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Schizophrenic patients with a substance abuse condition present one of the highest risks for violent behaviour. The traditional safety measures used in psychiatry are still in force but challenged by a trend to avoid all involuntary action, in respect of patient autonomy. There is an urgent need to develop strategies to cope with this situation, which is especially difficult to cope with in case of first encounters with dual diagnosis patients in psychiatry. The risk for open aggressiveness is difficult to assess and to manage in first encounters, avoiding an escalation and working a deescalation strategy. The strategy described in this paper is based on a distinction of the different types of first encounter and on general rules.

Background In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved. Aims Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning. Design Retrospective cohort study Setting An open prison with 120 places Subjects Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group). Measurements Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned). Findings Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group. Conclusions This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.

Background/Aims: We report on the rates of hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in 1,313 clients entering heroin-assisted treatment (HAT) in Switzerland from 2003 to 2013. We identify predictors of HCV infection. Methods: Data were collected using questionnaires within 2 weeks of clients' first entry into HAT. Prevalence of HAV, HBV, HCV and HIV was calculated using laboratory test results collected at entry or using reports of older test results. Predictors of HCV status were identified through multiple logistic regression analysis. Results: Results show stable rates of HIV-positive clients and decreasing proportions of HAV- and HBV-infected clients. In 2013, there were 12% (n = 8) HIV-, 20% (n = 12) HAV-, 20% (n = 12) HBV- and 52% HCV- (n = 34) positive clients. Vaccination against HAV and HBV had become more frequent. Predictors of positive HCV status included older age, female gender, earlier year of entry, having spent 1 month or more in detention or prison, use of injected heroin and more years of intravenous use. Conclusion: Our results highlight the fact that efforts to prevent and test for infections and to promote vaccination against HAV and HBV in heroin users need to be continued.

The medical prescription of diacetyl morphine (heroin) treatment is an addition to the therapeutic arsenal for patients gravely dependent or addicted to heroin use and for whom other forms of therapy have failed. In Switzerland, the Federal Office of Public Health SFOPH) has established directives and recommendations concerning prescription and administration of diacetyl- morphine.

Background/Aims: The Study on the Development of an EU Framework for Minimum Quality Standards and Benchmarks in Drug Demand Reduction (EQUS) has set up an inventory of quality standards and initiated a consensus-building process, aiming at establishing a set of European minimum quality standards (MQS) for treatment/rehabilitation and harm reduction in the field of drug abuse and dependence. Methods: Existing documents were collected by country-specific experts and integrated into a predefined framework of quality standards. Agreement, implementation status and expected implementation problems of the proposed standards were assessed by a survey of European stakeholders and the final lists of European MQS were established at a European conference. Results: Overall, 349 documents were identified as relevant. Major gaps were identified for ethical and legal standards, and for documents that provide grades of evidence for specific standards. A high level of acceptance was found for the treatment/rehabilitation MQS, while a somewhat lower level was found for the harm reduction MQS. The final lists of MQS were based on at least 80% of acceptance by European experts and stakeholders. Conclusion: A high consensus of European MQS for treatment/rehabilitation and harm reduction has been achieved. Further implementation and developmental steps are discussed.

Maintaining opiate addicts on opiates has a long history. The idea to prescribe pharmaceutical morphine as a substitute for street heroin started in USA and was abolished on the basis of prohibitionist legislation. A new approach to maintain opiate addicts on substitution therapy was initiated in USA in 1963, with the prescription of methadone. This approach found, although slowly, increasing acceptance, and is nowadays considered to be a cornerstone in the management of opiate dependence and for the prevention of HIV/AIDS in opiate injectors. Since 1975, the concept of heroin maintenance treatment was re-activated in order to reach out to treatment-resistant heroin addicts. Research projects were performed in Switzerland, the Netherlands, Germany, Spain, Canada and in England, another one is planned in Belgium. Based on the unanimously positive outcomes, heroin maintenance has become routine treatment for otherwise untreatable heroin addicts in Switzerland, the Netherlands, Germany and England, and Denmark has set up heroin maintenance without new research trials.[Uchtenhagen AA. Heroin maintenance treatment: From idea to research to practice. Drug Alcohol Rev 2011;30:130–137]

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

Anliegen: Der vorliegende Artikel gibt einen Uberblick uber das Ausmas des Kokainkonsums von 1994 bis 2001 von Patienten der heroingestutzten Behandlung in der Schweiz vor ihrem Eintritt, im Behandlungsverlauf und nach deren Austritt. Methode: Zum Kokainkonsum der Patienten liegen einerseits objektive Daten von Urinproben, andererseits Selbstangaben der Patienten zu ihrem Substanzkonsum zu verschiedenen Zeitpunkten (bis 6 Jahre nach Behandlungsbeginn) vor. Ergebnisse: Der Konsum von Kokain nimmt in der heroingestutzten Behandlung bereits innerhalb von 6 Monaten ab und liegt auch nach Austritt auf tieferem Niveau als bei Eintritt. Die Pravalenz des Kokainkonsums bei Behandlungsbeginn hat von 1994 bis 2001 abgenommen und ist bei den Patienten in der Stadt Zurich hoher als bei Patienten der restlichen Behandlungsstellen. Die letzte Stichtagserhebung an einer kleinen Stichprobe zeigt einen Anstieg des Kokainkonsums von in Behandlung stehenden Personen. Schlussfolgerungen: Kokainkonsum bleibt in der heroingestutzten Behandlung weiterhin ein Problem. Masnahmen gegen den Neben- und namentlich den Kokainkonsum haben deshalb weiterhin hohe Prioritat. Objective: This paper gives an overview of cocaine consumption among patients in heroin-assisted treatment in Switzerland at treatment entry, during treatment and at discharge. It includes patients entering this form of treatment from 1994 to 2001. Methods: At entry, urinalysis and self-report for the patients; at different follow-up times (up to 6 years), self-reports, in part corroborated by urinalysis; additionally random urinalysis testing on one set day. Results: Cocaine consumption decreased within the first 6 months in heroin-assisted treatment and stays at a lower level even after treatment discharge. Prevalence of cocaine consumption at entry has been decreasing from 1994 to 2001, and has been higher in town of Zurich. The last small study showed increases in prevalence among persons in treatment. Conclusions: Cocaine consumption remains a problem in heroin-assisted treatment. Thus, measures to cope with this problem continue to have high priority.

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

Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries. Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its application varies internationally with respect to treatment regulations and delivery modes. In order to effectively treat those patients who have previously been resistant to methadone maintenance treatment, several countries have been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence problem internationally, the current opiate dependence treatment landscape in several countries, and the status of ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.

Aims: The aim of this paper is to illustrate how Switzerland was able to play such a pioneering role in the field of addiction treatment, in creating a drug policy that includes the medical prescription of diacetylmorphine (heroin). The paper will also describe the role of knowledge brokering processes and coalition building in the different phases of the development of the Swiss drug policy. Discussion: The medical prescription of diacetylmorphine was the exotic element of the Swiss drug policy of 1991 and probably still is one of the most controversial practices in clinical medicine despite its documented effectiveness. Coalitions of change actors, across stakeholder groups from many professions and politicians on various levels, succeeded in formulating and starting initiatives for a new drug policy and its innovations. Clear, shared objectives and a common feeling of urgency brought the coalitions together. Conclusion: In the case of Switzerland, the Confederation took a leading role by facilitating communication, encouraging scientific knowledge and bringing the various stakeholders on a platform to deliver a consensual political policymaking basis. This was facilitated by the Swiss direct democracy system. Sustained dialogue between researchers and the users of research enhances the likelihood of research affecting policy.

Part of this development is already visible from the differential terminology in use: abstinence is perceived as instrumental for health and social improvements (‘abstinence based therapy’) or else as the final objective (‘abstinence oriented therapy’). Recovery is used to describe a rehabilitation process in various shades (‘back to normal’), but also to describe a socialisation process to model citizenship (‘better than well’). And maintenance therapy goes as a temporary approach to engage those in treatment who otherwise cannot be reached (‘maintenance to abstinence’) or else as the treatment of a chronic condition (‘unlimited maintenance’).

Background: Policies and practices related to the quasi-compulsory treatment (QCT) of substance-dependent offenders are currently implemented in many countries, despite the absence of reliable knowledge about significant predictors of treatment retention. This study aimed to identify such predictors in QCT and voluntary treatment. Methods: Participants were treated in one of 65 institutions in 5 European countries. They were interviewed at intake on substance use, crimes committed, perceived pressure for treatment, self-efficacy, stage of change, employment, and health-related variables. Binary logistic regression models were computed to identify predictors of treatment retention at an 18-month follow-up. Moderator analyses were computed to investigate whether these predictors vary by treatment condition (QCT vs. voluntary). Results: A higher number of working days in the previous month was positively associated with treatment retention, while use of heroin, crack, and multiple drugs, psychiatric problems in the previous month, and lifetime depression were negatively associated with treatment retention. Higher perceived medical pressure resulted in higher treatment retention rates only for participants in QCT. Conclusion:Predictors of substance abuse treatment retention are quite similar across both QCT and voluntary treatments. Perceived medical pressure is of higher relevance than the often-believed legal pressure for treatment retention in QCT.

Background: To assess the long-term course of the feasibility and safety of orally administered heroin [diacetylmorphine (DAM)] tablets in substitution treatment of severely addicted opioid users. Design: Open-label, prospective cohort study with 2 non-randomly assigned treatment arms: DAM tablets only (n = 128) or DAM tablets combined with injected DAM and/or other opioids (n = 237). The average duration of the observation period was 62 months. Study endpoints were the time to discharge from treatment and the number of serious adverse events. Results: Both patient groups had a higher than 70% retention rate after the first 48 months of treatment, with similar long-term retention rates (after 8 years both groups had retention over 50%). The physician-verified rate of serious adverse events was 0.01 events per application year among the exclusively oral substitution group (intention-to-treat analysis) during the last year of observation, and 0.005 events per application year in the other group. Conclusions: Because of their feasibility and safety over years, DAM tablets may be a valuable long-term therapeutic alternative. Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

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

Background: Opiate substitution therapy (OST) in the Ukraine was not provided until 2004. As part of the introduction of OST, the first feasibility study was conducted in 2007. Six clinics in 6 cities were involved in providing OST and collecting data. Methods: A total of 151 opiate-dependent patients were given buprenorphine as a substitute, and a survey of substance use, HIV transmission risks, and legal and social status was conducted at baseline and at 6 and 12-month follow-up. Results: Illegal substance use and illegal activities and incomes were highly reduced, whereas employment rates and psychiatric problems improved. Retention was comparatively high (79.5%) after 12 months. No significant adverse events were reported. Conclusion: A successful implementation of OST in the Ukraine is feasible.

Summary: Objectives:: The aim of the study was to obtain an overview on diagnostic and therapeutic activities concerning hepatitis A, B, C virus and HIV in Swiss prisons. Methods:: A standardized questionnaire was sent to 91 prisons in the German and Italian speaking parts in October 2004; 41 institutions (45%) answered the questionnaire. Results:: In almost all prisons serological examinations were not done routinely, but were provided when demanded by inmates or recommended by the medical service. Vaccination against hepatitis A or B infection and initiation of antiviral therapy was possible in most institutions. Conclusions:: Most of the prisons investigated offered diagnostic and antiviral treatment for hepatitis virus and HIV infections. A reported problem was the discontinuation of ongoing treatments or vaccination cycles after discharge. In some cases deficient funding was an obstacle

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

Background:: Hepatitis C virus (HCV) remains very prevalent in injection drug users (IDUs). In spite of recommended vaccinations against hepatitis A virus (HAV) and hepatitis B virus (HBV), many IDUs remain susceptible to HAV and HBV. Study population and methods:: Patients entering heroin-assisted treatment between 2000 and 2002 (N=210) were compared for infectious disease status with patients entering this treatment in 1998 (N=243) and between 1994 and 1996 (N=1035). Infection status was determined with the aid of questionnaires and blood tests for antibodies against HAV, HBV core antigen, HCV and HIV. Results:: In the cohort 2000-2002 78.3% of the patients were HCV positive, 53.3% were HBV positive, 41.2% were HAV positive and 12.6% were HIV positive. In comparison to the cohorts entering the heroin- assisted treatment at an earlier time, there was a significant reduction of HBV and HAV infections, but not of HCV and HIV infections. 15.6% of the patients entering between 2000 and 2002 were vaccinated against HBV and 10.3% against HAV. 31.1% of patients at entrance were susceptible for HBV and 48.5% for HAV. In comparison to patients entering treatment in 1998 there was no significant increase in patients who were vaccinated against HBV. Conclusions:: This data illustrates the need for improving HCV prevention and more consequent vaccination against HBV and HAV in IDUs

Summary: Objectives: Switzerland introduced heroin-assisted treatment as a routine treatment for drug addicts. As a result the evaluation instruments were changed from a detailed scientific project to a routine monitoring system. The process for developing this monitoring system is described. Methods: The questionnaires and assessment instruments were restyled with staff of the treatment agencies. Indicators measuring quality of treatment and measures from the future national statistic on the addiction support system were integrated into admission, course and discharge questionnaires. Currently a system for feedback to treatment agencies is being developed. Results: All 21 treatment agencies are participating in the monitoring. Assessment quality is high. Conclusions: The described monitoring should provide continuous delivery of basic relevant data on patients

Las sociedades organizadas democraticamente estan obligadas a encontrar la manera de proceder en caso de necesitar una reformulacion de las estrategias frente a los nuevos avances sociales y tecnologicos, especialmente cuando hay preferencias e intereses controvertidos. Los cambios en politica de drogas son un ejemplo excelente para discutir el problema y el proceso de formacion de coaliciones para encontrar respuestas aceptables a los nuevos desafios. La moderna teoria sociologica ha desarrollado conceptos y herramientas para la descripcion y el analisis de tales procesos. El estudio de casos concretos referentes a ciudades suizas pueden servirnos para la discusion avanzada de conceptos teoricos. El seguimiento observacional de la formacion de coaliciones en la ciudad de Zurich, ayuda a ilustrar los elementos inherentes, los problemas, y los resultados. Un analisis mas detallado del proceso centrado en las fases iniciales y el desarrollo subsiguiente de diversas coaliciones formales e informales introduce la importancia de los objetivos compartidos y la necesidad de actividades concertadas. No se dispuso al principio de un concepto de politica clara y un plan de accion coherente, pero resulto ser un paso importante en la consolidacion de lo que fue un comienzo no sistematizado. Lo que se inicio a nivel local y llego a ser una nueva politica nacional, dejo de ser un enfrentamiento constante entre dos ideologias - la reduccion de danos contra la prohibicion estricta -, para convertirse en el comienzo de una nueva forma de pensar acerca de como los elementos de las diferentes estrategias podrian combinarse con exito en la busqueda de un objetivo concreto a compartir. Estas observaciones pueden ser consideradas en futuros desarrollos teoricos y consideracion sobre politicas.