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Objective To review the scientific literature on the pharmacokinetics, pharmacodynamics and clinical efficacy and safety of (supervised) oral diacetylmorphine for patients with severe heroin dependence. Methods The PubMed, Embase, Web of Science and PsycINFO databases were searched. Eleven published studies were identified and selected based on defined eligibility and exclusion criteria. Results Four pharmacokinetic studies reported negligible plasma concentrations of diacetylmorphine and its active metabolite 6-monacetylmorphine. Among six pharmacodynamic studies, three trials showed that oral diacetylmorphine reduced opioid withdrawal symptoms, one open-label pilot study reported that two patients experienced a modest ‘rush’ after oral diacetylmorphine and two studies found that patients could not distinguish between oral diacetylmorphine, methadone, or morphine. Regarding the clinical studies, a Swiss prospective cohort study in patients with heroin dependence showed high retention rates of oral diacetylmorphine treatment with few serious adverse events, whereas in the Canadian SALOME trial, oral diacetylmorphine treatment was prematurely discontinued because treatment retention of oral diacetylmorphine was lower than injectable diacetylmorphine maintenance treatment. Finally, two case studies illustrate the limitations and potential problems of oral diacetylmorphine in the treatment of treatment-refractory heroin dependent patients. Conclusions Based on all published data, it is unlikely that oral diacetylmorphine produces a substantial ‘rush’. Prescription of oral diacetylmorphine might therefore be effective only for treatment-refractory patients with heroin dependence (i) as maintenance treatment for those who never injected or inhaled opioids; (ii) as maintenance treatment for those who want to switch from injection to oral administration of diacetylmorphine; and/or (iii) to reduce opioid withdrawal symptoms.

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.

Keywords: Addiction treatment policy; addiction treatment research; heroin assisted treatment; randomized controlled studies; risk factors; cost-effectiveness; treatment objectives

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]

European policy and practice in caring for people living with addictions is based on defined values (human rights, medical ethics) and on research evidence for the effects and impact of interventions. The focus of the paper is on risk management approaches to reduce the negative consequences of continued illicit drug use, being the ethically most debatable issue. The legal and policy positions are set by the European Council and Commission, and their translation into practice is documented centrally in the European Monitoring Centre on Drugs and Drug Addiction, showing the general trends as well as national differences. The European experience with the risk management approaches is presented in terms of research evidence on their effects and side-effects; this evidence is justifying the present practice. The perspectives for the future are set to follow the same lines, in a continued effort to find a balance of interests, in cooperation of authorities and civil society, and guided by ongoing research.

Background Opioid substitution therapy (OST) in the Ukraine was not provided until 2004. Methadone maintenance therapy only became available in May 2008. Injecting drug users in Ukraine are predominantly injecting self-made opioid solution (‘Shirka'). A feasibility study on buprenorphine and methadone maintenance treatment was conducted in 2008. Methods A total of 331 opioid dependent patients were given buprenorphine ( n =191) or methadone ( n =140) as a substitute, and a survey of substance use, HIV transmission risks, and legal and social status was conducted at baseline and at six months follow-up. Results Illegal substance use, illegal activities, incomes and HIV related transmission risks were highly reduced, whereas employment rates and psychiatric problems improved. Retention was comparatively high among the patients in buprenorphine (84.8%) and in methadone maintenance treatment (85.0%) after six months of treatment. Conclusion These data show the successful implementation of OST in the Ukraine among drug users who were predominantly injectors of self-made opioid solutions. Continuing scale-up of OST in the Ukraine is therefore both feasible and highly recommended.

OBJECTIVE To identify prognostic factors for a positive or negative termination of heroin-assisted treatment (HAT) in Switzerland. METHOD A complete census of all 3155 patients ever admitted was analysed using the proportional hazard model (including time dependent covariates). RESULTS Median length of stay was 11.4 years; the maximal length of stay was 13.9 years. 299 positive and 463 negative terminations were registered. Terminations clustered in the first year. Both time to positive and negative termination was significantly dependent on historical treatment cohorts since 1994. Positive termination was negatively associated with treatment in larger treatment centres (OR: 0.77, CI: 0.61-0.97) and positively with income from the social system (OR: 1.33; CI: 1.03-1.72). Negative terminations were positively associated with HIV infection before treatment (OR: 1.74; CI: 1.40-2.16), delinquence (OR 1.36; CI: 1.09-1.69), and higher levels of distrust (OR: 1.18 per scoring point; CI = 1.05-1.31). CONCLUSIONS Length of stay in Swiss HAT is considerable. The proportion of positive terminations did not increase with longer stays, indicating that the majority of patients are in chronic palliative care. Negative terminations outweighed positive terminations, with a low predictive power from co-variates. The routine assessment and analysis of different covariates, such as indicators of treatment process, has the potential to improve the therapeutic outcomes of HAT.

Ein masvoller Umgang mit Suchtmitteln ist Bestandteil des Lebensstils einer Mehrzahl von Menschen. Lange Zeit ging die Therapie von Suchtmittelabhangigen davon aus, dass diese das nicht leisten konnen, und strebte volligen Konsumverzicht an. Es gibt gute Grunde, das in seiner Allgemeingultigkeit in Frage zu stellen; solche Grunde werden anhand von Forschungsergebnissen dargestellt. Wichtigster Befund ist dabei, dass auch Abhangige in erheblicher Zahl den Weg zuruck in einen masvollen Konsum finden konnen, mit oder ohne Therapie. Dem ist sowohl in der individuellen Therapieplanung wie in der Entwicklung des Behandlungssystems Rechnung zu tragen. = Moderate use of psychotropic substances belongs to the lifestyle of a majority of people. For a long time, treatment of addicts was based on the belief that such moderate use is an unrealistic goal and that abstinence only should be intended. We discuss some of the reasons this belief must be challenged, on the basis of research evidence. The most important findings show that all kind of treatment approaches may result in moderate use, as well as spontaneous recovery. Individual treatment planning must consider this as well as the development of treatment systems.

BACKGROUND: Switzerland introduced a pragmatic national drug policy when the former conservative abstinence-orientated politics proved unable to cope with an escalating number of users and related negative consequences for public health and public order. The high visibility of 'needle parks' and the size of the acquired immune deficiency disorder (AIDS) epidemic called for a new approach and for national leadership. AIMS: To describe the intentions, the process and the results of setting up the new treatment approach of prescribing heroin to treatment resistant heroin addicts, as an example of drug policy change. MATERIALS AND METHODS: A systematic collection of relevant documents is analysed and used as evidence for describing the process of policy change. RESULTS: Measures to reduce the negative consequences of continued use and to prevent the spread of AIDS were started mainly by private initiatives and soon taken up officially in the 'four-pillar' drug policy (including harm reduction, prevention, treatment and law enforcement). Medical prescription of heroin to chronic, treatment-resistant heroin addicts was one of the innovations, based on extensive scientific and political preparation. Detailed documentation and evaluation, ample communication of results, adaptations made on the basis of results and extensive public debate helped to consolidate the new policy and heroin-assisted treatment, in spite of its limitations as an observational cohort study. All necessary steps were taken to proceed from a scientific experiment to a routine procedure. DISCUSSION: Comparable policy changes have been observed in a few other countries, such as The Netherlands and Germany, based on the Swiss experience, with equally positive results of heroin-assisted treatment. These experiments were designed as randomised controlled trials, comparing intravenous heroin against oral methadone, thereby demonstrating the specific value of pharmaceutical diamorphine for maintenance treatment in opiate dependence. The positive impact of policy change and the positive outcomes of heroin-assisted treatment were acknowledged increasingly nationally and internationally, but made it difficult to continue the process of adapting policy to new challenges, due to the low visibility of present drug problems and to changing political priorities. CONCLUSION: A major change in drug policy was effectively realised under typical conditions of a federalist country with a longstanding tradition of democratic consensus building. Facilitating factors were the size and visibility of the heroin problem, the rise of the Aids epidemic, and a pragmatic attitude of tolerating private initiatives opening the way to official policy change.

Continued education of professionals is a major factor for service improvement and evidence-based good practice. This project explores the strategies used for this purpose across countries (CET = continued education and training in the substance abuse field). A structured questionnaire was circulated internationally by an expert committee of the Swiss Federal Office of Public Health. Reports from 11 countries were collected in 2005. The following review is based on these reports and structured according to the questionnaire (questions in italics). The authors of the reports are listed in the acknowledgements. The countries are Australia, Austria, Finland, France, Germany, Greece, Italy, The Netherlands, Scotland, Switzerland, and the United States. As a result of this project, an international think tank on continued education and training was established and is briefly described.

Social psychiatry started over a century ago under the auspices of mental and racial hygiene, but after World War II it embraced concepts of community-based care and de-institutionalization. The major psychiatric reforms in the second half of the last century were mainly based on such concepts, including the reforms of Swiss and especially Zurich psychiatry. The present needs for psychiatric care, and the specific political and economic conditions for a continuation along this line are explored and found to be favourable. Also, the profile of future psychiatrists, as formulated by professional associations and expert groups, corresponds to concepts of social psychiatry. The World Health Organization stimulates service improvements in the same direction. The consequences concern the education and training, and the professional role of future psychiatrists. Finally, the future of social psychiatry will be shaped by public expectations and acceptance of community-based services.

This article contributes to the literature on drug users, victimization and offending using data on 545 dependent drug users entering treatment in four European countries. Members of the sample were exposed to high levels of criminal victimization. Sub-groups who were particularly vulnerable to crime were women (and especially sex workers), the homeless, recent offenders and those with a history of poor mental health. Multivariate analysis indicated that frequent drug use, recent offending and histories of depression and anxiety were significantly predictive of violent victimization, and only gender and a history of anxiety were significantly predictive of property victimization. The article discusses how these findings relate to theoretical approaches to victimization, in both positivist and critical frameworks.

Monitoring and evaluation (M & E) are research activities dedicated to document and analyze the processes and outcomes of addiction treatment. Before starting M & E, some conceptual issues apply, such as considering the objectives of a given treatment or treatment system, the outcome indicators to be used, the characteristics of the target population, and the basic understanding of the nature of addiction.

The focus of this section is mainly on the treatment system and on the community, at a regional or national level, as a comprehensive network of different approaches, services, and actors, covering all types of addictive behaviors. This implies the preference for a public health perspective, combining the care for the individual patients in their diversity with the intention to cover the treatment needs in a specific catchment area and for a given population. In addition, there are some chapters focusing on diagnostic issues and reviews of specific therapeutic approaches.

Aims To assess the efficacy and safety of orally administered heroin [diacetylmorphine (DAM)] tablets in substitution treatment of severely addicted opioid users. Design An open-label, prospective cohort study with two non-randomly assigned treatment arms and historical controls: DAM tablets only versus DAM tablets combined with injected DAM and/or other opioids, with an observation period of 1 year. Setting Twenty-one out-patient treatment centres of the Swiss heroin-assisted treatment programme. Participants A total of 128 patients received DAM tablets only, and 237 patients received a combination of orally and intravenously applied DAM and other opioids. Measurements Retention rate after 1 year; number of serious adverse events; dosage of DAM over time; subjective tolerance of study medication. Findings In the intention-to-treat analysis, 1-year retention rates after 1 year in the DAM tablets-only group [0.804, 95% confidence interval (CI) = 0.735–0.873] as well as in the subgroup combining oral application of DAM with intravenous application or other opioids (0.843, 95% CI = 0.797–0.889) were higher compared to historical controls (Swiss cohort of patients who had been substituted intravenously with DAM; 1-year retention rate = 0.70). Rates of serious adverse events under study medication (tablets only = 0.038 per application year; tablets in combination = 0.028 per application year) were comparable to the historical rate of the Swiss heroin-assisted treatment (0.043). Conclusions DAM tablets seem to be an effective and safe application mode of heroin-assisted substitution treatment. Randomized clinical trials to compare its relative efficacy to other substances are necessary.

Background: A major goal of heroin-assisted treatment in Switzerland has been to reduce the drug-related mortality of heroin users. Therefore, a continuous monitoring of deaths under treatment is essential. Aims: To assess mortality of participants in heroin-assisted treatment in Switzerland over a 7-year period from 1994 to 2000, and to compare this mortality to the general population and to other populations of opioid users, as reported in the literature. Method: Estimation of person years under heroin-assisted treatment from the complete case registry of heroin-assisted treatment in Switzerland. Estimation of standardized mortality ratios comparing the population in treatment to the Swiss population (standardized to the year 2000). Results: Over the 7-year period, the crude death rate of patients in heroin-assisted treatment, and including one month after discharge from treatment, was 1% per year. The standardized mortality ratio for the entire observation period was 9.7 (95% C.I. 7.3–12.8), with females having higher standardized mortality ratios (SMR 17.2) than males (SMR 8.4). There was no clear time trend. Conclusion: Mortality in heroin-assisted treatment was low compared to the mortality rate of Swiss opioid users 1990s (estimated to be between 2.5 and 3%). It was also low compared to mortality rates of opioid users in other maintenance treatments in other countries as reported in the literature. The SMR was also lower than that reported in the only meta-analysis in the literature: 13.2 (95% C.I. 12.3–14.1). The low mortality rate is all the more noteworthy as heroin-assisted treatment in Switzerland included only refractory opioid addicts with existing severe somatic and/or mental problems. Declaration of interest: No conflicts of interest declared

1994 wurde in der Schweiz die heroingestützte Behandlung (HegeBe) für anderweitig nicht oder nur mit unbefriedigendem Ergebnis behandelte Opioidabhängige eingeführt. Die Begleitforschung untersuchte in der ersten Versuchsphase (von 1994 bis 1996) die Wirksamkeit von HegeBe hinsichtlich sozialer und medizinischer Entwicklung und Legalverhalten der Patienten sowie der Wirtschaftlichkeit dieser Therapieform. Die vorliegende Arbeit gibt nun einen Überblick über neuere Forschungsresultate, welche die in der ersten Studienphase gefundenen Verbesserungen bei medizinischen Indikatoren und hinsichtlich sozialer Lebenssituation einschließlich Kriminalität im Langzeitverlauf bestätigen. In Zukunft benötigen die häufig vorkommenden komorbiden Störungen der Patienten, die schwierige Integration der Patienten in den freien Arbeitsmarkt und – trotz Rückgang während der Behandlung – der Konsum nicht verordneter Substanzen (Beikonsum) weiterhin große Aufmerksamkeit. Verschiedene Bemühungen zur Qualitätssicherung und -entwicklung dienen der weiteren Optimierung der heroingestützten Behandlung.

Background objectives: Since the beginning of the 1990 s the number of treated opioid addicts has markedly increased in Switzerland. This study examines the cause of health service utilisation of one specific type of treatment - heroin-assisted maintenance - the length of stay in this kind of treatment, and characteristics of admissions and discharges. Methods and sample: Data on all admissions into and discharges from heroin-assisted treatment were collected from the start of this treatment modality on January 1, 1994 to December 31, 2001. These data were used to calculate length of stay, and number of patients at the end of each calendar year. Data were analysed according to sex and age and the Kaplan-Meier survival statistics were calculated. Finally, the discharges from 1994 to 1998 were compared to the discharges of 1999 up to December 2001. Results: Since the introduction of heroin-assisted treatment, the number of patients in this form of treatment has markedly increased. Simultaneously, the average age of the patients entering treatment increased, whereas the proportion of women decreased continually. Compared to the earlier phase (1994-1998), in the last three years fewer patients terminated treatment at an early stage (within the first 4 months). Conclusions: Substitution programmes are the most common form of treatment for opioid dependence in Switzerland. The increase in the average age of patients in this treatment modality as well as in the abstinence-oriented treatment at admission may be interpreted favourably as an indicator that fewer less young people are opioid dependent than at the beginning of the 1990 s. The decrease in the proportion of females may be an indicator that females were overrepresented in heroin-assisted treatment at the beginning of this treatment modality and that the proportion gradually became more similar to the proportion in the opioid-dependent population as a whole. The decrease of early treatment terminations can be seen as positive, since with longer length of stay the probability of changing into abstinence-oriented treatment is becoming more probable.

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.

Ziel: Seit Januar 1994 wird in der Schweiz die Heroin-gestützte Behandlung für Opiatabhängige angeboten. Die ersten Resultate der Begleitforschung zeigten im kurz- und mittelfristigen Verlauf eine Verbesserung der Lebensumstände der Patienten. Der vorliegende Artikel untersucht die Situation der ersten Behandlungskohorte sechs Jahre nach Eintritt und diskutiert die Langzeitwirkung dieser Behandlungsform. Methodik und Stichprobe: In die Studie einbezogen wurden Personen, die in der Schweiz zwischen Januar 1994 und März 1995 in die Versuche für eine ärztliche Verschreibung von Betäubungsmitteln (PROVE) eingetreten sind. Sie wurden rund sechs Jahre nach Ersteintritt in Face-to-face-Interviews ausführlich zu ihrer Lebenssituation befragt. Ergebnisse: Sowohl bei den Patient/innen, die sich noch in Behandlung befinden, als auch bei ausgetretenen Personen ist eine Verbesserung der Lebenssituation eingetreten. In früheren Untersuchungen festgestellte positive Veränderungen dauern an und zwar über die Beendigung der Heroin-gestützten Behandlung hinaus. Schlussfolgerungen: Die Einbindung in die Heroin-gestützte Behandlung wirkt sich im Allgemeinen positiv auf den weiteren Lebensverlauf der Patient/innen aus. Handlungsbedarf besteht hauptsächlich bezüglich einer verbesserten Eingliederung in den Arbeitsmarkt. Dies könnte auch die soziale Integration, die zu einem großen Teil über die Berufstätigkeit erfolgt, erhöhen.

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.

The United Nations (UN) conventions present the international legal framework; they urge member states to provide treatment and rehabilitation but prohibit consumption and possession of scheduled drugs. This creates problems for providing treatment and harm reduction programs to patients who are not or not yet ready to stop illicit drug use. Other international documents, notably from the World Health Organization and the United Nations Office on Drugs and Crime, are strongly in favor of agonist substitution treatment and harm reduction measures. Within this framework, national legislation has much room for diverse preferences; the International Narcotic Control Board regularly comments the national practices, as well as the European Monitoring Centre for Drugs and Drug Addiction for the EU member states. An international trend gradually prefers therapeutic measures over criminal sanctions for drug users.

Psychiatric disorders occur frequently in individuals with opiate dependence in epidemiology and in clinical studies. A relief from emotional distress is considered to contribute to these elevated rates. Such an effect may contribute to the attractiveness of opioid maintenance treatment for dual diagnosis patients.

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.

Purpose: In recent years the incidence of adolescent smokers has increased steeply. Taking this into account, current anti-smoker campaigns should be reconsidered. Great importance must be attached to the apprentice group, since adolescents in professional training have frequently not been reached sufficiently by the preventive efforts. This study presents a tobacco prevention campaign among adolescents which was conducted in a large Swiss industrial company in 1998. Methods and Sample: A total of 430 apprentices took part in the prevention campaign which intentionally targeted adolescent behaviour. Of these, 40 apprentices were trained as mediators for tobacco prevention in advance. On the prevention day, the mediators communicated their know-how and experiences to their working groups. To evaluate the campaign, the apprentices were surveyed via standardised questionnaires on their smoking habits before the prevention campaign began. One month after the prevention day they were surveyed again on their current smoking habits and how the campaign had affected them. Results: The study showed that apprentices smoke heavily despite high awareness of the negative consequences. Some 30% of the trainees admitted smoking regularly. Another 11 % said they were occasional tobacco consumers. No significant gender difference was noticeable. Especially striking was that the adolescents often justified their own smoking as habit and dependence on tobacco. The prevention campaign was well received by the adolescents. It set about half of the smokers thinking over their smoking habits. No change in smoking habits, however, could be demonstrated one month after the campaign. Conclusions: Prevention among adolescents beyond the mandatory school period is a special challenge, since one cannot take advantage of the school's network. Within the scope of the campaign described here, it was possible to reach 430 apprentices of a major company. The study shows a great need for on-target smoking prevention in this sector. In the future, studies should examine whether tobacco prevention campaigns for apprentices should already contain secondary prevention elements from the outset. They should also assess if the effects could be further improved by introducing structural and other ongoing health-promotion measures.

Dieser Studienbericht uber die heroingestutze Behandlung von Opiatabhangigen erganzt den anderen Artikel im gleichen Heft, in dem uber die Methadon-Substitution referiert wird (vgl. die Arbeit von M. Krausz et al.). Bemerkenswert ist, das die Verschreibung von injizierbarem Heroin der von injizierbarem Morphin und Methadon hinsichtlich der Rekrutierbarkeit, Verweildauer in Behandlung und Compliance uberlegen ist. Als positiv ist auch die geringere Nebenwirkungsrate bei Heroin-Substitution einzustufen. Im einzelnen wird sodann uber den somatischen Zustand der Abhangigen, den Konsum von illegalem Heroin und Kokain, die soziale Integration, Delinquenz, Haltequote und Sterberate referiert. Zu den wesentlichen Daten der Hauptstudie, die Thema dieser Arbeit ist, seien Interessierte besonders auf die begleitenden medizinischen, sozial- und wirtschaftswissenschaftlichen Studien verwiesen, die im Text erwahnt und im Literaturverzeichnis aufgefuhrt sind.

In the 1994-1996 trial of medically controlled prescription of narcotics to dependent users, 800 places were ascribed to heroin substitutes and another 200 for methadone and morphine substitutes. The trial was evaluated with the aid of an accompanying research. Among the results demonstrated in the evaluation was an improvement of the health of the participants. The economic assessment was drawn from observations of health effects within a sub-sample of 142 participants from four centers. In a retrospective statistical survey, for each acute illness which could be influenced through the trial, the number of diagnoses was recorded in the first and thirteenth month after study entry. Also, based on a number of representative cases for each of these acute illnesses, the resource use, i.e. the types and numbers of medical products and services rendered to the patients, was recorded. The results showed a clear decline in depressive episodes, skin diseases, digestive system disorders as well as epileptic attacks and intoxication. Treatment costs could be reduced from a total of CHF 94875.--to CHF 21,998.--/month or from CHF 22.27 to CHF 5.15/patient per day. The improvement of somatic and psychic health due to the medically controlled prescription of narcotics resulted in a benefit of CHF 17.11/person per day.

The national study on medically controlled prescription of narcotics (heroin, morphine and intravenous methadone) was evaluated and a report on the main findings is made available, based on the main study and a number of additional special studies. The study with an intention-to-treat design includes data on 1035 probands. They received treatment following a uniform study protocol in 17 out-patient clinics and 1 penitentiary. The attribution of substances varied however (2 double-blind studies, 3 randomisation studies, the rest followed an individual indication). Intravenous heroin was well accepted and superior to intravenous morphine and methadone concerning compliance (reduction of illegal drug use) and retention, due to less negative side-effects. Dosages were stabilised, no lethal overdose occurred. The study documented significant improvement in health and social status of participants, especially in a reduction of depressive and anxiety states, of contacts with the drug scene and of illegal activities and prostitution. Half of those who left treatment proceeded to detoxification or methadone maintenance. Mortality, to a large extent due to infectious diseases acquired before participation in the study was by 1 % of the cohort per year. A continuation of this treatment approach is recommended for chronic and marginalised heroin addicts who failed in other treatment modalities. Similar conditions and safety controls as established for the study should be applied.

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’).