, EU)
Mauri Aalto, Helsinki, Finland, <[email protected]> Lubomir Okruhlica, Bratislava, Slovak Republic, EU <[email protected]>
Adrian-Octavian Abagiu, Bucharest, Romania, <[email protected]> Matteo Pacini, Pisa, Italy <[email protected]>
Oleg Aizberg, Minsk, Belarus, <[email protected]> Pier Paolo Pani, Cagliari, Italy, EU <[email protected]>
Mickey Arieli, Ramla, Israel, <[email protected]> Luis Patricio, Lisbon, Portugal, <[email protected]>
Marc Auriacombe, Bordeaux, France, EU <[email protected]> Tijana Pavicevic, Podgorica, Montenegro, <[email protected]>
Safet Blakaj, Prishtina, Kosovo, <[email protected]> Paul Quigley, Dublin, Ireland, <[email protected]>
Olof Blix, Jonkoping, Sweden, Eu <[email protected]> Marina Roganovic, Kotor, Montenegro, <[email protected]>
Jean Jacques Deglon, Geneve, Switzerland, <[email protected]> Slavko Sakoman, Zagreb, Croatia, <[email protected]>
Sergey Dvoryak, Kiev, Ukraine, <[email protected]> Rainer Schmid, Wien, Austria, <[email protected]>
Gabriele Fischer, Vienna, Austria, EU <[email protected]> Aneta Spasovska, Trajanovska, Skopje, Macedonia <[email protected]>
Milazim Gjocjaj, Prishtina, Kosovo <[email protected]> Karina Stainbarth-Chmielewska, Warsaw, Poland <[email protected]>
Martin Haraldsen, Sandefjord, Norway <[email protected]> Marlene Stenbacka, Stockholm, Sweden, EU <[email protected]>
Liljana Ignjatova, Skopje, Macedonia <[email protected]> Heino Stöver, Frankfurt, Germany, <[email protected]>
Ante Ivancic, Porec, Croatia, <[email protected]> Emilis Subata, Vilnius, Lithuania, <[email protected]>
Nikola Jelovac, Split, Croatia, <[email protected]> Marta Torrens, Barcelona, Spain, EU <[email protected]>
Minja Jovanoviƒá, Kragujevac, Serbia <[email protected]> Didier Touzeau, Bagneux, France, <[email protected]>
Euangelos Kafetzopoulus, Athens, Greece, EU <[email protected]> Giannis Tsoumakos, Athens, Greece, <[email protected]>
Alexander Kantchelov, Sofia, Bulgaria, EU <[email protected]> Albrech Ulmer, Stuttgart, Germany, EU <[email protected]>
Sergey Koren, Moscow, Russia, <[email protected]> Peter Vossenberg, Deventer, Netherlands, <[email protected]>
Alexander Kozlov, Moscow, Russia, <[email protected]> Nikola Vuckovic, Novi Sad, Serbia, <[email protected]>
Gunnar Kristiansen, Oslo, Norway, <[email protected]> Helge Waal, Oslo, Norway, <[email protected]>
Mercedes Lovrecic, Ljubjana, Slovenia, EU <[email protected]> Stephan Walcher, Munich, Germany <[email protected]>
Garrett McGovern, Dublin, Ireland <[email protected]>
Nermana Mehic-Basara, Sarajevo, Bosnia and Herzegovina, <[email protected]>
Haim Mell, Jerusalem, Israel, <[email protected]>
Vladimir Mendelevich, Kazan, Russia, <[email protected]>
Genci Mucollari, Tirane, Albania, <[email protected]>
World Federation for the World Federation for the Treatment of Opiod Dependence (WFTOD)
Treatment of NGO with Special Consultative Status with Economic and Social Council (ECOSOC)
Opiod Dependence E-mail: [email protected] - Web: www.wftod.org
The World Federation for the Treatment of Opioid Dependence (WFTOD) officially started during the EUROPAD conference Ljubljana,
Slovenia during July 2007. EUROPAD and AATOD have worked together since the AATOD conferences of 1989 in Newport, Rhode Island.
EUROPAD conducted a major panel presentation from a number of its member nations for the conference participants. EUROPAD and AA-
TOD have exchanged such collegial presentations at all of the AATOD and EUROPAD meetings since that date, creating the foundation for
the working relationship, which led to the development of the WFTOD. EUROPAD and AATOD also worked together in filing an application
to the NGO branch of DESA during 2010. The application was accepted on February 18, 2011 during the regular session of the Committee
on Non-Governmental Organizations to the U.N. Department of Economic and Social Affairs (DESA). In the regular session held on July 25,
2011, the Economic and Social Council of the United Nations granted Special Consultative Status to the WFTOD.
Officers: President: Icro Maremmani (Pisa, Italy, EU); Vice-President: Mark. W. Parrino (New York, NY, USA);
Treasurer: Michael Rizzi (Cranston, RI, USA); Corporate Secretary: Marc Reisinger (Brussels, Belgium, EU)
Editorial Board
Editor
Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, "Santa Chiara" University
Icro Maremmani
Hospital, Pisa, Italy, EU
Associate Editors
Thomas Clausen SERAF, Norwegian Centre for Addiction Research, University of Oslo, Norway
Pier Paolo Pani Social Health Division, Health District 8 (ASL 8), Cagliari, Italy, EU
Marta Torrens University of Barcelona, Spain, EU
International Advisory Board
Hannu Alho National Public Health Institute (KTL), University of Helsinki, Finland, EU
Marc Auriacombe Université Victor Segalen, Bordeaux 2, France, EU
James Bell South London and Maudsley NHS FoundationTrust & Langston Centre, Sydney, Austrelia
Olof Blix County Hospital Ryhov, Jönköping, Sweden, EU
Barbara Broers University Hospital of Geneva, Switzerland
Miguel Casas University Hospital of "Vall d’Hebron" - University of Barcelona, Spain, EU
Liliana Dell'Osso Department of Clinical and Experimental Medicine, University of Pisa, Italy, EU
Michael Farrell National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
Loretta Finnegan National Institutes of Health, Bethesda, ML, USA, [Retired]
Gabriele Fischer Addiction Clinic, University of Vienna, Austria, EU
Health and Human Development Section, Division for Operations, United Nations Office on
Gilberto Gerra
Drugs and Crime (UNODC), Vienna
Gian Luigi Gessa University of Cagliari, Italy, EU, [Emeritus]
Michael Gossop King’s College, University of London, UK, EU
Department of Neuroscience, Institute of Addictive Diseases, University Hospital of Uppsala,
Leift Grönbladh
Sweden, EU
Lars Gunne University of Uppsala, Sweden, EU, [Emeritus]
Andrej Kastelic Center for Treatment of Drug Addiction, University Hospital, Ljubljana, Slovenia, EU
Michael Krausz St.Paul’s Hospital, University of British Columbia, Canada
Mary Jane Kreek The Rockfeller University, New York, USA
Evgeny Krupitsky St. Petersburg Bekhterev Psychoneurological Research Institute, Saint Petersburg, Russia
Mercedes Lovrecic Institute of Public Health of the Republic of Slovenia, Ljubljana, Slovenia, EU
Joyce Lowinson Albert Einstein College of Medicine, The Rockfeller University, New York, USA, [Emeritus]
Robert Newman Baron de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York, NY, USA
Charles P. O'Brien University of Pennsylvania, Phildelphia, USA
Lubomir Okruhlica Centre for Treatment of Drug Dependencies, Bratislava, Slovak Republic, EU
Mark Parrino American Association for the Treatment of Opioid Dependence, New York, USA
Giulio Perugi Department of Psychiatry, University of Pisa, Italy, EU
Marc Reisinger European Opiate Addiction Treatment Association, Brussels, Belgium, EU
Lorenzo Somaini Addiction Treatment Center, Cossato (Biella), Italy, EU
Marlene Stenbacka Karolinska Institute, Stockholm, Sweden, EU
Alessandro Tagliamonte University of Siena, Italy, EU
Ambros Uchtenhagen Research Foundation on Public Health and Addiction, Zurich University, Switzerland
Helge Waal Center for Addiction Research (SERAF), University of Oslo, Norway, [Emeritus]
George Woody University of Pennsylvania, Phildelphia, USA
Editorial Coordinators
Marilena Guareschi Association for the Application of Neuroscientific Knowledge to Social Aims, AU-CNS,
Pietrasanta, Lucca, Italy, EU
Matteo Pacini "G. De Lisio" Institute of Behavioural Sciences, Pisa, Italy, EU
Angelo G.I. Maremmani Association for the Application of Neuroscientific Knowledge to Social Aims, AU-CNS,
Pietrasanta, Lucca, Italy, EU
School of Psychiatry, University of Pisa, Italy, EU
Luca Rovai School of Psychiatry, University of Pisa, Italy, EU
Publishers
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Assessing the current state of opioid-dependence treatment across Europe: methodology
of the European Quality Audit of Opioid Treatment (EQUATOR) project 5
Gabriele Fischer and Heino Stöver
Is substance use disorder with comorbid adult attention deficit hyperactivity disorder
and bipolar disorder a distinct clinical phenotype? 71
Giuseppe Ceraudo, Cristina Toni, Giulia Vannucchi, Salvatore Rizzato, Francesca Casalini,
Liliana Dell’Osso, Icro Maremmani and Giulio Perugi
Economic evaluation of opioid substitution treatment in Greece 77
Mary Geitona, Vilelmine Carayanni and Pythagoras Petratos
The journey into injecting heroin use 89
David Barry, Hussain Syed and Bobby P Smyth
Cognitive behavioural coping skills therapy in cocaine using methadone maintained
patients: a pilot randomised controlled trial 101
Catherine D. Darker, Brion Sweeney, Haytham El Hassan, Alan Kelly, Bobby P. Smyth
and Joe Barry

Regular article
Heroin Addict Relat Clin Probl 2012; 14(3): 5-70
Assessing the current state of opioid-dependence treatment across Europe:
methodology of the European Quality Audit of Opioid Treatment (EQUATOR)
project
Gabriele Fischer1 and Heino Stöver2
1 Center of Public Health, Medical University Vienna, Austria, EU
2 Faculty of Health and Social Work, University of Applied Sciences, Frankfurt, Germany, EU
Summary
Opioid-dependence treatment varies between countries despite the underlying condition being similar. The European
Quality Audit of Opioid Treatment (EQUATOR) project utilised a survey design in 10 European countries to characterise
the treatment of opioid dependence from the perspective of treating physicians, patients in treatment, and opioid users
currently outside the medication-assisted treatment system. The survey covered topics including treatment goals; knowl-
edge about and experience of treatment; drug use, misuse and diversion; employment; and prison experience. EQUATOR
provides the opportunity to generate important new insights to guide treatment policy and practice. This article presents a
detailed overview of the study methodology.
Key Words: Opioid dependence, treatment, Europe, survey, methodology.
1. Introduction medications are used (e.g., methadone, levometha-
done, buprenorphine, buprenorphine–naloxone or
Opioid dependence causes substantial harm to slow-release morphine), who can prescribe therapies,
both the user and to society (e.g., overdose mortality, whether psychosocial counselling is mandatory or
infectious-disease transmission, crime). It also places compulsory, and the levels of supervision and con-
a substantial economic burden on society owing to trol that apply to treatment participation. Importantly,
both direct (e.g., healthcare requirements, criminal- these differences in treatment provision do not appear
justice costs) and indirect costs (e.g., social securi- to stem from variation in the underlying clinical needs
ty benefits due to unemployment, lost productivity) or patient populations in each country, but rather re-
(29). Opioid maintenance treatment (OMT) com- flect a range of non-clinical influences on treatment
bined with psychosocial therapy has been recognised practice. These may include the structure of the treat-
by the World Health Organization as the most effec- ment system, politics, religious and cultural values,
tive intervention for opioid dependence (29), with ev- financial and human resources, and public attitudes
idence-based reviews demonstrating that OMT posi- and stigma towards drug users (5). Between-country
tively impacts retention in treatment and decreases variations are likely to be compounded by differ-
heroin use (15,16), but it is implemented in different ences in their expectations of the outcome of treat-
ways by different countries. For example, treatment ment. Many countries are building upon the success
varies between countries in Europe in terms of where of harm reduction to promote more ambitious ‘recov-
and how easily patients can access treatment, which ery-orientated’ outcomes (8,25,28). Harm-reduction
Corresponding author: Prof. Dr Gabriele Fischer, Center of Public Health, Medical University Vienna, 1090 Vienna, Austria
Tel: [phone], Fax: [phone], E.mail: [email protected]
5
Heroin Addiction and Related Clinical Problems 14 (3): 5-70
strategies are primarily targeted at reducing the nega- buprenorphine is frequently not conducted in this way
tive consequences of opioid dependence on the user and maintenance schedules are also often suboptimal
and on society (e.g., blood-borne virus transmission, (1,4,10,27), which has been found to be associated
crime, drug-related deaths). Recovery-orientated ap- with reduced treatment retention (1,4,10,27). Beyond
proaches differ from harm-reduction in that they em- the initial induction period, there is evidence that
phasise the importance of achieving positive health many patients receive sub-optimal maintenance doses
and social outcomes in a broader sense for individual of methadone and buprenorphine (1). Patients receiv-
patients (e.g., improved health and wellbeing, social ing sub-optimal doses of OMT may self-medicate ei-
functioning and reintegration), encouraging individu- ther by misusing their medication via the parenteral
als to progress along their own recovery journey. route to increase bioavailability, or may use other
Inter-country variation in systems of treatment medications or illicit drugs (13,14). Drug interactions
delivery could have important consequences in terms are a particular cause of concern among opioid-de-
of how effective each system is in attracting and re- pendent patients as they may be using multiple illicit
taining opioid users in treatment and therefore re- drugs and may also have co-occurring medical and
alising the benefits of treatment. For example, in mental illnesses that require medication (17). Co-in-
some countries (e.g., France and Austria) treatment gestion of benzodiazepines and methadone (and, to
is predominantly delivered via general practition- a lesser extent, benzodiazepines and buprenorphine)
ers or family doctors, an approach that may be ben- has been associated with fatal respiratory depres-
eficial in fully normalising and medicalising opioid sion (17). Caution should therefore be exercised in
dependence as a chronic medical condition. In other prescribing benzodiazepines to those receiving OMT
countries (e.g., Italy, Spain and Greece) treatment is and with regard to the potential for drug interactions
predominantly provided by specialist publicly fund- in general.
ed clinics focussed exclusively on drug dependence. Another important example of variable treat-
These clinics enable the concentration of expertise ment delivery that may also pose a threat to quality
and integrated resources necessary to cater for more of care concerns the use of supervised dosing. This
difficult patients and to meet demand for treatment strategy may be used with the aim of ensuring that
in more densely populated areas; however, such spe- patients receive their prescribed dose of OMT and/or
cialised clinics can also contribute to the stigma and to reduce misuse and diversion. However, supervised
make entering or staying in treatment unattractive for dosing is a contentious issue, since a positive cor-
opioid users who wish to separate themselves from relation is observed between methadone dosage and
other drug users. In addition, clinics may not be con- treatment compliance (13) but restrictive policies of
veniently located for all patients making it challeng- supervised dosing can discourage patients from enter-
ing for them to access treatment. Many countries ing and remaining in treatment (23,34). Furthermore,
combine both options, often with linkages established supervised dosing may not have the intended effect:
between community-based physicians and specialist misuse and diversion of prescribed medications of-
treatment clinics, allowing a ‘shared-care’ approach ten occurs despite supervised dosing (2,3,6,30,31).
to patient care. These types of structural differences In addition to treatment access and setting, provision
may have an important impact on how easily opioid of psychosocial counselling, availability of OMT op-
users can access treatment, how they behave while in tions, dose levels and the use of supervision, there
treatment, and the outcomes they achieve. are a multitude of other aspects of treatment delivery
Among opioid users who do present for treat- that may influence attitudes towards treatment and
ment, there is evidence that the quality of care they re- the likelihood that the benefits of treatment will be
ceive varies between countries and is often sub-opti- realised.
mal at the level of individual patients. One important The considerable variation in approaches to
illustration of this is inappropriate dosing of opioid treatment delivery and access across Europe pro-
medications during the critical induction phase and vides an opportunity to compare the impact of dif-
subsequent maintenance phase. For example, where- ferent treatment models on quality patient care and
as methadone induction should be conducted using a outcomes. However, few studies have sought to as-
‘start low, go slow’ approach (19,22), most guidelines sess the state of treatment across Europe using a con-
recommend that buprenorphine induction should pro- sistent methodology. The European Quality Audit of
ceed rapidly (11,21). Despite this recommendation, Opioid Treatment (EQUATOR) seeks to explore what
European studies have demonstrated that induction of is actually happening in the treatment of opioid de-
- 6 -
G. Fischer & H. Stöver: Assessing the current state of opioid-dependence treatment across Europe: methodology of the European Quality Audit of
Opioid Treatment (EQUATOR) project
pendence from the perspective of the physicians who communities within countries. Additional surveys,
provide treatment, the patients who receive it, and the which may supplement this analysis in the future, are
opioid users who are currently outside the treatment ongoing in other countries in Europe and beyond.
system, through a survey design covering a broad The rigour of the methodology used in the main
cross-section of topics relating to treatment access, EQUATOR survey was assessed retrospectively using
quality and outcomes. EQUATOR is one of the larg- a second sample of OMT patients (N=53) recruited
est ever evaluations of opioid-dependence treatment specifically for a retest reliability study. Patients were
in Europe and promises to generate important new in- recruited from multiple types of centres including
sights to guide future policy and practice. This article half-way houses, Narcotics Anonymous meetings,
presents a detailed overview of how the methodology hospitals and treatment centres.
of EQUATOR was designed and implemented in or-
der to achieve these aims, and a brief exploration of 2.2. Survey instrument
the current state of treatment across Europe.
Separate questionnaires were used for each of
2. Methods the three sample groups (see Appendix) and were
based on the instruments used in the previously re-
2.1. Subjects and setting ported 2009 Project IMPROVE study, which includ-
ed German opioid-dependent patients and users and
Three groups of individuals were recruited across physicians who were either active or inactive as treat-
ten countries between 2009 and 2012: physicians ac- ment providers (26). The German questionnaire was
tively treating opioid-dependent patients with OMT translated into the primary languages of each of the
(physicians), patients currently receiving OMT (pa- ten countries in EQUATOR as shown in Figure 1.
tients) and opioid users not currently in OMT (users). The topics addressed by the questionnaires are
The majority of users had prior experience of OMT. summarised in Table 1. The patient, user and physi-
A single-point-in-time, self-report survey design was cian questionnaires had approximately 60, 40 and 50
employed to capture as much data as possible from core items respectively, and required approximately
the broadest possible sample. Patients (N=2298), us- 40, 30 and 45 minutes to complete. Each participat-
ers (N=887) and physicians (N=703) completed the ing country was permitted to add a limited number of
survey in ten participating European countries (Aus- questions of local relevance but only the core ques-
tria, Denmark, France, Germany, Greece, Italy, Nor- tionnaire items common to all countries are included
way, Portugal, Sweden, UK). Minor variations from in the EQUATOR analysis. Using standard questions
the overall design included: across the countries allowed direct comparisons to be
• In Germany, an additional sample of physi- made and increased the power of the individual coun-
cians authorised to prescribe OMT but not try surveys. Additional local questions may be includ-
currently doing so was surveyed and is ex- ed in publications specific to the country in question.
cluded from the EQUATOR analysis
• In Italy, there was no sample of opioid users 2.3. Procedures
out of treatment due to legal constraints on
surveying this population Participants were identified and recruited us-
• In Portugal, a sample of patients in non- ing convenience sampling methods given the limited
OMT treatment was included in the local treatment community and difficulty in accessing opi-
survey but is excluded from this analysis, oid-dependent individuals. Physicians were identified
since no other countries collected data from by research collaborators/advisers or via official lists
patients in non-OMT treatment. This sam- or the internet; patients via physicians and/or treat-
ple of patients may be included in publica- ment centres and users via user groups and support
tions that focus exclusively on the Portu- centres. Information was gathered anonymously and
guese data. kept confidential. Participation was voluntary and all
In order to increase comparability of the sample participants were informed about the study and pro-
and generalisability of the results, participants were vided consent prior to participating. To allow statisti-
recruited from a wide geographical distribution in cally meaningful comparisons to be made according
each country and an array of location types represent- to which treatment option patients received, strati-
ative of the predominant treatment settings and user fied sampling was employed to increase the power
- 7 -
Heroin Addiction and Related Clinical Problems 14 (3): 5-70
Translated

UK

German

  English

ques+onnaire
  ques+onnaire

Denmark

Back-­‐translated

Not

translated,

changes
 to

Norway

Qs
 only

bT
Translated

  acra
Austria
  kn
Switzerland
  Sweden
  -­‐transslated
la
 a
tednd

Not
  Portugal

translated,

changes
 to

Qs
 only

Italy

French

  French

ques+onnaire
  ques+onnaire

Greece

Cross-­‐checked

Figure 1: Translation of questionnaires from German into other languages
of smaller sub-populations of patients. Recruitment sic items for daily use (e.g., backpack, windbreaker,
minimums were set for each of the main opioid treat- shampoo) and patients in Italy, where regulations did
ment medication options (usually methadone, bu- not allow reimbursement. Results from the question-
prenorphine and buprenorphine–naloxone) for each naires were entered into a database collated by the
country; however, there were no caps on recruitment. market-research company.
All countries had to meet a minimum quota of 30 The retest reliability data capture followed the
patients per medication option for it to be reported same procedures as those for the main survey, except
separately. that participants were administered the same ques-
Data were collected on behalf of the research tionnaire on two occasions within 5–14 days of each
collaborators/advisers by independent market re- other. Participants were given US$10 after initially
search agencies in each country in accordance with completing the survey and were given another US$20
the European Pharmaceutical Market Research Asso- upon completion of the retest.
ciation (EphMRA) code of conduct. Physician data
were collected using telephone or face-to-face inter- 2.4. Statistical analyses
views, while patient and user data were collected us-
ing paper-and-pencil questionnaire packs distributed Data from the 10 countries in the main survey
by participating treatment providers (in the case of were merged into a pan-European data set (EQUA-
patients) or user support centres (in the case of us- TOR). Where differences occurred in the wording of
ers), which were self-completed and returned by post. responses (e.g., highest level of schooling attained),
After completing the survey, participants were re- the different wordings were mapped into equivalent,
imbursed for their time. Methods of reimbursement standard wording to increase comparability. Re-
varied across countries. Physicians received cash in- sponses that could not be modified in this way were
centives (~€40–70); support centres were given cash handled and analysed separately. ‘Tick all that apply’
or equipment donations for their support with users items and collective score coding were also checked
not on OMT; patients and users received a grocery for internal consistency. Open-ended questions were
voucher of ~€25–40 or vouchers for food/hot drinks, excluded from this analysis but may be included in
except users in Portugal, who received a pack of ba- future publications.
- 8 -