Heroin Addiction and Related Clinical Problems 2004; 6(1):5-18
Addressing violence in methadone maintenance treatment
Quigley P.
HIV and Addiction Service, Domville House Ballymun, Dublin 9, Ireland
Summary: Violence is a core public health issue which is linked to substance misuse in complex and interactive ways. Qualitative data on 220 violent episodes was collected over a three year period from service users and staff at Dublin methadone clinics. Inductive analysis of the data led to a typology of violent events, which may help to enhance clinical and social responses to the problem.Witnessed clinic episodes were interpreted as consequences of disturbed individual states or traits, or in terms of immediate situational conflict. Client narratives were construed as illustrations of family violence, local feuds, delinquency, dealing, retribution and abuse. A variety of pertinent clinical and organisational solutions are put forward in the context of a necessary community development and social inclusion process.
Publication Type: Research Article
Heroin Addiction and Related Clinical Problems 2004; 6(1):19-34
'Vedette' study and 'Tracking' project: Their integration and preliminary results
Mollica R., Carleo P., Gatti R. C.
6 via S. Galdino, Milan, Italy
Summary: Since the end of 2000, our Department has managed two independent research activities. The first, the VEdeTTe Study, is a national multicentric cohort study which aims to evaluate the efficacy of treatment provided by outpatient units (called Servizi Tossicodipendenze, “Ser.T.” or SERTs) at national level. The second, Tracking Project, is a local form of research which was devised to “track” the careers of addicts and evaluate changes within therapeutic courses using ASI. As the Study and the Project had the same time frame, we thought it right that each should take account of the other, to yield a result capable of fulfilling the aims of both, and to exploit the potentialities of both research protocols. The preliminary results now available refer to a population consisting of subjects enrolled in 2001 and 2002, and this paper aims to investigate and describe any differences between the two main subgroups: cases of addiction to heroin and cocaine, where one or other was the primary drug abused.
Publication Type: Research Report
Heroin Addiction and Related Clinical Problems 2004; 6(1):35-42
Methadone Treatment. Safe induction techniques
Payte T. J.
Corporate Medical Doctor, Colonial Menagement Group, LP. 8811, Cypress Reserve Circle, Orlando, FL 32836, USA
Summary: The motivation to develop a simple guideline for safe induction with methadone came largely from methadone-related deaths occuring during the induction phase of treatment. Clinical pearls for a safe induction are the following: 1) Very severe withdrawal signs/symptoms do not mean very high tolerance or the need for higher doses of methadone. 2) Consider use of instant opiate screens on admission with 2000 ng cut-off. 3) Document signs/symptoms of withdrawal with at least 2 objective signs. 4) Document daily assessment during induction includding basis for decisions to increase dose.
Publication Type: Expert Opinion
Heroin Addiction and Related Clinical Problems 2004; 6(1):43-52
Naltrexone as maintenance therapy for heroin addiction: Predictors of response
Maremmani I., Pacini M., Giuntoli G., Lovrecic M., Perugi G.
Department of Psychiatry NPB, University of Pisa, Via Roma 67- 56100 PISA, Italy
Summary: Naltrexone has been shown to have poor results on unselected populations of heroin addicts. Its use is mostly confined to detoxification-related procedures, whereas its long-term effects and properties have been largely neglected. The present study investigates the predictors of successful outcome in a population of 149 current heroin abusers selected as being opioid non-tolerant by a baseline naloxone test, and diagnosed as heroin addicts on the basis of DSM-IV criteria and undergoing long-term naltrexone treatment (naltrexone maintenance). Positive outcome is related to ongoing treatment, whereas negative outcome is due to treatment discontinuation through addictive relapse. Retained individuals are more likely to have no problems at work and to be psychosocially adjusted. Earlier substance users are those most likely to drop out. Global psychopathological impairment, with special reference to mood, aggressiveness and delusions are negatively related to treatment retention. Naltrexone maintenance appears to be suitable for a subgroup of heroin abusers whose clinical pictures combine a low level of addictive disease with the absence of major dysphoria, aggressive behaviour and psychosis.
Publication Type: Research Article
Heroin Addiction and Related Clinical Problems 2004; 6(2):5-52
Craving in Opiate, Cocaine and Alcohol Addiction
Kreek M. J., Zhon Y., Schussman S.
Laboratory of the Biology of Addictive Diseases, The Rockefeller University Hospital, New York, NY, USA
Summary: In this overview, we have very briefly covered our basic clinical research studies, as well as a few of our molecular, neurobiological, and behavioural laboratory studies, each of which have given insights into the possible contributors to the neurobiological basis of craving and “drug hunger”. We have also proposed recently that specific medications might be directed at each of these disrupted components of physiology to achieve a “steady-state” and thus normalization of physiological function. We hypothesized years ago, and renew the hypothesis now ,with respect to long-acting opioid agonist treatment of heroin addiction, specifically and primarily methadone maintenance, but also more recently LAAM maintenance and bupernorphine-naloxone treatment, each by the oral (or sublingual) route, that these treatments may achieve normalization of disrupted functions and, at the same time, lead to a reduction of elimination of “drug hunger,” “drug craving,” drug-seeking behavior, and drug self-administration. Future studies, especially studies looking at the interface of genetic factors and environmental factors, combined, of course, with the profound drug-induced factors, may allow us to develop further insights into the biological substrates of craving, and thus enhance our capability of developing both behavioural and pharmacological early interventions, as well as treatments for those with chronic diseases of specific types (see Figure 32 and Figure 33).
Publication Type: Expert Opinion
Heroin Addiction and Related Clinical Problems 2004; 6(2):53-72
Clinical foundations for the use of methadone in jail
Maremmani I., Pacini M., Lovrecic M.
Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies - University of Pisa, Via Roma 67 - 56100 Pisa - Italy
Summary: Interventions against drug addiction aim to achieve a satisfactory level of individual well-being, which does not vary despite different starting conditions. Spending time in jail is a common experience in the personal history of addicts; in response, the prison system should implement medical skills that have proven effective in ensuring behavioural control and health preservation for free individuals. Agonist maintenance by methadone or buprenorphine is feasible within prison walls, applying the same criteria that are adopted outside. Firstly, agonist drugs allow a safer relationship with the jailed addict. In addition, they improve the prospects for early release: therapies that started behind bars pave the way towards a life of freedom. Different schedules are suitable for different grades of addictive severity. Less severe patients may be forced out of an ill-chosen style of life as a free individual into an option of therapeutic parole. Hard-core addicts may benefit from the isolation of prison life, in so far as they are initiated and become stabilized on therapeutic regimens during custody. This solution will at least grant them a better quality of prison life. On this view, the prison system can play a crucial role in leading addicts towards therapy, mental health and social adjustment.
Publication Type: Point of view
Heroin Addiction and Related Clinical Problems 2004; 6(3):5-16
Patient-treatment matching and opioid addicted patients: Past methods and future opportunities
Strain E. C.
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University - 5510 Nathan Shock Drive - Baltimore, Maryland - 21224 USA
Summary: Patient-treatment matching (PTM) is a proactive process in which individual characteristics of a patient are addressed by specific aspects of a treatment modality. While there is considerable interest in PTM for substance abuse disorders, there has been relatively little work showing its efficacy for addictions in general, and virtually no systematic work on PTM for persons with opioid dependence. This paper addresses three assumptions that underlie the idea of PTM: that meaningful subtypes of patients can be reliably identified, that distinguishably different types of treatment are available, and that those treatments can be provided reliably. Different approaches that are relevant to studying PTM are then briefly reviewed: the Addiction Severity Index, the Transtheoretical Model of Behaviour Change, the subtyping of patients, and the American Society of Addiction Medicine’s Patient Placement Criteria. The paper concludes by outlining possible future directions for research on PTM, especially with respect to opioid dependence.
Publication Type: Review article
Heroin Addiction and Related Clinical Problems 2004; 6(3):17-26
Methadone patients' sexual dysfunctions: Clinical and treatment issues
Déglon J. J., Martin J. L., Imer
Foundation Phénix, Route Chêne 100, case postale 215 - 1224 Chêne-Bougeries, Geneve, Switzerland
Summary: Opiates are known to cause loss of libido, erectile and ejaculatory dysfunctions among men, and lack of menstruation and sterility among women. Over the last 30 years, several research studies have shown low testosterone levels causing sexual dysfunction in many heroin addicts or patients treated with opiates (morphine and methadone). Unfortunately, only a few studies on the sexual dysfunctions of patients following a substitution treatment with methadone have become available. We must take these difficulties seriously, as they prevent the development of intimate affective relationships, so inhibiting the social rehabilitation process of these patients.
This article provides an overview of recent research studies on the various causes of sexual dysfunctions for patients in substitution treatment, the benefits and risks associated with hormonal replacement therapies, and the value and limitations of bromocryptin prescription, while emphasizing the role of prolactin in sexual dysfunctions.
Evaluations of several hundreds of men and women treated at the Phenix Foundation in Switzerland are presented. The sexual dysfunctions that these patients present with are defined by considering the many psychological, psychiatric and neurobiological factors involved.
Based on the successful findings of a recent French study comprising the short-term prescription of Viagra, a new hypothesis is put forward on the possible natural increase of testosterone levels after comprehensive treatment involving testosterone level evaluation before and after Viagra prescription, psychosocial counselling and medical supervision.
It is hoped that those of our patients who resume sexual activity after months of abstinence will naturally increase their levels of testosterone, thanks to the stimulation of the psyche and of the hypothalamus-hypophyso-testicular axis. The main advantages of this approach seem to lie in enhancing the social rehabilitation of our patients by helping them regain self-confidence and reducing the pressure to perform, along with the fact that patients can gradually quit taking the medication.
Publication Type: Proposals
Heroin Addiction and Related Clinical Problems 2004; 6(3):27-32
Lovrecic M., Lovrecic B., Dernovsek M. Z., Tavcar R., Maremmani I.
Dr. Rok Tavcar, University Psychiatric Hospital, Studenec 48, SI-1260 Ljubljana-Polje, Slovenia - tel +386 1 5872312, fax +386 1 5284618, E-mail: rok.tavcar@mf.uni-lj.si
Summary: The aim of this chart review was to find out the extent of unreported double frequency (UDF) and characteristics of patients. A total of 37 patients with heroin addiction who were treated simultaneously in both services (Mental Health Service [MHS] and Centre for Prevention and Treatment of Illegal Drug Addiction [CPT]) in the last 10 years (the period during which the two services have coexisted) were identified. Patients were interviewed and case records were analyzed. Sociodemographic and clinical data were collected and the AbSo instrument was used. Factor analysis was used to identify clusters of symptoms reported by patients and models of drug prescription in patients receiving or not receiving methadone. Lastly we studied Pearson’s correlation between identified symptomatological factors and identified models of drug prescription. In two thirds of our patients in the MHS, drug addiction was not recognized at first consultation. Patients tended to deny their drug-related problems and methadone maintenance. Depressive symptoms and anxiety were the features most commonly found in our sample, while psychotic symptoms were rare. There was poor cooperation between general psychiatric and addiction services, which led to addiction being underdiagnosed and withdrawal symptoms being mistreated.
Publication Type: Research report
Heroin Addiction and Related Clinical Problems 2004; 6(3):33-36
Evaluation of effectiveness of drug treatment programmes
Dvoryak S.
All-Ukrainian Narcological Association - Kiev, Ukraine. E-Mail: sergdvor@un.kiev.ua
Summary: Not available
Publication Type: Letter to the editor
Heroin Addiction and Related Clinical Problems 2004; 6(3):37-40
Bad patients or bad treatment?
Payte J. T.
14050 Town Loop Blvd, Suite 204, Orlando, Florida 32837 USA - Phone: (407) 351 7080 - Fax (407) 351 6930
Summary: Not available
Publication Type: Letter to the editor
Heroin Addiction and Related Clinical Problems 2004; 6(3):41-50
Opiate Dosage Adequacy Scale (O.D.A.S.): A clinical diagnostic tool as a guide to dosing decisions
Gonzales-Saiz F.
Avd. Libertad 48. Pinar Hondo- 11500 Puerto de Santa Maria, Càdiz, Spain, EU - Phone 626301559; e-mail: pacogonzalez@comcadiz.com
Summary: Not available
Publication Type: Letter to the editor