Substitution management in opioid dependence.

Substitution treatment (replacement therapy) is the most widespread and the most frequently researched therapeutic approach to heroin dependence. At present, the "gold standard" is methadone maintenance, but the use of other agonists and of combined compounds with antagonists are increasingly used, especially Buprenorphine. This paper reviews the main findings from research and their consequences for best practice rules. The evolution and organisation of substitution treatment in Europe is described, indicating a major discrepancy in administrative regulations. Emerging trends are also mentioned, as well as the merits and limitations that mark the place of substitution treatment in a comprehensive therapeutic network for opioid dependence.

[8 years experience with heroin-assited treatment in Switzerland--current results and future improvements]. / Acht Jahre Erfahrung mit der heroingestützten Behandlung in der Schweiz--aktuelle Ergebnisse und künftige Weiterentwicklung.

In 1994, Switzerland introduced experimental heroin assisted treatment for refractory opioid addicts as last line of treatment. An evaluation research was established examining effectiveness and cost-benefit of heroin-assisted treatment for the first project phase between 1994 and 1996. The present publication intends to provide an overview for the newer results of the evaluation. In summary, the positive outcomes found at first follow-ups continued to persist regarding somatic and mental improvements, social integration including reduction of criminal behaviour, and reduction of use of illicit drugs. In future, treatment of co-morbid mental disorders, integration into the labour market and persistent consumption of cocaine in some patients still need focussed attention. Different efforts to assure quality control and development hopefully will serve towards further optimisation of heroin-assisted treatment.

[Heroin-assisted treatment of opioid addicts in Switzerland from 1994-2001--utilisation and characteristics of admissions and discharges]. / Heroingestützte Behandlung für Opioidabhängige in der Schweiz von 1994-2001--Inanspruchnahme und Charakteristik der Ein- und Austretenden.

BACKGROUND OBJECTIVES: Since the beginning of the 1990 s the number of treated opioid addicts has markedly increased in Switzerland. This study examines the cause of health service utilisation of one specific type of treatment--heroin-assisted maintenance--the length of stay in this kind of treatment, and characteristics of admissions and discharges. METHODS AND SAMPLE: Data on all admissions into and discharges from heroin-assisted treatment were collected from the start of this treatment modality on January 1, 1994 to December 31, 2001. These data were used to calculate length of stay, and number of patients at the end of each calendar year. Data were analysed according to sex and age and the Kaplan-Meier survival statistics were calculated. Finally, the discharges from 1994 to 1998 were compared to the discharges of 1999 up to December 2001. RESULTS: Since the introduction of heroin-assisted treatment, the number of patients in this form of treatment has markedly increased. Simultaneously, the average age of the patients entering treatment increased, whereas the proportion of women decreased continually. Compared to the earlier phase (1994-1998), in the last three years fewer patients terminated treatment at an early stage (within the first 4 months). CONCLUSIONS: Substitution programmes are the most common form of treatment for opioid dependence in Switzerland. The increase in the average age of patients in this treatment modality as well as in the abstinence-oriented treatment at admission may be interpreted favourably as an indicator that fewer less young people are opioid dependent than at the beginning of the 1990 s. The decrease in the proportion of females may be an indicator that females were overrepresented in heroin-assisted treatment at the beginning of this treatment modality and that the proportion gradually became more similar to the proportion in the opioid-dependent population as a whole. The decrease of early treatment terminations can be seen as positive, since with longer length of stay the probability of changing into abstinence-oriented treatment is becoming more probable.

Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study.

BACKGROUND: Heroin-assisted substitution treatment for severely opioid-dependent drug users has been available in Switzerland since 1994. Our aim was to ascertain the feasibility, safety, and efficacy of this treatment. METHODS: We did a cohort study in 21 community outpatient treatment centres. We assessed 1969 opioid-dependent drug users, who began heroin-assisted substitution treatment between January, 1994, and December, 2000, to ascertain admission and discharge patterns, and patient characteristics. We also followed up a subset of 237 patients who began treatment between Jan 1, 1994, and March 31, 1995, and who stayed with the programme for at least 18 months. We used questionnaires, interviews, and medical examinations done at entry and after 6, 12, and 18 months to assess somatic and mental health, social integration, and treatment outcomes. FINDINGS: More than 70% (1378) of patients remained in treatment for more than a year. Treatment showed positive effects with respect to health and social outcomes. A long stay in treatment was related to a higher chance of starting abstinence-oriented therapy than a short stay. INTERPRETATION: Heroin-assisted substitution treatment might be an effective option for chronically addicted patients for whom other treatments have failed.

[Tobacco prevention in apprentices--evaluation of a general practice project "not smoking is cool!"]. / Tabakprävention bei Lehrlingen--Evaluation des Praxisprojekts "Nichtrauchen ist cool!"

PURPOSE: In recent years the incidence of adolescent smokers has increased steeply. Taking this into account, current anti-smoker campaigns should be reconsidered. Great importance must be attached to the apprentice group, since adolescents in professional training have frequently not been reached sufficiently by the preventive efforts. This study presents a tobacco prevention campaign among adolescents which was conducted in a large Swiss industrial company in 1998. METHODS AND SAMPLE: A total of 430 apprentices took part in the prevention campaign which intentionally targeted adolescent behaviour. Of these, 40 apprentices were trained as mediators for tobacco prevention in advance. On the prevention day, the mediators communicated their know-how and experiences to their working groups. To evaluate the campaign, the apprentices were surveyed via standardised questionnaires on their smoking habits before the prevention campaign began. One month after the prevention day they were surveyed again on their current smoking habits and how the campaign had affected them. RESULTS: The study showed that apprentices smoke heavily despite high awareness of the negative consequences. Some 30% of the trainees admitted smoking regularly. Another 11% said they were occasional tobacco consumers. No significant gender difference was noticeable. Especially striking was that the adolescents often justified their own smoking as habit and dependence on tobacco. The prevention campaign was well received by the adolescents. It set about half of the smokers thinking over their smoking habits. No change in smoking habits, however, could be demonstrated one month after the campaign. CONCLUSIONS: Prevention among adolescents beyond the mandatory school period is a special challenge, since one cannot take advantage of the school's network. Within the scope of the campaign described here, it was possible to reach 430 apprentices of a major company. The study shows a great need for on-target smoking prevention in this sector. In the future, studies should examine whether tobacco prevention campaigns for apprentices should already contain secondary prevention elements from the outset. They should also assess if the effects could be further improved by introducing structural and other ongoing health-promotion measures.

[Heroin-assisted treatment of opiate addicts--former and current research emphasis]. / Die heroingestützte Behandlung von Opiatabhängigen--bisherige und aktuelle Forschungsschwerpunkte.

Heroin-assisted treatment has been examined broadly in Switzerland since 1994 within the context of scientific studies. The goal was to clarify the suitability of this treatment for opiate addicts whom previous therapy had failed to reach. Results of the initial research phase show that the target group could be reached for treatment extending 18 months with a satisfactory retention rate of 69%. The patients could improve their health and social situation during treatment and reduce illegal consumption of narcotics. Studies during the initial years primarily examined the viability of heroin-assisted treatment and its effects on the patients' psychosocial and somatic development. A second study phase ongoing since 1998 pursues the specific importance of medical and psychosocial treatment for patients' health and social development in heroin-assisted treatment. The focal point is the effort to optimise treatment of patients with comorbidity of psychiatric disorders and severe somatic diseases, particularly AIDS. Investigations carried out in Switzerland have been discussed broadly at an international level. Studies on heroin-assisted treatment are also being conducted at present in various countries. In future, co-operation should be further intensified with researchers on an international scale.

[New treatment concepts in smoking cessation]. / Neue Behandlungsansätze bei der Rauchertherapie.

Although the smoking rate in Switzerland had declined during the 1970s and 1980s, it has not continued to decrease during the 1990s. About one third of the population in Switzerland smoked in 1997. Striking is a sharp increase in young female smokers during recent years. The portion of 15- to 25-year-old female smokers rose from 26% (1992) to 41% (1997). This undesirable development calls for making the most of preventive initiatives to date. Beside primary prevention steps, the range of assistance for smokers also needs to be extended. In addition to the smoking withdrawal counselling introduced, development of a range of programmes should also be expanded to assist smokers who have currently been unable to quit. Reduction in the number of cigarettes smoked within the framework of intensive specialist care can make sense in this situation. In the near future, pharmacological aids (nicotine substitute preparations) are also anticipated for this purpose. The most important resources for such smoker counselling will be presented. Future studies should focus on optimising reduction treatment as a new approach toward treatment.

[Economic evaluation in a trial of medically controlled prescription of narcotics to dependent users (PROVE)]. / Gesundheitsökonomische Bewertung der Versuche für eine ärztliche Verschreibung von Betäubungsmitteln (PROVE).

In the 1994-1996 trial of medically controlled prescription of narcotics to dependent users, 800 places were ascribed to heroin substitutes and another 200 for methadone and morphine substitutes. The trial was evaluated with the aid of an accompanying research. Among the results demonstrated in the evaluation was an improvement of the health of the participants. The economic assessment was drawn from observations of health effects within a sub-sample of 142 participants from four centers. In a retrospective statistical survey, for each acute illness which could be influenced through the trial, the number of diagnoses was recorded in the first and thirteenth month after study entry. Also, based on a number of representative cases for each of these acute illnesses, the resource use, i.e. the types and numbers of medical products and services rendered to the patients, was recorded. The results showed a clear decline in depressive episodes, skin diseases, digestive system disorders as well as epileptic attacks and intoxication. Treatment costs could be reduced from a total of CHF 94875.--to CHF 21,998.--/month or from CHF 22.27 to CHF 5.15/patient per day. The improvement of somatic and psychic health due to the medically controlled prescription of narcotics resulted in a benefit of CHF 17.11/person per day.

[How much truth can the patient endure?]. / Wieviel Wahrheit erträgt der Patient?

Truth is not conceived by the doctor alone who then is expected to communicate it to an uninformed patient. Diagnostic and prognostic findings in each individual case are a result of an interactive process, where the patient as well as the doctor are participating. Adequate information of patients is inevitable, but in practice not yet quite satisfactory. Some proposals for improvement are made.

[Schizophrenia and substance dependence]. / Schizophrenien und Suchtrankheiten.

A review of epidemiological data regarding the prevalence of substance abuse in schizophrenia and vice versa points out differences which are hard to interpret, owing to inconsistent sampling procedures and to the application of different diagnostic criteria. Stimulant abuse in schizophrenics has apparently increased over the years, eventually alcoholic abuse, whereas no increase is evidenced for cannabis abuse. Patients with dual diagnosis have an increased risk for morbidity and mortality, for psychotic relapse and for social disintegration. No increased risk for schizophrenic psychosis is found for drug abusers. Possible explanations why schizophrenics could show an increased susceptibility to become substance abusers are discussed, and therapeutic recommendations added.

[Diversified prescription of narcotics to heroin addicts. Basis, design, research plan]. / Diversifizierte Verschreibung von Betäubungsmitteln an Heroinabhängige. Grundlagen, Versuchsplan, Begleitforschung.

The measures taken by the National Government in 1991 against drug problems in Switzerland included new therapeutic experimentation; among others, it mentioned trials with diversified prescription of narcotics (including injectable heroin, morphine and methadone as well as smokable heroin and cocaine) to heroin-dependent persons with severe health and/or social problems. The number of persons receiving heroin is limited to 250, for a period not exceeding the end of 1996. The trials have to respond to scientific criteria of evaluation as well as to standards of comprehensive care. Research questions concern the feasibility, the efficacy and the cost effectiveness of trials in comparison with usual methadone maintenance programs. First trials started in Zurich, others are planned in Basle, Berne, Fribourg, Olten, Schaffhausen, Thun and Zug.

[Current drug problems]. / Aktuelle Drogenprobleme.

From the multifaceted and complex catalog of problems in drug abuse those are selected that are relevant for medical practise. After a short introduction the situation of drug abuse in the canton of Zürich is described, based on estimates about users, descriptions of consumed amounts, market prices of heroine and cocaine and a summary of some epidemiologic data and the sequelae of drug-dependence. In a second part substitution by methadone is described in detail. In a third part cocaine with its effects and adverse effects is presented in more detail.

[Epidemiology of substance dependence]. / Epidemiologie der Suchtmittelabhängigkeit.

Objectives of epidemiological research in the field of substance dependence are presented, as well as the main sources of information and some problems of data collecting. Concerning the nature and degree of substance dependence and their adverse consequences, the present state at a global level is described and also the main trends. Factors are discussed which may have an impact on future developments. Furthermore the usefulness of epidemiological data in the analysis of risk factors and in the analysis of intervention effects are discussed.

[The psychiatrist at the institution]. / Der Psychiater in der Institution.

The role of psychiatrists working in institutions is interdependent with a number of factors such as: changes in needs for care, changes in the structure of institutions and interinstitutional collaboration, demands for a professional training adequate to future priorities in psychiatric care. Problems and some experiences are discussed on the levels of psychiatric residents, psychiatric executives and external supervisors or consultants.

[AIDS epidemiology and prevention in i.v. drug addicts]. / AIDS-Epidemiologie und Prävention bei i.v.-Drogenabhängigen.

The incidence of AIDS cases in intravenous drug abusers is growing faster than in other risk groups, in Switzerland as well as in Europe in general. By end of May 1988, 27% of all AIDS cases registered nationally were injecting drugs. The prevalence of HIV antibodies is known from selected samples only, on the basis of voluntary testing. In 1986, among all intravenous drug users in residential treatment nation-wide, 90% were tested and thereof 55% seropositive. In a sample of drug abusers in out-patient treatment in Zurich in 1987, seropositivity was documented for 42% of male and 63% of female patients. According to registered AIDS cases, there is no differential risk for both sexes. Duration of intravenous drug abuse is the only relevant risk factor so far. Preventive change in risk taking behaviour is a minimalization of utilizing contaminated syringes/needles and a minimalization of unprotected sex (safer sex by regular use of condoms). An analysis of published data demonstrates that dissemination of information and availability of syringes/condoms are a pre-requisite for behaviour change, but by no means sufficient in order to elicit behaviour change. Drug abusers engaged in out-patient/residential treatment are available in high proportions for voluntary testing and for the intended behavioural changes. It is therefore of primary preventive interest to engage as many intravenous drug abusers as possible in treatment. Apart from drug-free residential treatment, out-patient treatment using Methadone provides positive results, whereas compulsory measures are considered to be of doubtful value.