Cyprus is a member state of the European Union (EU) with a population of 855 000 inhabitants, comparably high living standards and a low unemployment rate. Despite its relative wealth, mental healthcare expenditure is considered low compared with the average in the EU. People with substance use disorders in Cyprus usually seek treatment in the public sector but can also be treated privately. The country has 11 psychiatrists per 100 000 people, compared with an average of 16 per 100 000 in the EU (European Commission, 2017). There are currently only two psychiatrists working full time in the department of addiction psychiatry in the public sector.
Heroin and other opioids
It is estimated there are up to 1200 high-risk opioid users in Cyprus. In 2016, 253 of them were undergoing opioid substitution treatment (OST). The average number of drug-induced deaths in Cyprus is eight per year, of which 90% are males who use opioids intravenously (European Monitoring Centre for Drugs and Drug Addiction, 2017). Causes of death include both illegal opioids and legal opioids diverted from medical to recreational use, as well as legally prescribed opioids for medical use.
Until 2007, there was no OST available in Cyprus. The only available treatment was within abstinence-based therapeutic communities. In August 2007 the first OST unit (named ‘Gefyra’ meaning ‘The Bridge’) opened in Nicosia, the capital city of Cyprus. The unit started with 13 patients in 2017, increased to 32 in 2011 and to 84 patients in 2017. A low-threshold approach was implemented in this harm-reduction intervention in recent years, especially after 2011, because an increasing body of evidence suggested there were generally better treatment outcomes for low treatment-threshold compared with high treatment-threshold designs (Kourounis et al, Reference Kourounis, Richards and Kyprianou2016). The OST program aimed to improve accessibility to treatment and to offer personalised treatment options regarding medication choice and dose titration, as well as flexibility of treatment duration. There is an emphasis on maintenance, harm reduction and retention of low adherence patients.
In recent years the number of OST units in the public sector has increased from one to five (one in each of the main cities of Cyprus). In addition, an OST service is now available in the prison setting. The main medication that is used in all OST programs is a combination of buprenorphine plus naloxone for short-term as well as for long-term/maintenance treatment, following established guidelines (Taylor et al, Reference Taylor, Paton and Kapur2015). Methadone is only used for short-term in-patient use until the patient is cross-titrated to a buprenorphine–naloxone combination, which increases safety. In the private sector, oxycodone and dihydrocodeine have also been used for OST.
Cannabis
In Cyprus, cannabis for personal recreational use is illegal. Medical cannabis is strictly controlled by the Ministry of Health and only a few people are approved each year to receive it, mainly in the form of cannabis oil. Currently, there is a draft law under discussion for the regulation of medical cannabis; it includes a provision for medical use in specific circumstances (House of Representatives, 2018). The prevalence of recreational cannabis use is stable, involving less than 5% of the population. Nevertheless, within that sub-population there has recently been a decrease in the use of herbal cannabis and an increase in synthetic cannabinoids.
Cannabis-induced psychoses are treated in out-patient psychiatric clinics in the public and private sectors. When accompanied by severe behavioural disturbance, patients are treated in a psychiatric hospital, usually under court-ordered, temporary, obligatory admission to hospital. Cannabis users who commence treatment on an out-patient voluntary basis are usually offered only counselling, with the addition of psychiatric care if they present with psychotic symptoms or with other psychiatric comorbidity.
Cocaine and other stimulants
In 2016, cocaine, 3,4-methylenedioxymethamphetamine (MDMA) and amphetamines were used only by 0.4, 0.3 and 0.1% of the population aged 15–34 years, respectively. There are no available data regarding stimulants classified as new psychoactive substances. Despite their relatively low popularity among young people, those taking recreational stimulants are receiving treatment disproportionally often; they constitute over 15% of people that are treated for a substance use disorder. It is notable that stimulants comprised three of the five most commonly seized classes of illicit drugs in Cyprus over the past year (European Monitoring Centre for Drugs and Drug Addiction, 2017).
The prevalence of both cocaine and amphetamine misuse in Cyprus peaked in 2009. There has been a consistent decrease each year since then. MDMA is currently rarely taken and its use has steadily decreased, at least since 2006. Despite this, a recent multi-city wastewater study found Limassol to be among the top ten European cities for crystal methamphetamine use, which is a relatively new drug in Cyprus (European Monitoring Centre for Drugs and Drug Addiction, 2018).
There is no dedicated program for the treatment of stimulant use disorder, but detoxification, rehabilitation and relapse prevention are offered in the general addiction psychiatry setting. Most of these patients also present with mental health comorbidities that are treated in an integrative care setting. The young stimulant misusers are referred to a special counselling centre for adolescents in the public sector.
Alcohol
The first drug and alcohol detoxification and rehabilitation centre, named ‘THEMEA’, was established in the public sector in 1991 as a division of the Psychiatric Clinic of the General Hospital of Nicosia. Originally, that unit only had four beds and admitted ‘alcoholics’ as well as people with illegal substance use disorder, who were known at that time as ‘drug addicts’.
Alcohol is a very popular legal recreational substance in Cyprus, with the prevalence of alcohol use disorder just below the European average, at around 3%. There is an increasing prevalence of alcohol use among adolescents in Cyprus. A recent multi-centre study of 15- to 16-year-old school students found that almost all of them had taken recreational alcohol at some time and 70% reported alcohol use within the past 30 days, compared with a European average that is less than 50% at that age (European Monitoring Centre for Drugs and Drug Addiction, 2015).
At present, THEMEA is still the only drug and alcohol detoxification and rehabilitation centre in the public sector in Cyprus. It has been developed into a university clinic that offers full in-patient and out-patient detoxification, rehabilitation and relapse prevention services under the care of an experienced multidisciplinary team including addiction psychiatrists, clinical and counselling psychologists, specialist nurses, an occupational therapist and a social worker. Medical students of the three medical schools of Cyprus as well as residents in psychiatry are trained in this clinic during their rotation in the field of addiction psychiatry. The therapeutic program includes devising an individualised treatment plan. A biopsychosocial approach is used, which is divided into a short-term in-patient phase and a longer-term out-patient phase of treatment and relapse prevention. The treatment consists of a combination of pharmacological and non-pharmacological interventions, according to established guidelines (NICE, 2011). Non-pharmacological interventions include counselling, cognitive–behavioural therapy, mindfulness and behavioural techniques, which take place in an individual and/or group context. Since 2011 the therapeutic program is not entirely abstinence oriented; decreased/controlled alcohol consumption may now be a treatment goal for some patients, in line with published evidence (Adamson et al, Reference Adamson, Heather and Morton2010; Heather et al, Reference Heather, Adamson and Raistrick2010). Medications used in the treatment of alcohol and substance use disorders include naltrexone, nalmefene, disulfiram and baclofen.
Most patients have comorbidities – especially other substance use disorders, mood disorders or personality disorders – which are usually treated by the same multidisciplinary team in an integrative care setting (Prodromou et al, Reference Prodromou, Kyritsi and Samartzis2014).
Tobacco
Smoking cigarettes is very common in Cyprus, with 25% the population (37% of men and 14% of women) aged 15 and above being daily smokers. To help those tobacco-dependent people who want to stop smoking, public mental health services currently offer a structured smoking cessation program consisting of nicotine replacement treatment with patches along with a 3-month counselling intervention (Ministry of Health, 2018).
Discussion
Cyprus’ psychiatric community follows scientific evidence and international medical guidelines in the treatment of mental health disorders. Substance use disorders are considered to be chronic remitting and relapsing mental health disorders, as classified in DSM-5 (2013) and the forthcoming ICD-11. Treatment of legal or illegal substance use disorders is offered on a voluntary basis, in the public sector or privately. Despite this, drug possession for personal use is regarded by the law as a serious criminal offence. It is punishable by up to 12 years in prison for class-A drugs (opioids and cocaine). Recently, new legislation allows young drug users who are arrested for the first time to opt for treatment instead of prosecution and imprisonment.
As substance use disorders are usually chronic conditions, patients need long-term care using an evidence-based multidisciplinary biopsychosocial approach. The health services in Cyprus are changing to implement recent laws regarding the economic and administrative autonomy of public hospitals and an emerging general health system. Modern health policies, integrated with medical research achievements and clinical guidelines, will play an important role in advancing further the treatment of substance use disorder.
Open access
eLetters
No eLetters have been published for this article.