Peter Degkwitz

Long-term effects of heroin-assisted treatment in Germany.

AIMS Trials in Switzerland, the Netherlands and Spain have found that heroin-assisted treatment (HAT) as maintenance treatment for opioid-dependent patients reduces illicit drug use. A German trial also found diamorphine treatment to be superior to methadone treatment. The present study describes the association between 2 years of heroin treatment and improvements in health and social stabilization, as well as illicit drug use. DESIGN A prospective cohort study design. PARTICIPANTS A total of 515 patients were assigned to diamorphine treatment; 278 patients remained in the study treatment for the entire period of 24 months (54.8%). MEASUREMENTS The results on physical (Opiate Treatment Index Health Symptoms Scale) and mental (Symptom Checklist 90-Revised Global Severity Index) health and illicit drug use (number of days with drug use within the last month-European Addiction Severity Index) were examined by repeated-measures analyses. FINDINGS Symptoms of physical (Pillais trace = 0.837, df = 4, P < 0.001) and mental health (Pillais trace = 0.450, df = 4, P < 0.001) improved during treatment. Street heroin use declined rapidly (Pillais trace = 0.836, df = 4, P < 0.001), as did cocaine use (Pillais trace = 0.280, df = 4, P < 0.001). CONCLUSIONS HAT is associated with improvements in mental and physical health in the long term.

Drug Consumption Rooms in Hamburg, Germany: Evaluation of the Effects on Harm Reduction and the Reduction of Public Nuisance

In order to evaluate the impact of consumption rooms (CRs) on the promotion of health among drug users and the reduction of the public nuisance of drug use, a study examining CRs in three countries was carried out in 2000. The study, supported by the European Commission, examined CRs in Rotterdam (The Netherlands), Innsbruck (Austria), and Hamburg (Germany). This paper evaluates the findings from the study of Hamburg CRs. In order to get evidence-based information on the effects of CRs, 616 drug users in the Hamburg drug scene or in the vicinity of low-threshold institutions were investigated with a standardized questionnaire. Qualitative problem-centered interviews were also carried out with staff members of the CRs, and representatives from the community, including neighborhood residents, business people, police, and politicians. Research findings show that the Hamburg CRs reached the target group of drug users who practice risky behaviors and engage in public drug use. Findings also show that the Hamburg CRs lead to positive changes in health-related behavior for drug users. In addition, the findings indicate that the Hamburg CRs played an important role in the reduction of public disturbances in the vicinity of open drug scenes.

Significance of Comorbidity for the Long-Term Course of Opiate Dependence

Objective: Studies on drug dependence show a high prevalence of comorbidity with additional mental disorders. Comorbidity patients also show more poly-substance use and other psychosocial problems. This study analyzed the importance of comorbidity for the long-term course of opiate dependence. Method: 350 opiate-dependent patients were examined at yearly follow-ups over 4 years using the EuropASI for the assessment of drug-related problems and the CIDI for diagnostic of psychiatric disorders. 196 patients were reached at final follow up (56%). Results: Of the patients reached at final follow-up, 30% had severe, 29% mild and 41% no clinically relevant disorders at baseline. However, the linear relationship at baseline – the more severe the disorder, the greater the impairment through drug-related problems – was not present at final follow-up. The results show that lifetime diagnosis of mental disorder had no prognostic relevance for the long-term course of drug dependency. Conclusion: The assumption that opiate users with an additional mental disorder are more vulnerable in their course of addiction could not be confirmed.

Psychiatric Comorbidity in Opiate Addicts

The present study investigates whether a correlation exists between mental symptoms and opiate dependency. During a 5-year follow-up study in Hamburg, of 350 opiate addicts who were in contact with the help system at the time of the initial investigation, 219 (63%) could be interviewed three times at 1-year intervals. The investigation instruments were standardized questionnaires such as EuropASI, CIDI, SCL-90-R and BDI. The general life situation of the investigated persons had, on the whole, improved in the course of the last 2–3 years. Drug consumption had markedly decreased. One third of the opiate addicts were in a comparatively good mental condition on all three survey interviews, for 17% there was a worsening of the condition, and for another 17% the negative mental condition was reinforced. A correlation can be established between mental disorders/symptoms and drug addiction or drug-related problems. The more unfavorable the course of the mental symptoms, the greater the problems of the client’s current life situation. There is also an overall relationship between increased drug consumption and mental symptoms like depressivity and anxiety, and the psychosocial functioning level. However, the expected correlations between mental disorders and the extent of drug consumption are not very marked. This indicates that specific constellations of drug consumption and mental disorders are not isolated but are related, as elements of a complex behavioral pattern, to the development of other life areas of the client.

Cocaine Use and the Utilisation of Drug Help Services by Consumers of the Open Drug Scene in Hamburg

In order to describe the patterns of use in the open drug scene in Hamburg, a study was carried out among 616 drug users in the drug scene and in or in the vicinity of low-threshold institutions close to the drug scene in summer 2000. The special focus was on the prevalence of cocaine and crack use as well as on the utilisation of help services for drug users. 80% of the interviewed persons were male, the average age was 32.6 years. They had been using drugs such as heroin or cocaine for an average of 11 years. 84% had used heroin and 74% cocaine within the last 24 h. Use was intravenous for 66%. 57% used cocaine intravenously, the percentage of crack smokers was 22%. Compared to previous studies, an increase in cocaine use can be noted among the scene users in Hamburg, mainly related to intravenous cocaine use. Crack smoking has only increased slightly over the past few years. Based on cluster analysis, four consumption pattern groups can be established. The largest group (38%) mainly uses cocaine and heroin. The second group (26%) consists of polyvalent drug consumers using methadone in addition to heroin and cocaine, as well as, partially, benzodiazepines, cannabis or alcohol. Group 3 (19%) mainly uses heroin only, some of them also using methadone and/or cannabis. The fourth group (17%) is mainly related to alcohol, the greater part of them additionally using heroin. On the whole, it appears that those users who currently do not use cocaine (or crack) are in a better health and social situation. The group using only heroin (cluster 3) also compares favourably with the other three consumption pattern groups with regard to the intensity of use, consumption in public and risk behaviour. Almost all the interviewed persons are in contact with general practitioners. However, the increasing cocaine use has not been met by sufficient intervention and treatment programmes so far.

Opioid Addiction and Suicidality

The prevalence of suicide attempts among opioid addicts is reported to lie between 8% and 17%, with some studies reporting an even higher rate among special groups of addicts. Yet there is insufficient knowledge about which addicts have a higher risk of suicide and which other factors seem to be involved in the constellation leading to the suicide attempt; the study of different subgroups of addicts is thus necessary. This paper reports a study on suicide attempts among a sample population in a detoxification unit and another group undergoing codeine maintenance treatment. There was a high rate of suicide attempts among both groups (23% of those in the detoxification unit and 28% of those maintained on codeine), but treating physicians tended to underestimate suicidality. The results lead to the conclusion that among a subgroup of addicts suicidality plays a larger role; a greater emphasis should thus be placed on the underlying psychopathology and the treatment needed.

Prävalenz psychischer Störungen bei Opiat- abhängigen mit Kontakt zum Drogenhilfesystem

ZusammenfassungIm Rahmen einer 5 Jahre andauernden Verlaufsstudie zur Komorbidität bei Opiatabhängigen sind in der Ausgangsbefragung 350 Klienten, die in sich in verschiedenen Hamburger Drogenhilfeeinrichtungen aufhielten, untersucht worden. Über zwei Drittel der Untersuchungsteilnehmer sind männlich, sie sind zum Erhebungszeitpunkt im Durchschnitt 29 Jahre alt. Der Großteil befindet sich in der Methadonsubstitution (42%), etwa ein Viertel in stationärer Langzeittherapie und weitere 17% im stationären Entzug. Die Klienten konsumieren seit durchschnittlich 9 Jahren Heroin. Bei 55% der Opiatabhängigen wurde (mindestens) eine weitere psychische Störung nach ICD-10 festgestellt (Lifetimeprävalenz). Unberücksichtigt bleiben dabei die F6-Persönlichkeitsstörungen. Die 6-Monats-Prävalenz liegt bei 37%, die 2-Wochen-Prävalenz beträgt 23%. Die vorherrschenden Störungsbilder finden sich bei insgesamt 43% der Opiatabhängigen in der Gruppe der neurotischen, Belastungs- und somatoformen (F4) sowie bei 32% der Klienten in dem Bereich der affektiven Störungen (F3). Seltener treten Störungen aus der Gruppe der Schizophrenie, schizotypischen und wahnhaften Störungen (F2) auf (5%). Ebenfalls 5% der Opiatabhängigen leiden unter Eßstörungen (F5). Hierbei handelt es sich z. T. um Mehrfachdiagnosen, im Durchschnitt liegen pro Klient 1,3 Diagnosen vor. Die Frauen sind von der Komorbidität deutlich stärker betroffen. Die meisten Störungen treten bei den Opiatabhängigen zwischen dem 18. und dem 21. Lebensjahr zum ersten Mal auf. Damit liegen die (Lifetime)prävalenzraten nach den bisherigen Erkenntnissen doppelt bis dreimal so hoch wie in der bundesdeutschen Allgemeinbevölkerung. Dies unterstreicht die große Bedeutung, spezifische diagnostische bzw. explorative Verfahren in die Suchttherapie zu integrieren. Psychische Störungen oder Beeinträchtigungen, die den Behandlungsverlauf negativ beeinflussen können, sollten in der Suchttherapie verstärkte Berücksichtigung finden.SummaryIn the course of a 5-year follow-up study concerning comorbidity in opiate addicts, 350 patients were investigated initially in various addiction centres in Hamburg. More than two thirds of the participants of the study are male, with an average age of 29 years at the time of the investigation. Most of them are receiving methadone maintenance treatment (42%), about one fourth is in residential rehabilitation and another 17% in inpatient detoxification treatment. The patients have been consuming heroin for an average of 9 years. For 55% of the opiate addicts (at least) one more psychic disorder in accordance with ICD-10 has been diagnosed (lifetime prevalence). F6 personality disorders have not been taken into consideration. The 6-month prevalence is 37%, 2-week prevalence 23%. For 43% of the opiate addicts, the predominant disorders belong to the group of neurotic, endurance, and somatoform disorders (F4), and for 32% of the patients to the group of affective disorders (F3). Schizophrenic, schizotypic and delusional disorders (F2) are less frequent (5%). Another 5% of the opiate addicts suffer from eating disorders (F5). These are partly multiple diagnoses cases; there is an average of 1.3 diagnoses per patient. Women are clearly more often affected by comorbidity than men. Most disorders first occur between the age of 18 and 21 years. Therefore, (lifetime) prevalence rates are twice to three times as high as that of the average German population, according to the present state of knowledge. This underlines the great importance of specific diagnostic and explorative methods for the treatment of addiction. Psychic disorders or disturbances that might adversely affect the course of treatment should be given more consideration.

NIH Consensus Panel Recommends Expanding Access to and Improving Methadone Treatment Programs for Heroin Addiction

Accessible online at: http://BioMedNet.com/karger A consensus panel convened by the National Institutes of Health (NIH) today strongly recommended a broader access to methadone maintenance treatment programs for people who are addicted to heroin or other opiate drugs and that the Federal and State regulations and other barriers impeding this access be eliminated. Many people believe that opiate drug addictions are self-inflicted and efforts to treat them will inevitably fail. However, the 12-member panel concluded that opiate drug addictions are diseases of the brain and medical disorders that can indeed be effectively treated. Studies have shown that methadone maintenance treatment significantly lowers illicit opiate drug use, reduces illness and death from illicit opiate drug use, reduces crime and enhances social productivity. Existing Federal and State regulations limit the ability of physicians and other health care professionals to provide methadone maintenance services for their patients. Additionally, these regulations require excessive paperwork and impose burdensome administrative and oversight costs. The panel recommended that these regulations be eliminated and that alternative means, such as accreditation, for improving the quality of methadone maintenance treatment programs be instituted. ‘We know of no other area of medicine where the Federal Government intrudes so deeply and coercively into the practice of medicine’, said panel chair Lewis L. Judd, MD, Chairman, Department of Psychiatry, University of California at San Diego School of Medicine. ‘If extra levels of regulation were eliminated, many more physicians and pharmacies could prescribe and dispense methadone, making treatment available in many more locations than is now the case’, Dr. Judd said. In the USA, approximately 600,000 people are addicted to heroin. Opiate drug dependence typically begins in the teens and early to mid twenties, when young people are in their formative, early occupational, and reproductive years. Most do not receive treatment, and the financial costs of untreated heroin addiction to the individual, the family and to society are estimated to be approximately US

Qualitative research on drug use in Europe.

20 billion per year. Most recent data indicate that there are about 115,000 patients in methadone maintenance treatment, many of whom require continuous treatment over a period of years and perhaps for life. Many of the barriers to an effective use of methadone maintenance treatment are related to misperceptions and stigmas attached to heroin addiction, the people who are addicted, those who treat them and the settings in which services are provided. The panel advocated vigorous and effective Federal and State leadership to educate the public that heroin addiction is a medical disorder that can be effectively treated with significant benefits for the individual and society. Another barrier preventing broader access to methadone maintenance programs is the shortage of physicians and other health care providers who can competently treat heroin addiction. The panel recommended that all primary care medical specialists, psychiatrists, nurses, social workers, psychologists, physician assistants, and other health care professionals should be taught the principles of diagnosing and treating patients with heroin addiction. The panel stressed the importance of providing substance abuse counseling, psychosocial therapies and other supportive services to enhance retention and successful outcomes in methadone maintenance treatment programs. The panel urged that funding be sufficient to provide access to treatment for all who require it. They strongly recommended that legislators and regulators recognize that methadone maintenance treatment is both cost effective and compassionate and that benefits for treatment be part of public and private insurance programs.

Heroin-assisted treatment for opioid dependence: randomised controlled trial.

Accessible online at: http://BioMedNet.com/karger ‘Of all the differences that artificially divide social sciences, the one between subjectivism and objectivism is the most basic one.’ [1, p. 49]. Unfortunately, the opposition between these two ways of cognition is real. This dualism has been manifest in the history of social sciences and their related subjects since the second decade of this century and was intensified after World War II. There is no reason why addiction research should make an exception. On the contrary, the gap between objective approaches (social, physical, mental) on the one hand and subjective approaches and the aims of the drug consumers on the other hand seems to be especially wide. If oppositions are ‘detrimental’ for social sciences in general, this is even more true for addiction research. Its task is the investigation of the conditions under which addiction problems develop and are overcome, and this task can be best fulfilled beyond the arguments of qualitative and quantitative research. Even in European Addiction Research, the quantitative methods predominate. This corresponds to the general orientation of contemporary addiction research and does not reflect a poor opinion of qualitative methods. Therefore, this issue of European Addiction Research presents a general view on the ‘qualitative research on drug use in the European Union’. Qualitative and Quantitative Methods