One size does not fit all-evolution of opioid agonist treatments in a naturalistic setting over 23 years.

BACKGROUND AND AIMS: Opioid agonist treatment (OAT) is currently the most effective treatment for people with opioid dependence. In most countries, however, access to the whole range of effective medications is restricted. This study aims to model the distribution of different OAT medications within a naturalistic and relatively unrestricted treatment setting (Zurich, Switzerland) over time, and to identify patient characteristics associated with each medication. METHODS: We used generalized estimating equation analysis with data from the OAT register of Zurich and the Swiss register for heroin-assisted treatment (HAT) to model and forecast the annual proportion of opioids applying exponential distributions until 2018 and patient characteristics between 1992 and 2015. RESULTS: Data from 11 895 patients were included in the analysis. Methadone remains the mainstay of OAT, being prescribed to two-thirds of patients. Following its approval, the proportion of HAT increased rapidly and is now constant at 12.16% [95% confidence interval (CI) = 11.15-13.17]. The initial increase of proportions of buprenorphine or slow-release oral morphine (SROM) following their approval for OAT was slower. While in 2014 both medications had a proportion of 10.2% and 10.3%, respectively, our model predicts a further increase of SROM to 19.9% in 2018, with a ceiling level of 25.19% (21.40-28.98%) thereafter. SROM patients display characteristics similar to those treated with methadone; buprenorphine patients show the highest social integration; and HAT patients are the most homogeneous group, with highest mean age, most widespread injecting experience and lowest social integration. CONCLUSIONS: Based on data from Zurich, Switzerland from 1992 to 2015, there is no evidence for an excessive demand for a single medication in a naturalistic and liberal opioid agonist treatment setting. Rather, the specific patient characteristics associated with each medication underline the need for diversified treatment options for opioid dependence.

Symptom complaints of patients prescribed either oral methadone or injectable heroin.

Many methadone patients and untreated heroin users have an ambivalent attitude toward methadone maintenance. This may be a result of the widespread belief that methadone produces various side effects not found with heroin. This study compared the symptom complaints of patients on oral methadone maintenance (MMT) with those of patients prescribed injectable heroin (IHT). A convenience sample of 117 (63 MMT, 54 IHT) patients was recruited from two maintenance clinics. With the use of a self-completion questionnaire, patients were interviewed about a range of symptoms they had experienced and which, in their view, were due to maintenance substance immediately after the last 10 opioid administrations, during the previous week and previous year. The complaints of the two groups overlapped considerably with only few significant differences; these appeared related to the route of administration. IHT patients reported a larger number of complications experienced immediately after administration than MMT patients (p = .007). From the patients' view, methadone does not produce many more or side effects very different from heroin and thus seems at least as tolerable as heroin for maintenance treatment.

Complaints of heroin-maintained patients: A survey of symptoms ascribed to diacetylmorphine.

Prescribing of injectable diacetylmorphine (DAM) for heroin dependence has raised concerns about its safety. In light of various reports by heroin-maintained patients of DAM-related adverse events, and previously established unwanted effects of opioids in pain management, we undertook a survey in February 2001 of a random sample of 132 (127 participated) of 1061 patients prescribed DAM in Switzerland at that time. The purpose was to document the prevalence rates of a list of unintended symptoms experienced and attributed to DAM by patients. To assess symptom complaints and other data, staff administered a six-page self-report questionnaire. The patients ascribed numerous symptoms to DAM, with the best-known being the most frequently reported (e.g. skin itching, sweating, constipation). Among potentially more problematic complaints ranged irregular menses, cognitive deficits, muscle twitches, labored breathing, pains in the cardiac region, and temporary paralysis of limbs. In the absence of a control group, however, these may also be due to other factors, such as expectation, co-medication, concomitant substance use or co-morbidity. This pilot study emphasizes the necessity of rigorous assessment of the true rates, types, severity and preventability of such complications, especially given the current efforts to establish heroin maintenance as an optional treatment for heroin dependence.