Ambros Uchtenhagen

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.

Quasi-Compulsory Treatment of Drug Dependent Offenders: An International Literature Review

This paper reports on a review of the literature on the quasi-compulsory treatment (QCT) of drug dependent offenders in five languages; English, German, French, Italian and Dutch. The findings of this review on previous reviews and on the availability, process, and outcomes of QCT are summarized. The review found that previous, anglophone reviews have tended to present positive outcomes from QCT, but that there are some problems with this research. QCT is increasingly available internationally, but may be applied at different stages of the criminal justice process, and to different types of offender. Research on the process of QCT is comparatively rare. The available research does suggest problems of system integration between criminal justice and treatment agencies in implementing QCT. The research in languages other than English shows a wider range of outcomes (including negative effects) for QCT than was found in the English literature. We conclude that the international literature shows that QCT does not inevitably produce worse outcome than voluntary treatment, but that we need more multimethod, multisite studies of QCT in order to inform policy and practice, which is currently being made in the absence of reliable evidence in many countries.

Evaluating Long-Term Effects of Heroin-Assisted Treatment: The Results of a 6-Year Follow-Up

Since January 1994, heroin-assisted treatment for opiate addicts has been available in Switzerland. This is the first report of the long-term effects of this form of treatment. The report examines subjects who entered a study involving medical prescription of opiates (Projekt zur ärztlichen Verschreibung von Betäubungsmitteln; PROVE) in Switzerland between January 1994 and March 1995 (n = 366). Opiates were dispensed in eight treatment centres. A follow-up was conducted 6 years after treatment entry. Two groups were assessed: clients who have continuously been on heroin-assisted treatment since entry into the PROVE study or who re-entered this treatment, and ex-clients who had discontinued heroin-assisted treatment at the time of follow-up. Two kinds of comparisons were conducted. Firstly, conditions at treatment entry were compared to 6-year follow-up outcomes, and secondly, outcomes were compared between clients still on heroin-assisted treatment and those who had been discharged. It was found that 46% of the clients still alive were on heroin-assisted treatment at the time of follow-up. A comparison of the present living conditions showed very little difference between those in treatment and those who had terminated treatment. Compared to the situation at entry, the results of the follow-up showed a significant decrease in the use of illegal substances, illegal income and most other variables concerning social conditions, but they also showed an increase in unemployment and reliance on social benefits. Heroin-assisted treatment is thus efficacious in the long-term course of treatment and is still effective after termination of treatment with respect to living conditions and use of illicit substances.

The Relationship between Legal Status, Perceived Pressure and Motivation in Treatment for Drug Dependence: Results from a European Study of Quasi-Compulsory Treatment

This paper reports on intake data from Quasi-Compulsory Treatment in Europe, a study of quasi-compulsory treatment (QCT) for drug dependent offenders. It explores the link between formal legal coercion, perceived pressure to be in treatment and motivation amongst a sample of 845 people who entered treatment for drug dependence in five European countries, half of them in quasi-compulsory treatment and half ‘voluntarily’. Using both quantitative and qualitative data, it suggests that those who enter treatment under QCT do perceive greater pressure to be in treatment, but that this does not necessarily lead to higher or lower motivation than ‘volunteers’. Many drug-dependent offenders value QCT as an opportunity to get treatment. Motivation is mutable and can be developed or diminished by the quality of support and services offered to drug-dependent offenders.

The Victimization of Dependent Drug Users Findings from a European Study, UK

This article contributes to the literature on drug users, victimization and offending using data on 545 dependent drug users entering treatment in four European countries. Members of the sample were exposed to high levels of criminal victimization. Sub-groups who were particularly vulnerable to crime were women (and especially sex workers), the homeless, recent offenders and those with a history of poor mental health. Multivariate analysis indicated that frequent drug use, recent offending and histories of depression and anxiety were significantly predictive of violent victimization, and only gender and a history of anxiety were significantly predictive of property victimization. The article discusses how these findings relate to theoretical approaches to victimization, in both positivist and critical frameworks.

Comparing outcomes of ‘voluntary’ and ‘quasi-compulsory’ treatment of substance dependence in Europe

Aim: This study evaluates quasi-compulsory drug treatment (QCT) arrangements for substance-dependent offenders receiving treatment instead of imprisonment in comparison to voluntary treatment within five European countries. Methods: Participants were interviewed with the European Addiction Severity Index, the ASI-crime module, questions on perception of pressure and self-efficacy, and the Readiness-to-Change Questionnaire at treatment entry and after 6, 12, and 18 months. Results: Reductions in substance use and crime as well as improvements in health and social integration were observed in QCT and voluntary treatment groups. After controlling for various factors, subjects in the QCT and the comparison group showed similar reductions in substance use and crime over time. Study retention was comparable in both groups. Conclusion: QCT is as effective as voluntary treatment provided in the same services in reducing substance use and crime.

Substance use problems in developing countries

“Recurring economic and political crises in various parts of the world, serious environmental problems, and widespread insecurity about the future” (W1) have increased the gap between rich and poor, between countries and also within countries. What do we know about the role of substance use and the risk factors and impact of sub-stance use problems in this context?The problems have to a large extent been stabilized in developed countries that have been exposed to substance use for decades, in contrast to many develop-ing countries and countries with former socialist economies (2). Alcohol use is rising rapidly in some of the developing regions (W3): early onset and excessive drinking are reported; large increases in cigarette smoking are also documented (4). For illicit drugs, data are more dif-ficult to obtain. Major increases in inject-ing drug use, which carries the highest health risks, are recorded: opiate injecting in eastern European countries and south and South-East Asia, and amphetamine injecting in many regions (W5).Research on social and environ-mental factors contributing to such increases has been less extensive in the developing world, but indicators and case studies (6, 7) direct attention to urban-ization, poverty, migration, technological change, educational deficits, and vested interests in marketing substances (W8).In Asia, Africa and Latin America, urban populations increased from 16% to 50% of the total. “Increased stressors and adverse events, such as overcrowded and polluted environments, poverty and dependence on a cash economy, high levels of violence and reduced social support” (9) have deleterious conse-quences for mental health in general and substance use problems in particular, in-creasing the risk of heavy drinking. Half of the urban populations in low- and middle-income countries live in poverty, and tens of millions are homeless; 77% of Brazilian street children drink heavily. Associated with poverty are unemploy-ment, low education and deprivation, all contributing to higher prevalences

Programme for a Medical Prescription of Narcotics

The national study on medically controlled prescription of narcotics (heroin, morphine and intravenous methadone) was evaluated and a report on the main findings is made available, based on the main study and a number of additional special studies. The study with an intention-to-treat design includes data on 1035 probands. They received treatment following a uniform study protocol in 17 out-patient clinics and 1 penitentiary. The attribution of substances varied however (2 double-blind studies, 3 randomisation studies, the rest followed an individual indication). Intravenous heroin was well accepted and superior to intravenous morphine and methadone concerning compliance (reduction of illegal drug use) and retention, due to less negative side-effects. Dosages were stabilised, no lethal overdose occurred. The study documented significant improvement in health and social status of participants, especially in a reduction of depressive and anxiety states, of contacts with the drug scene and of illegal activities and prostitution. Half of those who left treatment proceeded to detoxification or methadone maintenance. Mortality, to a large extent due to infectious diseases acquired before participation in the study was by 1 % of the cohort per year. A continuation of this treatment approach is recommended for chronic and marginalised heroin addicts who failed in other treatment modalities. Similar conditions and safety controls as established for the study should be applied.

Modes and Impact of Coercive Inpatient Treatment for Drug-Related Conditions in Switzerland

Background: Two forms of institutionalized pressure to treatment can be distinguished in Switzerland: civil commitment and court referral. In court referral, the referred patient has the right to refuse treatment. Objectives: To compare court referrals for inpatient treatment to voluntary therapy. Methods: Comparison of interviews at treatment entry and discharge records. Results: There were few systematic differences at entry except for voluntary subjects having had less contact with the legal system before treatment, independently of the specific court referral. At discharge, voluntary patients had a better social integration and fewer legal problems. Discussion: Legal problems waiting for court referrals at discharge may be a significant handicap for reintegration. Otherwise, voluntary patients and court referrals showed few systematic differences in inpatient treatment.

Die heroingestützte Behandlung von Opiatabhängigen Erfahrungen aus den Schweizerischen Versuchen für eine ärztliche Verschreibung von Betäubungsmitteln (PROVE)

Zum ThemaDieser Studienbericht über die heroingestütze Behandlung von Opiatabhängigen ergänzt den anderen Artikel im gleichen Heft, in dem über die Methadon-Substitution referiert wird (vgl. die Arbeit von M. Krausz et al.). Bemerkenswert ist, daß die Verschreibung von injizierbarem Heroin der von injizierbarem Morphin und Methadon hinsichtlich der Rekrutierbarkeit, Verweildauer in Behandlung und Compliance überlegen ist. Als positiv ist auch die geringere Nebenwirkungsrate bei Heroin-Substitution einzustufen.Im einzelnen wird sodann über den somatischen Zustand der Abhängigen, den Konsum von illegalem Heroin und Kokain, die soziale Integration, Delinquenz, Haltequote und Sterberate referiert. Zu den wesentlichen Daten der Hauptstudie, die Thema dieser Arbeit ist, seien Interessierte besonders auf die begleitenden medizinischen, sozial- und wirtschaftswissenschaftlichen Studien verwiesen, die im Text erwähnt und im Literaturverzeichnis aufgeführt sind.