Heroin Addiction and Related
Clinical Problems 2010; 12(1):5-16
Evaluation of
Opioid-Dependent Prisoners in Oral Opioid Maintenance
Therapy
Metz V., Matzenauer
C., Kammerer K., Winklbaur B., Ebner N., Radler D., Fischer G.
Correspondence: Prof. Gabriele
Fischer, Medical University of Vienna, Department of Psychiatry and
Psychotherapy, Waehringer Guertel 18-20 - 1090 Vienna, Austria
Phone: +43 1 40400 2117; Fax:
+43 1 40400 3629; E-mail: gabriele.fischer@meduniwien.ac.at
Summary: Background: Opioid maintenance treatment is available in prison
in many countries, but without a specific methodology or homogeneity. The aim
of our study was to investigate characteristics and differences among
opioid-dependent prisoners in an Austrian penitentiary. Methods: Structured
assessments were obtained from 57 (78.1%) of 73 opioid-maintained prisoners on
their demographic data, imprisonment terms, health status and quality of life.
Results: From 1996 until 2007, the number of opioid-maintained detainees
increased by 444%. Prisoners treated with methadone had significantly more
convictions (p=0.036) and a longer duration of polydrug abuse (p=0.093) and
opioid consumption (p=0.05) than patients maintained on slow-release morphine.
Conclusions: There is a strong need for a diversification of opioid maintenance
treatments, as well as the development of a specific methodology for the use of
therapeutic opioids in prison.
Publication Type: Regular
article
Heroin Addiction and Related
Clinical Problems 2010; 12(1):17-24
Dose Determination
in Dual Diagnosed Heroin Addicts during Methadone Treatment
Maremmani I.,
Pacini M., Canoniero S., Deltito J., Maremmani A. G. I., Tagliamonte A.
Correspondence: Icro Maremmani,
MD; Vincent P. Dole Dual Diagnosis Unit, Santa Chiara University Hospital,
Department of Psychiatry, University of Pisa, Via Roma, 67 56100 PISA, Italy,
EU. Phone +39 0584 790073 Fax +39 0584 72081 E-Mail: maremman@med.unipi.it
Summary: Ninety-nine consecutive responders to treatment for heroin
addiction (54 with one or more Axis I psychiatric diagnosis (DD-patients), and
45 without psychiatric comorbidity (NDD-patients), were monitored prospectively
(20 months on average, min.1, max. 51), in order to achieve some useful
clinical information pertaining to effective methadone dose determination for
double diagnosed heroin addicts. First day and first month dosages do not
differ between the two groups. Stabilization dosages are higher in DD patients
than in NDD patients. The time to reach stabilization phase is longer in DD
patients than in NDD patients. Tapering of methadone follows a similar trend in
both groups. DD patients need more attention from clinicians, especially when
stabilization dosage has to be established.
Publication Type: Regular
article
Heroin Addiction and Related
Clinical Problems 2010; 12(1):25-32
Urine Labelling
Marker System for Drug Testing Improves Patient Compliance
Simojoki K., Alho
A.
Correspondence: Hannu Alho,
Ph.D., M.D.; National Institute of Health and Welfare, Department of Mental
Health and Substance Abuse Services. POB 30, 00271 Helsinki, Finland
Phone: +358-20-6108123 Fax:
+358-20-6108133 E-mail: hannu.alho@thl.fi
Summary: Urine drug testing plays an important role in substance abuse
treatments. When strictly controlled, as it often is, urine sampling creates a
humiliating situation and ties up resources. A new sample labelling method has
been developed to make supervision unnecessary. This innovation is achieved by
labelling the urine with polyethylene glycols. In this study, 57 patients who
required urine sampling were randomized into two groups, the traditional
supervised (TS) group and the new marker (NM) group. The urine test return rate
was 98.3% in the NM group and 100% in the TS group. Attempts to manipulate the
urine samples were discovered in 2% of the NM group and 0% of the TS group. Most
patients preferred the NM testing method. The personnel too preferred the NM
system, and estimated that it reduced their workload dedicated to drug
screening by 50%. We conclude that the NM method is more acceptable to patients
and personnel, and may increase compliance as a result.
Publication Type: Regular
Article
Heroin Addiction and Related
Clinical Problems 2010; 12(1):33-36
Quality of Life As a Means
of Assessing Outcome in Opioid Dependence Treatment
Torrens M.
Correspondence: Marta Torrens
MD, Drug Addiction Unit, IAPS-Hospital del Mar, Barcelona, Universitat Autònoma
de Barcelona, Barcelona, Spain, E-mail mtorrens@imas.imim.es
Summary: Not available
Publication Type: Letter to
the editor
Heroin Addiction and Related
Clinical Problems 2010; 12(1):37-40
Why There Has Been an
Excess of Overdoses in Norway Since 1990?
Haraldsen M.
Correspondence: Martin
Haraldsen, Rodslia 12, 3222 Sandefjord, Norway
E-mail: mar.har@c2i.net
Summary: Not available
Publication Type:
Heroin
Addiction and Related Clinical Problems 2010; 12(2):5-8
Addiction:
Challenging the dual diagnosis construct
Pani P. P.
Correspondence:
Pier Paolo Pani, ASL 8 Cagliari, Direzione
dei Servizi Socio-Sanitari, Cittadella della Salute – Padiglione Q, Via
Romagna 16 – 09127 Cagliari, Italy.
Phone
+39 070 6096385/ +39 349 3280112; Fax: +39 070 6096387 E-Mail: pallolo@tin.it
Summary: Not
Available
Publication Type: Editorial
Heroin
Addiction and Related Clinical Problems 2010; 12(2):9-18
Adherence and social antecedents in
relation to outcome in Methadone Maintenance Treatment (MMT)
Gronbladh L., Öhlund L. S.
Correspondence:
Leif Grönbladh, MD, University Hospital, Se-75017
Uppsala, Sweden, EU, E-mail: Leif.Gronbladh@neuro.uu.se,
Leif.Gronblad@akademiska.se
Summary: Numerous
reports of the effectiveness of methadone in reducing opiate use as well as
mortality, criminality, prostitution and the risk for HIV-infection have been
published during the last forty years. However, poor adherence to treatment,
continuing drug use and increasing rate of premature termination may lead to
less than optimal outcome results or in too many cases death. The aim of this
paper is to investigate which of the background variables, collected at the
admission procedure, that can be used to tell which type of patient will adhere
to the treatment regime and succeed or who will fail and who either need
special considerations or ought not to be accepted for a methadone treatment
(MMT). As much as 86 percent of the compliers in this study did benefit from
the treatment and were rated as medium to very much improved according to
CGI-I. The group not improved or worse had significantly more background
problems such as school problems, a history of non-opioid abuse, many non-MMT
treatment episodes, low age at drug debut and opioid debut than the group much
or very much improved. Those moderately improved is usually situated somewhere
in between the others.
Publication Type: Regular article
Heroin
Addiction and Related Clinical Problems 2010; 12(2):19-24
Rupnik J. C.
Correspondence:
Jasna Cuk Rupnik, MD - CPZOPD Logatec, Notranjska 2, 1370 Logatec,
Slovenia, EU
Phone. +386
17508264, +386 17508220, Fax +386 17508222
e-mail:
cukovi@gmail.com, cpzopd@zd-logatec.si
Summary: Objectives:
The objective of the study was to analyse the
practice of giving take-home dosages of opioid medications to patients with
reference to the reasons for and the quantity of the medications given as
additional or extra take-home dosages. Methods: All the patients were checked
regarding the kind of medication, urine samples, reasons for extra take-home
dosages and their quantity. Results: Of the 150 patients selected for the group
in the programme, 27 needed one or more extra take-home dosages in 2007. 10
(11*) of those patients had negative urine samples for all illicit drugs and
never used alcohol at any stage of the year of the study. 7 patients used
marijuana, benzodiazepines or alcohol only once or just occasionally in that
year. 10 patients used other illicit drugs or used alcohol and benzodiazepines
more often. Among the reasons for extra take-home dosages, hard physical work
was listed 7 times, vomiting because of the bad taste of the medication 3
times, difficulties in intiating medical therapy
after entering the programme 3 times, vomiting as a part of illness twice and
lowering the dosage too quickly twice. Other reasons were listed once each.
Altogether, the percentage of the overall quantity of medications received by
patients during the year as extra take-home dosages was: 0.47% for methadone,
0.75% for buprenorphine and 0.10% for SR morphine.
Conclusions: Reviewing the fairly good results of treatment at the centre,
therapeutic decisions to give additional take-home dosages to the patients have
proved to be reasonable and usually correct. Throughout this study a continual
therapeutic wish to achieve a better understanding of opioid addiction as just
one among other chronic diseases has been made evident.
Publication Type: Regular article
Heroin
Addiction and Related Clinical Problems 2010; 12(2):25-28
From methadone to buprenorphine
or back to methadone. The Croatian experience
Ivancic A.
Correspondence:
Ante Ivancic, MD. Centre for Adddiction
Treatment, M.Gioseffi 2 52 440 Porec,
Croatia
E-mail
ante.ivancic@pu.t-com.hr
Summary: In
Croatia maintenance treatment is made widely available through a network of GP
offices that covers the whole of the country. More then 50% of all GPs in
Croatia have at least one patient in MT. Methadone was the only opioid agonist
used for over a decade, but this changed when buprenorphine
was introduced 4 years ago.
There
is little difference in the regimen for the prescription and provision of the
two medications: both are free of charge and are prescribed by GPs; in
addition, there are no restrictions on the dose to be used or on ‘take home’
policy. The decision on which medication will be used is based exclusively on
the clinical assessment and patient-doctor agreement.
The
example of Croatia gives an opportunity to compare the acceptance of this
medication by patients and doctors in situations of equal availability.
Publication Type: Brief Communication
Heroin
Addiction and Related Clinical Problems 2010; 12(2):29-36
Methadone
treatment for pregnant heroin addicted women
Finnegan L., Pacini M., Maremmani I.
Correspondence:
Finnegan Loretta, MD - Perinatal Addiction and
Women's Health, 700 Ocean Drive, Unit E-1, 08202 Avalon New Jersey, USA -
E-mail: finnegal337@aol.com
Summary: A
review of methadone-related issues and the approach to heroin addicted patients
is presented with the aim to clarify what is practiced by the establishment of
anti-craving treatment and what is expected within a history of addiction. A
series of clinical situations occurring throughout pregnancy to early child
development are described, and the etiological hypothesis discussed. Moreover,
some methodological considerations are described in order to better understand
some ambiguity about the effectiveness and harmlessness of methadone treatment,
particularly with regard to neonatal opiate withdrawal. Limitations to the
outcome of pregnancies in heroin addicted women seems to be due to
misconceptions about methadone toxicity and neonatal damage, which may lead to
the mishandling of methadone as a therapeutic modality, especially with regard
to maintenance at effective dosages.
Publication Type: Seminar
Heroin
Addiction and Related Clinical Problems 2010; 12(2):37-40
What is the right
dosage for our patients?
Ulmer A.
Summary: Not
Available
Publication Type: Letter to the editor
Heroin Addiction and Related
Clinical Problems 2010; 12(3):5-8
Psychological performance and sedation
following injectable opioid administration
Forzisi L.,
Mitchell T. B., Bond A., Lintzeris N., Spofforth N., Strang J.
Correspondence: Dr Luciana
Forzisi, National Addiction Centre, 4 Windsor Walk, London SE58AF, UK - Tel:
+44079510575814 Email: luciana.forzisi@kcl.ac.uk
Summary: Injectable opioid treatment (IOT) can be an effective strategy
for heroin users who respond poorly to treatment with oral methadone, but its
safety profile is yet to be fully characterised. This study assessed the risks
of sedation and impaired psychological performance in 13 IOT patients following
injection of their regular dose of heroin (n=7) or methadone (n=6). Measures of
psychological performance (digit symbol substitution task, DSST; cancellation
task, CT) and sedation (visual analogue scale, VAS) were taken at baseline and
15, 30 and 60 minutes post-injection. Comparisons were made between the
methadone and heroin groups, with reference to data collected in control groups
maintained on oral methadone or sublingual buprenorphine. Results indicated
that performance and sedation did not change significantly in the hour after
injection. However, patients prescribed injectable heroin or injectable
methadone showed significantly worse psychological performance at the time of
peak effect compared to patients prescribed oral methadone or buprenorphine.
These findings suggest that further research is required to characterise
possible psychological performance deficit in IOT patients
Publication Type: Regular
article
Heroin Addiction and Related
Clinical Problems 2010; 12(3):9-19
Treatment
practices and perceived challenges for European physicians treating opioid
dependence
Bacha J., Reast S.,
Pearlstone A.
Correspondence: Alisa
Pearlstone, PCM Scientific, 5 Greenwich View Place, London E14 9NN, United
Kingdom, Tel: +44 (0)20 7531 6693.
Summary: This survey investigated the current practices and challenges of
physicians treating opioid dependence in Germany, France, Italy and the UK.
Doses favoured in Europe appeared to conflict with recommended best practice,
with low mean methadone and buprenorphine maintenance doses reported (44.3 and
9.5 mg, respectively). Mean time to buprenorphine maintenance doses was longer
than recommended at 14.4 days. Respondents also rated diversion and misuse
management as their most difficult challenge in treating opioid dependence.
These data suggest that prescribing practices are likely to increase this
problem, as well as impeding treatment success by decreasing compliance and
retention.
Publication Type: Regular
article
Heroin Addiction and Related
Clinical Problems 2010; 12(3):21-30
Clinical
foundations for the use of methadone in patients with infectious
diseases
Somaini L., Pacini
M., Maremmani I.
Correspondence: Lorenzo
Somaini, MD, PhD; Addiction Treatment Centre, Health Local Unit, Biella, Italy,
EUVia P. Maffei, 59 13836 Cossato (BI); Phone +39 015 9899853; Fax +39 015
9892890; E-Mail: lorenzo.somaini@aslbi.piemonte.it
Summary: The immune system is an organization of cells and molecules with
specialized roles in defending against infection. Communication between the
central nervous and the immune system lies at the hart of the neuroimmune axis.
There are several data indicating that opioids drugs may influence the immune
system. One of the main features of opioid induced alteration of immune
function is the development of immunosuppression. However, evidence has been
provided to suggest that different opioids drugs may have distinctive effects
on the immune system. Methadone is a widely used synthetic
3,3-diphenylpropylamine opioid which primarily acts at the µ opioid
receptor. Its most common use is in the therapy for opioid dependence. Besides
to their therapeutic efficacy, opioids can produce several well known adverse
events, and, as has recently been recognized, can positively interfere with the
immune response. Infact, data obtain from animal and human studies have
demonstrated that long acting opioids drugs such as methadone is devoid of any
intrinsic immunosuppressive activity. This effect may partly depend on the
ability of methadone to restore the HPA axis function, that is altered in
heroin dependent patient, or by the long-lasting activation of opioid receptors
both in the central nervous system and on immune competent cells. HIV and HCV
infections are the most frequent infectious disease seen in drugs users.
Opioids may facilitate the outbreak of infections through marked
immunomodulating effects on the immune respsoses against a virus. The enrolment
of heroin patient in MMT programs represents a particularly effective measure
for the prevention of HCV and HIV virus transmission and the immunorestoring
properties of methadone are particularly relevant in the treatment of
concurrent infectious such as HCV frequently associated with heroin addiction.
It is evident that the possibility to reach an adequate control of addiction
and of concomitant infectious diseases choosing either immunosuppressive drugs
or drugs characterized by immunoneutral or immunostimulating effects could
represent an important point to be considered in the future in opioid therapy.
Publication Type: Seminar
Heroin Addiction and Related
Clinical Problems 2010; 12(3):33-38
Bioethical
preferences of supporters and opponents of agonist opioid therapy in
Russia
Mendelevich V.
Correspondence: Vladimir
Mendelevich, Prof., MD, PhD, Doc.Med.Sci. - Kazan State Medical University,
Russia,420012, Kazan, Butlerova str., 49. Phone +79872961795, +78432386074; Fax
+78432360393 E-mail: mend@tbit.ru
Summary: Not available
Publication Type: Letter to
the editor
Heroin Addiction and Related
Clinical Problems 2010; 12(3):39-40
Softic J.
Correspondence: Jasmin Softic,
MD - Head of the outpatient clinic, Cantonal Institution for Fighting
Addiction, Zenica, Bosnia and Herzegovina. E-mail: jsoftic@yahoo.com.
Summary: Not available
Publication Type: Letter to
the editor
Heroin Addiction and Related
Clinical Problems 2010; 12(4):5-16
Lieb M., Wittchen
H. U., Palm U., Apelt S. M., Siegert J., Soyka M.
Correspondence: Dr. Martin
Lieb, MD - Dept. of Psychiatry, Ludwig-Maximilian University, Klinikum
Grosshadern. Marchioninistr. 15, 81377 Munich, Germany - Tel: +49 / 89 /
7095-2717 Fax: +49 / 89 / 7095-2715 Email: martin.lieb@med.uni-muenchen.de
Summary: Although elevated rates of psychiatric comorbidity in drug-dependent
patients in methadone maintenance treatment are known, differences in
comorbidity, maintenance medications, provider settings and somatic morbidities
often remain unclear. Here, the prevalence and impact of comorbidity is
described in a large, nationally representative sample of substitution patients
with a cross-sectional naturalistic study in German buprenorphine or methadone
substitution patients. Over two thirds of both the males and females were
diagnosed by their physician as having a psychiatric diagnosis other than
substance dependence. Depressive and anxiety disorders were the most common
diagnoses. Men recorded higher rates for schizophrenic disorders, sleep
disorders and antisocial personality disorder, while a higher percentage of women
had a borderline personality disorder.
Publication Type: Regular
article
Heroin Addiction and Related
Clinical Problems 2010; 12(4):17-22
Methadone
maintenance therapy and feto-maternal outcomes of pregnancy
Igboekwu J., Wolff
K.
Correspondence: Dr Jide
Igboekwu, Specialist registrar in forensic psychiatry. Ravenswood medium secure
unit. Fareham, PO17 5NA, United Kingdom. Phone- 01329836000 E-mail-
jideigboekwu@googlemail.com
Summary: We studied a cohort of pregnant opioid dependent women (n = 30) on
methadone maintenance therapy aiming to identify obstetrics, neonatal and
pregnancy outcomes and characteristics including the level of antenatal contact
and its effect. There were statistical significant associations between birth
weight and use of illicit drug and between use of illicit drugs and gestational
age (crack use and length of labour r2 =.57 and r2 = .012. P = 0.05; Cocaine
use and type of delivery r2 = .515 and r2 = .006. P = 0.05; Birth weight and
length of gestation r2 .429 and r2 = .041. p= 0.05).
Publication Type: Regular
article
Heroin Addiction and Related
Clinical Problems 2010; 12(4):23-32
Vendramin A.,
Sciacchitano A.
Correspondence: Andrea
Vendramin, MD - Drug Addiction Department - Via dei Colli, 4 - 35100 Padova
(Italy). E-mail: andrea.vendramin@unipd.it
Summary: The system of opioid receptors is characterized by a high level
of complexity and has received much attention from scientists all over the
world. The aim of this article is to describe the present, updated situation
regarding scientific knowledge on the subject. Each opioid receptor is
distributed in CNS in a distinctive way. Some regions (striate body and dorsal
horns of spinal medulla) indicate the three receptor types, although not
necessarily in the same neurons. Conversely, other regions, such as the
thalamic nucleus for µ or the claustrum for k, show various sites for a single
type of receptor. Each receptor is involved in functions that are implemented
along different paths and extensions. At present, it seems clear that the role
of each receptor in mediating biological actions or physiological effects needs
to be deepened using methodologies that differ from the classic ones. It can
now be predicted that molecular cloning, re-combining DNA, antisense
holigonucleotides, knockout and knockdown techniques will soon make it possible
to understand many of the problems which make this system so ‘complicated’.
Publication Type: Seminar
Heroin Addiction and Related
Clinical Problems 2010; 12(4):33-40
Bignamini E.
Correspondence: Emanuele
Bignamini, MD, Addiction Department 1, ASL Torino 2, Corso Lombardia 187, 10137
Torino, Italy - E-mail: bignamini@aslto2.it
Summary: Addiction is a pathological condition which is still only partly
understood. the complexity of reality exceeds our capacity to elaborate and
synthesize the information that is currently available, so compelling us to
operations of simplification, in order to become operative. In this exposition
I will discuss how, starting from a view of addiction as a pathology of
relationships, and from a pragmatic vision of the available therapeutic
techniques as tools of intervention rather than interpretive theories of
realty, is it possible and necessary to evaluate the psychotherapeutic
approach.
Publication Type: Seminar
Heroin Addiction and Related
Clinical Problems 2010; 12(4):41-48
Treating heroin
addicts. Blocking dosages and stimulation-stabilization of opioidergic
system
Pacini M.,
Maremmani A. G. I., Rovai L., Rugani F., Maremmani I.
Correspondence: Icro Maremmani,
MD; Vincent P. Dole Dual Diagnosis Unit, Santa Chiara University Hospital,
Department of Psychiatry, University of Pisa, Via Roma, 67 56100 PISA, Italy,
EU. Phone +39 0584 790073 Fax +39 0584 72081 E-Mail: maremman@med.unipi.it
Summary: The paper that follows is an attempt to conceptualize a
clinically based classification of treatments for heroin addiction. In fact, a
distinction is drawn in classifying treatments between those that are
antagonists and those that are agonists; the latter can be further subdivided
into full and partial. On this view, the effectiveness of full agonists cannot
be displayed as dependent on a key antagonist action, originally described as
an ‘opioid blockade’ and regarded as the main therapeutic mechanism available
against addiction. On the other hand, the differences in levels of effectiveness
between antagonists and full agonists cannot be understood either in terms of
the presence of absence of antagonism, or as opposing two radically different
mechanisms of action (it remains true that they both produce an opioid
blockade). In proceeding further, the authors propose the concept of optimal
antagonism, which is centred around the original ‘opioid blockade’ mechanism
and also accounts for agonist potency providing a direct anticraving effect and
aversive effects. Also, acquired tolerance to opiates does function as a
drawback deriving from abrupt treatment termination or steep reduction, so as
to favour stability of the anticraving coverage. In practice, optimal
antagonism is a concept that helps to define the gold standard of retention, clinical
response and rehabilitative potential. Naltrexone only provides patients with
antagonism, which does not appear to be the crucial feature of the
‘narcotic blockade’ originally described for full agonists, since levels of
global effectiveness differ markedly. The balance between the level of narcotic
blockade and other properties corresponds to the level of global effectiveness
of a treatment regimen, which eventually explains why complete blockade brings
poorer results in the absence of other anticraving actions. Methadone and
buprenorphine appear to provide optimal antagonism; in other words, they offer
patients opioid blockade combined with tolerance to euphoria and direct
anticraving action.
Publication Type: Expert
opinion
Heroin Addiction and Related
Clinical Problems 2010; 12(4):49-52
It is time for a responsible
administration of gamma hydroxybutyrate and methadone
Caputo F.
Correspondence: Fabio Caputo,
M.D., Ph.D.; Department of Internal Medicine, SS Annunziata Hospital, Via
Vicini 2, 44042, Cento (Ferrara), Italy; tel: +39-051-6838314; fax:
+39-051-6838487; e-mail: f.caputo@ausl.fe.it
Summary: Not Available
Publication Type: Letter to
the editor
Heroin Addiction and Related
Clinical Problems 2010; 12(4):53-56
Opiate maintenance
treatment in primary health care in Germany
Ullmann R.
Correspondence: Rainer Ullmann,
MD; General Practitioner, Weidenallee 1, 20357 Hamburg, Germany, EU - Phone:
+49 40 438081 - Fax: +49 40-438082 or -46960196 - Email r.ullmann@gmx.de
Summary: Not Available
Publication Type: Letter to
the editor