Non-opiate Drugs Research Articles

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Drug Policy in Hungary: Current Trends and Future Prospects

The authors consider the theoretical and applied problems of preventing illicit traffic in drugs and psychotropic substances in Hungary in the legal and criminological aspects. The relevance of the study is determined by the fact that the Hungary's third drug strategy expires in 2020 (2013-2020), so a new strategy needs to be developed, but it is not yet known what guidelines it will have, what priorities will be offered to set in it.The study was conducted with a view to considering the legal framework for the prevention of illicit traffic of drugs and psychotropic substances and the problem of its improvement in Hungary. To achieve this goal, the authors analysed statistics on drug use, types and quantity of drugs seized by law enforcement agencies for the last five years. The authors give a description of the drug situation, territorial features of drug use and a multilevel system of measures to counter illegal traffic in drugs and psychotropic substances at the national level. The authors pay special attention to the age and gender characteristics of drug use, which makes it possible to identify the most vulnerable groups, which should be supported by state preventive programs. The authors also analysed data on mortality from drug use and concluded that from 2010 onwards methadone and other non-opiate drugs predominated in death.Based on the results of the study, current trends in drug use in Hungary were summarized. The results obtained are important for the development of an anti-drug strategy and the improvement of legislation, as well as for the prevention of law enforcement agencies, both Hungary and other European countries.

Patterns of Prescription Drug Use Before and After Fragility Fracture.

Patients who have a fragility fracture are at high risk for subsequent fractures. Prescription drugs represent 1 factor that could be modified to reduce the risk of subsequent fracture. To describe the use of prescription drugs associated with fracture risk before and after fragility fracture. Retrospective cohort study conducted between February 2015 and March 2016 using a 40% random sample of Medicare beneficiaries from 2007 through 2011 in general communities throughout the United States. A total of 168 133 community-dwelling Medicare beneficiaries who survived a fracture of the hip, shoulder, or wrist were included. Cohort members were required to be enrolled in fee-for-service Medicare with drug coverage (Parts A, B, and D) and to be community dwelling for at least 30 days in the immediate 4-month postfracture period. Prescription drug use during the 4-month period before and after a fragility fracture. Prescription fills for drug classes associated with increased fracture risk were measured using Part D retail pharmacy claims. These were divided into 3 categories: drugs that increase fall risk; drugs that decrease bone density; and drugs with unclear fracture risk mechanism. Drugs that increase bone density were also tracked. A total of 168 133 patients with a fragility fracture (141 569 women; 84.2%) met the inclusion criteria for this study; 91.8% were white. Across all fracture types, the mean (SD) age was 80.0 (7.7) years, and 53.2% of the fracture cohort was hospitalized at the time of the index fracture, although this varied significantly depending on fracture type (100% of hip fractures, 8.2% of wrist fractures, and 15.0% of shoulder fractures). The frequency of discharge to an institution for rehabilitation following hospitalization also varied by fracture type, but the mean (SD) duration of acute rehabilitation did not: 28.1 (19.8) days. Most patients were exposed to at least 1 nonopiate drug associated with increased fracture risk in the 4 months before fracture (77.1% of hip, 74.1% of wrist, and 75.9% of shoulder fractures). Approximately 7% of these patients discontinued this drug exposure after the fracture, but this was offset by new users after fracture. Consequently, the proportion of the cohort exposed following fracture was unchanged (80.5%, 74.3%, and 76.9% for hip, wrist, and shoulder, respectively). There was no change in the average number of fracture-associated drugs used. This same pattern of use before and after fracture was observed across all 3 drug mechanism categories. Use of drugs to strengthen bone density was uncommon (≤25%) both before and after fracture. Exposure to prescription drugs associated with fracture risk is infrequently reduced following fragility fracture occurrence. While some patients eliminate their exposure to drugs associated with fracture, an equal number initiate new high-risk drugs. This pattern suggests there is a missed opportunity to modify at least one factor contributing to secondary fractures.

Treating drug dependence with the aid of ibogaine: a retrospective study.

Ibogaine is an alkaloid purported to be an effective drug dependence treatment. However, its efficacy has been hard to evaluate, partly because it is illegal in some countries. In such places, treatments are conducted in underground settings where fatalities have occurred. In Brazil ibogaine is unregulated and a combined approach of psychotherapy and ibogaine is being practiced to treat addiction. To evaluate the safety and efficacy of ibogaine, we conducted a retrospective analysis of data from 75 previous alcohol, cannabis, cocaine and crack users (72% poly-drug users). We observed no serious adverse reactions or fatalities, and found 61% of participants abstinent. Participants treated with ibogaine only once reported abstinence for a median of 5.5 months and those treated multiple times for a median of 8.4 months. This increase was statistically significant (p < 0.001), and both single or multiple treatments led to longer abstinence periods than before the first ibogaine session (p < 0.001). These results suggest that the use of ibogaine supervised by a physician and accompanied by psychotherapy can facilitate prolonged periods of abstinence, without the occurrence of fatalities or complications. These results suggest that ibogaine can be a safe and effective treatment for dependence on stimulant and other non-opiate drugs.

“Every ‘Never’ I Ever Said Came True”: Transitions from opioid pills to heroin injecting

This qualitative study documents the pathways to injecting heroin by users in Philadelphia and San Francisco before and during a pharmaceutical opioid pill epidemic. Data was collected through in-depth, semi-structured interviews (conducted between 2010 and 2012) that were, conducted against a background of longer-term participant-observation, ethnographic studies of street-based drug users and dealers in Philadelphia (2007–12) and San Francisco (1994–2007, 2012). Philadelphia and San Francisco were selected for their contrasting political economies, immigration patterns and source type of heroin. In Philadelphia the ethnographers found heroin injectors, usually white users, who had started their opiate using careers with prescription opioids rather than transitioning from other drugs. In both Philadelphia and San Francisco, most of the young heroin injectors interviewed began, their drug-use trajectories with opioid pills – usually Percocet (oxycodone and acetaminophen), generic short acting oxycodone or, OxyContin (long-acting oxycodone) – before transitioning to heroin, usually by nasal inhalation (sniffing) or smoking at first, followed by injecting. While most of the Philadelphia users were born in the city or its suburbs and had started using both opioid pills and heroin there, many of the San Francisco users had initiated their pill and sometimes heroin use elsewhere and had migrated to the city from around the country. Nevertheless, patterns of transition of younger injectors were similar in both cities suggesting an evolving national pattern. In contrast, older users in both Philadelphia and San Francisco were more likely to have graduated to heroin injection from non-opiate drugs such as cannabis, methamphetamine and cocaine. Pharmaceutical opioid initiates typically reported switching to heroin for reasons of cost and ease-of-access to supply after becoming physically and emotionally dependent on opioid pills. Many expressed surprise and dismay at their progression to sniffing and subsequently to injecting heroin. Historically and structurally these users found themselves caught at the intersection of two major developments in the opiate supply: (1) an over 500% increase in opiate pill prescription from 1997 to 2005 resulting in easy access to diverted supplies of less stigmatized opiates than heroin and (2) a heroin supply glut, following the US entry of Colombian-sourced, heroin in the early 1990s, that decreased cost and increased purity at the retail level. A nationwide up-cycle of heroin use may be occurring among young inner city, suburban and rural youth fueled by widespread prescription opioid pill use.

Epidemic of Prescription Opiate Abuse and Neonatal Abstinence

IN THIS ISSUE OF JAMA, PATRICK ET AL 1 DESCRIBE THE EFfects on newborn infants of the widespread availability of prescription opiate medications. These medications provide superior pain control for cancer and chronic pain, but have been overprescribed, diverted, and sold illegally, creating a new opiate addiction pathway and a public health burden for maternal and child health. Overdose mortality and dependence rates are highest among disadvantaged, young adults in rural areas (eg, Maine and Kentucky). Young women are nearly as likely as men to abuse opiate medications, leading to an increase in opiate-dependent newborns treated for withdrawal syndrome or neonatal abstinence syndrome (NAS). The standard of care for opiate addiction during pregnancy is methadone maintenance and psychiatric care. Patrick et al demonstrate that the increase in NAS (from an incidence of 1.20 [95% CI, 1.04-1.37] per 1000 hospital births per year in 2000 to 3.39 [95% CI, 3.12-3.67] per 1000 hospital births per year in 2009) has created a health care encumbrance primarily for state Medicaid budgets. In affected states, methadone treatment programs have expanded rapidly and voluntary prescription monitoring programs identify opiate medication use patterns (ie, opiate prescriptions are tracked and individuals who are “shopping” for physicians to prescribe opiates can be identified). However, the burden of addiction on state Medicaid budgets threatens retrenchment of recently established programs despite increased need. This poses a crisis of care for affected fetuses and newborns. However, without accessible treatment of both maternal opiate addiction and new methods of treating NAS, state and federal systems may pay in the future because many of these infants require special services for developmental and behavioral disorders. Patrick et al also observed that over the last decade, there has been no improvement in NAS treatment efficiency as measured by length of stay (LOS). Furthermore, health care expenditures for NAS have increased during the same period. Even within the context of the status quo of medically managed prenatal methadone treatment, opiate-exposed infants risk adverse effects besides the specter of protracted withdrawal. In their analyses of hospital complications of infants with NAS, Patrick et al confirmed other data demonstrating increased rates of prematurity, respiratory disease, and seizures. Opiate withdrawal is often compounded by comorbid polydrug exposure and maternal psychiatric medications, such as antidepressants and benzodiazepines, which have their own withdrawal syndromes. Although the withdrawal from these agents is milder than opiates, such combinatorial withdrawal complicates neonatal care and often extends LOS. Neonatal abstinence syndrome withdrawal severity affects adaptation to postnatal life in critical regulatory areas of sleep, feeding, and autonomic function. Although 60% to 80% of infants exposed in utero to opiates develop NAS and require prolonged hospitalization, averaging 16 days in the study by Patrick et al, there is still considerable uncertainty regarding optimal detoxification protocols and criteria for opiate withdrawal status typically based on symptoms assessed by the Finnegan score calculated every few hours from birth to day 5. Hospitals and clinicians burdened by the increase in NAS incidence can expend substantial efforts to develop treatment protocols to decrease LOS. As outlined by Patrick et al, most clinicians use oral opiate medication (eg, methadone or morphine) and, in difficult cases, a second-line nonopiate drug with -aminobutyric acid (eg, phenobarbital), benzodiazepine (eg, clonazapam), or anti-adrenergic (eg, clonidine) action. Novel pharmacotherapy research is needed to improve maternal opiate maintenance strategies to protect the fetus from in utero withdrawal, and to reduce the incidence and severity of NAS. These efforts have been frustrated by lack of controlled clinical trials. Methadone maintenance therapy during pregnancy is currently idiosyncratic (eg, lack of standardization in maternal care related todosing)andbasedonmaternalwithdrawal symptoms as gestation progresses. Research aimed at predicting which newborns are most at risk for a difficult withdrawal, or will require prompt treatment, has yielded few leads. In the adult pain management literature, individual genetic differences have been found to predict opiate response and dose

Nasal Tramadol delivery system: A new approach for improved pain therapy

Abstract The present work investigates Tramadol nasal delivery for effective analgesia with a rapid onset of action. The pharmacokinetic and pharmacodynamic behavior of Tramadol, a non-opiate analgesic drug, following its administration to rodents from a nasal delivery system was compared to oral aqueous solution. Following Tramadol nasal administration in animals at a dose of 10 mg/kg, a C max value of 2421 ± 651 ng/ml was obtained as compared to a four time lower value after oral delivery (644 ± 349 ng/ml). The high plasma concentration was achieved at 10 min ( t max ), indicating a rapid systemic absorption of the drug. Tramadol nasal delivery system treatment in animal Writhing model at a relative low dose of only 5 mg/kg significantly increased the analgesic effect, as compared to the oral administration, both 30 min before and immediately with pain induction. The local safety of Tramadol nasal system was good with no histological or nasal cavity changes. The outcomes of this work are that nasal administration of Tramadol could improve pain therapy and shorten its onset of action. The treatment by the nasal pathway could overcome the side effects associated with parenteral and oral delivery. Furthermore, due to the rapid and efficient delivery of the drug to the blood, nasal administration of Tramadol could be considered for the treatment of breakthrough pain.

A survey of the use of analgesia in newborn intensive care

Abstract The use of analgesia and sedation in 70 United Kingdom units which practise newborn intensive care was examined by questionnaire. Sixty-one units (87 per cent) responded. Fifty-nine per cent of units used drugs for this purpose very commonly (more than once a week) and 26 per cent used them commonly (more than once a month). The commonest indication was to provide analgesia and/or sedation during mechanical ventilation, but drugs were frequently used in post-operative pain relief, in necrotising enterocolitis, for fractures and in meningitis, as well as for several less common indications. Opiates were widely used, particularly morphine (77 per cent of units), diamorphine (31 per cent), fentanyl (16 per cent) and pethidine (16 per cent). They were administered by bolus injection or continuous infusion, usually intravenously. The range of doses used, especially for morphine and diamorphine, was wide and adverse effects (cardiovascular, respiratory, bowel and bladder) were commonly reported (48 per cent). Non-opiate drugs, especially chloral hydrate and paracetamol, were commonly used, too; adverse effects were rarely reported. There is a need to examine the most effective and safest ways of adminstering analgesia and sedation, particularly opiates, to the newborn.

The temporal influence of a heroin shortage on pregnant drug users and their newborn infants in Sydney, Australia

Heroin availability and purity decreased precipitously in Australian markets between 2000 and 2001. This led to increased use of non-opiate drugs in the general community but whether pregnant drug users and their newborn infants were affected remains unknown. To determine if perinatal drug exposure and outcomes are affected by changes in street drug availability. Retrospective review was carried out of known drug-exposed mothers delivering live-born infants at the Royal Hospital for Women, Randwick, Australia (n = 316). Study periods were divided into preshortage (A = 1998-2000, n = 79), shortage (B = 2001-2002, n = 92) and post-shortage (C = 2003-2006, n = 122) periods. Cannabis-only users were excluded (n = 23). The percentage of confined women who admitted to using heroin decreased significantly (65%(A) vs 34%(B), P < 0.01) as did women on methadone programmes (90%(A), 80%(B), 75%(C), P = 0.024). The use of cocaine (7% (A) vs 33% (B), P = 0.031) and amphetamines (4% (A) vs 22% (C), P = 0.01), tripled. Most infants were born full-term and healthy but the duration of infant hospitalisation increased significantly from (median [interquartile range]) 8 [10, 38](A) to 13 [7, 23](C) days (P < 0.01). Approximately 50% of infants required withdrawal treatment but more needed phenobarbitone as an adjunct to morphine during the shortage (4/80 (0.5%) vs 15/93 (16%), P = 0.026), probably because of increased exposure to non-opiate drugs. The types of drugs used by pregnant drug users follow street trends and may affect infant hospitalisation and withdrawal treatment. Of concern is the rise in amphetamine-use and there needs to be increased vigilance for similar trends, especially in previously unidentified drug users.

Addressing pain in burn injury

The pain associated with burn injury can be challenging to treat. It is frequently time consuming and resource dependent, and as a result is often poorly managed. The pain experienced is patient specific with numerous factors influencing the nature and the intensity of the pain. Many of these factors will alter during the course of treatment and rehabilitation. Pain assessment should be performed regularly with the aid of one of the scoring systems available. The management of burn pain should be tailored to the underlying cause (background pain, breakthrough pain, procedural pain, post-operative pain or chronic and complex pain associated with the healing process). Although opiates remain the mainstay of treatment of burn pain they are not always effective or appropriate. Non-opiate drug therapy should always be considered as it maybe more effective and better suited to treating the complex nature of burn pain. Non-pharmacological interventions are an important adjuvant to drug treatment. The most effective approach uses all of these methods, is flexible, has multidisciplinary input and is tailored to the individual patients needs.

Are we becoming more alike? Comparison of substance use in Australia and the United States as seen in the 1995, 1998, 2001 and 2004 national household surveys

This paper reports the results of the 1995, 1998, 2001 and 2004 Australian and US household surveys, with emphasis on changes since 2001. The US survey data were recalculated to match age groups in the Australian data. Statistically significant changes are reported. Differences in prevalence of use by gender within age group were tested for significance. The past-year use of 'any illicit drug', cannabis, cocaine, tranquillisers and injecting drugs decreased between 2001 and 2004 in Australia, but remained stable for all these drugs except ecstasy between 2002 and 2004 in the United States. The use of hallucinogens decreased in both countries. Alcohol and use of many illicit drugs by teenage girls in both countries increased to rates similar to or higher than boys, and teens in both countries reported binge and heavy drinking in the past month. Australians in their 20s had the highest rates of use, but in the United States, past-year use of many drugs was highest among teenagers. More treatment services are needed, particularly for people dependent upon non-opiate drugs. The changes in acceptability of use of different drugs and their perceived availability are related to changes in prevalence rates. Even with the similarities in levels of use, there are differences in patterns of use and preferences for certain drugs in each country, and geographic proximity to drug sources is a factor.

An Exploratory Study of OxyContin Use Among Individuals with Substance Use Disorders

This study surveyed 422 individuals being treated in a substance abuse treatment program that offers various levels of care in order to learn about OxyContin® use among this population. Focus areas included exposure and use of OxyContin, how this medication was obtained, reasons for initial use, and whether users of OxyContin were drug naive or experienced users of opiate or non-opiate drugs. Whether OxyContin users who previously had never used opiates would report migrating to heroin was also explored. Findings revealed that 48% of the population had used OxyContin and of this population. only 1% had no history of prior substance use. Seventy percent of this sample obtained them from friends and 14% obtained them directly from physicians. Many reported that their friends obtained their OxyContin from physicians, bringing the percentage of people who directly or indirectly obtained OxyContin through a physician to 37%. While most users of OxyContin had a history of past opiate use, a small percentage had not. and of this later group, 73% migrated to using heroin. The majority of individuals who obtained OxyContin from a physician had a history of recreational or problematic opiate or non-opiate drug use. Finally, over time, 90% had stopped using this drug. although other drug use continued.

Efficacy of Buspirone in the Treatment of Opioid Withdrawal

In an attempt to develop a new opiate detoxification approach, the authors assessed the efficacy of buspirone in the treatment of acute heroin withdrawal. Buspirone, a drug interacting with the serotonergic system, was selected because there is evidence that a decrease in serotonergic neurotransmission may be involved in opiate withdrawal symptoms. Twenty-nine hospitalized heroin addicts were randomized to 4 groups: (1) placebo; (2) methadone; (3) buspirone 30 mg daily; (4) buspirone 45 mg daily. The double-blind trial started in all patients with a 5-day methadone stabilization period ending with a 30-mg dose. This was followed from days 6 through 12 by placebo in group 1 and by a methadone taper in group 2. Because of its delayed action, buspirone was started on day 1 in groups 3 and 4 and was continued, after methadone discontinuation, through day 12. On day 13, drugs and placebo were discontinued and patients were observed through day 14. Withdrawal symptoms were assessed with the "Subjective Opiate Withdrawal Scale" (SOWS) and the "Objective Opiate Withdrawal Scale" (OOWS). The SOWS and OOWS scores were significantly higher in the placebo group than in the methadone, buspirone 30 mg, and buspirone 45 mg groups. There were no significant differences in SOWS or OOWS scores when the methadone group was compared with each of the two buspirone groups or when the two buspirone groups were compared with one another. In conclusion, buspirone, a nonopiate drug with no abuse potential, a safe side effect profile and no withdrawal symptoms, at doses of 30 and 45 mg, was as effective as a methadone taper in alleviating the withdrawal symptoms of heroin addicts stabilized for 5 days with, and then withdrawn from, methadone. The use of buspirone could be particularly helpful in outpatient settings where the duration of the methadone taper recommended for detoxification can be lengthy.

Drug problem – What problems? Concurrent predictors of selected types of drug problems in a london community sample of young people who use drugs

Four variables potentially indicative of different aspects of drug problems have been selected for study in a community sample of young people aged 16–20 who use drugs; Severity of Dependence Score; Whether or not interactional problems caused by own drug use were experienced; Number of college or work days missed specifically as a result of drug use; and 12-item General Health Questionnaire Score. The study population comprised 200 young cannabis users, approximately one-third of whom were also stimulant drug users. Substantial levels of these problems were observed.A range of predictors of these problems were identified in regression models. Lifetime stimulant drug use emerges as a principal indicator of risk. In addition, age, ongoing drug consumption variables and satisfaction with personal drug use emerge are recurrent predictors. An indicator of deprivation is identified as being associated with interactional problems. The need for development of the study of drug problems in the context of the normalisation of recreational drug use within British youth culture is discussed. More elaborate and sophisticated studies of problems will be required to identify significant harms as consequences of teenage patterns of non-opiate drug use.

Post-Vietnam heroin use and injection by returning US veterans: clues to preventing injection today.

To seek clues in the Vietnam study of 30 years ago that might shed light on which previous users of heroin are at special risk of relapsing and, among relapsers, to identify those likely to begin or return to injecting heroin. To analyse information in military records and in two interviews given in the first 3 years after return from Vietnam to find predictors of post-Vietnam injection by soldiers who had used heroin while in Vietnam in 1970-71. A total of 374 Vietnam veterans who had used heroin while in Vietnam and had been interviewed twice since their return from Vietnam. Post-Vietnam heroin injection was determined in either of two post-Vietnam interviews. Possible predictors came from interviews and military records and describe pre-Service and in-Vietnam status and behavior. Included are region of residence, race, antisocial behavior, type and level of drug use and association with illicit drug users. Possible post-Vietnam correlates of heroin injection were no job or school enrollment, alcohol problems, depression, absent or transient marriage, association with illicit drug users and other Vietnam veterans. Only a minority of those who used heroin in Vietnam had ever injected it there. Most smoked or snorted it. After their return, most of the men who had used heroin in Vietnam used it very occasionally or not at all. Among those who did use heroin more than five times after their return, most had tried injecting it. Significant predictors of post-Vietnam injection included living on the east or west coast, deviant behavior both before and in Vietnam, opiate use before Vietnam, serious involvement with heroin in Vietnam, use of non-opiate drugs before and in Vietnam, and associating with drug users before Service. The variables that increased significantly the probability of injection among men who relapsed to heroin use after return to the United States were living on the east or west coast and having a history of using non-opiate illegal drugs before they entered Service. Blacks who returned to heroin use after return were less likely to inject than were non-blacks. These results suggest that a high-risk group for intervention to prevent future injection would consist of people with a history of past heroin use who are currently either in remission or using without injection and who reside on either coast, have a history of antisocial behavior and have used a variety of illicit drugs other than heroin.

CONCURRENT SUBSTANCE USE AND OUTCOME IN COMBINED BEHAVIORAL AND NALTREXONE THERAPY FOR OPIATE DEPENDENCE

The effect of concurrent nonopiate drug use on outcome of treatment for opiate dependence. Method: Forty-seven opiate-dependent patients received a 6-month course of outpatient treatment with naltrexone and cognitive-behavioral therapy (behavioral naltrexone therapy, BNT) at a university-based research clinic. Opiate-negative urines and naltrexone ingestion were rewarded with monetary vouchers. Abstinence from other drugs was encouraged verbally, but no contingencies were placed on nonopiate drug use. The proportions of all urines (collected twice weekly) positive for cocaine, cannabis, and benzodiazepines over the course of treatment were evaluated as predictors of outcome of opiate dependence treatment, as measured by proportion of opiate-positive urines, days retained in treatment, and proportion of naltrexone doses taken, using Pearson product moment correlations and oneway analysis of variance (ANOVA). Results: The majority of patients (78%) used a nonopiate drug at least once during the trial. There were no significant correlations between concurrent drug use measures and opiate dependence treatment outcomes, indicating no simple linear relationship between these measures. However, when concurrent drug use was trichotomized into abstinent, intermittent, and heavy use groups, groups with intermittent use had superior outcome compared to both abstinent and heavy use groups in several contrasts. Conclusions: Intermittent use of nonopiate drugs is common during outpatient treatment for opiate dependence and may be a favorable prognostic indicator. This may support a “harm reduction” approach as opposed to a strict abstinence-oriented approach. Further research is needed to identify the optimal therapeutic stance toward other drug use during treatment for opiate dependence.

Heroin as Evil: ecstasy users' perceptions about heroin

Information gleaned from several studies suggests that non-opiate drug users view heroin and heroin users in negative terms. The present study examines this issue in greater detail through analysis of Ecstasy users' perceptions about heroin, heroin users and injectors. The data were collected through in-depth interviews with 98 current or former users of Ecstasy who were recruited through various methods in 1997-98. The findings confirm earlier reports and suggest that Ecstasy users tend to distance themselves from heroin users. The data also show that several Ecstasy users tend to believe that bad experiences with Ecstasy can be attributed to tablets laced with heroin. Explanations for these findings are offered.

Dear Editors:

I read the critique of the Swiss heroin trial by Sally L. Satel and Ernst Aeschbach (Journal of Substance Abuse Treatment, Vol. 17, No. 4, pp. 331–335, 1999) with interest. While their ostensible aim is to review the scientific soundness of the Swiss trials, they go beyond this limited objective to attack heroin prescription in general. In so doing, they draw largely on anecdotal or descriptive historical material rather than on sound scientific evidence of the standard they themselves demand. As they note, “only one random design outcome study of the so-called British system has been published” ( Hartnoll et al. 1980 Hartnoll R.L. Mitcheson M.C. Battersby A. Brown G. Ellis M. Fleming P. Hedley N. Evaluation of heroin maintenance in a controlled trial. Archives of General Psychiatry. 1980; 37: 877-884 Crossref PubMed Scopus (165) Google Scholar ). As co-author of that study, I would wish to draw attention to the selective manner in which Satel and Aeschbach quote the conclusion that “despite the greater retention of the heroin sample (74%, compared to only 29% of methadone recipients), follow-up revealed the minimal improvements in employment status, health and consumption of nonopiate drugs were comparable between the two groups.” They do not mention that there were also differences—refusal to prescribe heroin and offering oral methadone instead was associated both with a higher level of illicit drug involvement and crime amongst those who did not become abstinent, whilst prescribing heroin was associated with a decreased level of illicit drug involvement and crime.

The effect of stimulant and sedative use on treatment outcome of patients admitted to methadone maintenance treatment.

While methadone maintenance treatment (MMT) has been demonstrated to be an effective treatment for opiate dependence, its impact on the treatment outcome of other illicit drug abuse is not as clear. Using the initial urine drug screen (UDS) and follow-up UDS at 1, 6, 12, and 24 months, 167 patients consecutively admitted to MMT were evaluated for opiate, sedative (predominantly benzodiazepine), and stimulant (predominantly cocaine) use. Retention for the opiate only group was 97.32 days longer on average than for patients using opiates along with stimulants, sedatives, or both stimulants and sedatives. Patients abusing opiates only had the greatest decrease in drug use; however, MMT was also associated with decreases in cocaine and sedative use over the 24 month follow-up period. There was no evidence that patients "switched" their drugs of abuse with time in treatment. The negative impact of non-opiate drug use on outcome in MMT and its implications for treatment planning are discussed.

Heroin snorters versus injectors: comparison on drug use and treatment outcome in age-matched samples

Drug use histories and treatment outcomes were compared for age, race and gender-matched samples of intravenous (IV; n=28) versus intranasal (IN; n=28) opiate abusers entering a 3-day inpatient detoxification unit. Data were derived from the Addiction Severity Index (ASI) interview. Both groups reported daily heroin use prior to detoxification, but IV users reported more days of alcohol and multiple drug use during the past 30 days. Despite age matching, IV users also started using alcohol at an earlier age and accumulated more lifetime months of regular alcohol, cocaine and multidrug use. IV users were more likely to enter treatment following the detox, but no significant outcome differences were noted at 1 and 3 months post-detoxification. The results show that intravenous, as compared to intranasal, opiate users have both a more severe pattern and a more extensive history of the use of non-opiate drugs.