Abstract: Within the Swiss Detoxification Coordination (SwiDeCo) framework, a number of randomised clinical trials on opiate detoxification took place, comparing different settings (in- and outpatient), medications (antagonists under anaesthesia, methadone, buprenorphine high/low dosage) and duration of treatment (fixed and flexible). A standard assessment with validated instruments and standard follow-up was used throughout all the studies. One study concerned neonatal opiate detoxification. The scientific framework offered by SwiDeCo provided an opportunity for links and exchange between different drug treatment centres (over 20 centres participated in the studies) and persons working in the field of substance abuse in Switzerland. Overall, 279 patients were included in the different trials, of whom three-quarters were male, on average 30 years old; multi substance abuse was frequent. All procedures to withdraw patients from opiates tested in the different trials resulted in an equally poor outcome regarding abstinence after 3 months (22%). There were no patient baseline characteristics predicting differences in outcome. However, in-patient detoxification resulted in higher short-term abstinence rates, but this advantage disappeared over time. Patients’ level of distress at baseline evaluation decreased independently of treatment outcome during the first three months. Therefore, there seems to be a beneficial, but outcome-independent, treatment initiation effect. Two patients died within 3 months of detoxification. Although we cannot formally conclude whether withdrawal treatment resulted in an excess mortality, this fact is disquieting. During the detoxification phase overdose prevention should be discussed. Finally, based on our study results and on similar results from other groups, we cannot recommend the UROD procedure for withdrawal. We would rather suggest engaging patients who insist on this treatment modality in outpatient treatment, where tapering of substitution opiates could be performed while monitoring resumption of heroin consumption or the consumption of other substances. Given the high relapse rates independent of the specific detoxification treatment offered, it is important to offer flexible treatment goals to patients undergoing withdrawal treatment, so that substitution treatment might be offered in case of failure. The technique is simple and can be applied by trained family doctors.

Abstract: Fragestellung: In der vorliegenden kontrollierten Doppelblind-Studie wurde die Sicherheit und Wirksamkeit von sublingualen Buprenorphin-Tabletten mit oralem Methadon über sechs Wochen verglichen. Methodik: Die Studienteilnehmer wurden in den drei Zentren Basel, Genf und Freiburg rekrutiert. Die Stichprobe setzte sich aus 58 opiatabhängigen, ambulanten Patienten zusammen, welche die DSM-III-R-Kriterien für eine Opioidabhängigkeit erfüllten und eine Substitutionsbehandlung anstrebten. Die Patienten wurden randomisiert entweder einer Behandlung mit Buprenorphin oder mit Methadon zugewiesen. In den ersten drei Wochen wurde ein flexibler Dosierungsplan verwendet. Die zulässigen Tagesdosen betrugen für Buprenorphin (SL) 4, 8, 12 bzw. 16 mg/d und für Methadon 30, 60, 90, bzw. 120 mg/d. Die Buprenorphingruppe (n = 27) und die Methadongruppe (n = 31) unterschieden sich nicht bezüglich soziodemographischer Variablen und drogenanamnestischer Daten (Alter: 27,3 ± 5,9 Jahre, 81% Männer, 45% i.v. HeroinkonsumentInnen). Resultate: In der Maintenancephase (Studienwoche 6) betrugen die durchschnittlichen Dosierungen für Buprenorphin 10 mg/d und für Methadon 69 mg/d. Die Haltequote für Methadon war signifikant besser als für Buprenorphin (durchschnittliche Tage in Behandlung: 30 Tage für Buprenorphin und 40 Tage für Methadon; p<0.001). Bezüglich Anzahl opiatpositiver Urinproben gab es keine signifikanten Unterschiede (Methadon 65% vs. Buprenorphin 56%; p > 0,5). Die Anzahl opiatpositiver Urinproben nahm im Verlauf der Studie in beiden Gruppen signifikant ab. Vier Patienten, die mit Buprenorphin behandelt wurden, berichteten über unerwünschte Wirkungen (Kopfschmerzen, allergische Hautreaktionen), welche jedoch nicht häufiger auftraten als in der Methadongruppe. Zusammenfassend weisen diese Resultate auf eine gute Verträglichkeit und Wirksamkeit (Reduktion des Heroingebrauchs) sublingualer Buprenorphin-Tabletten in der Substitutionsbehandlung Opiatabhängiger hin. Hingegen war die Haltequote unter Methadon besser.

Abstract: The cost of treating approximately 150,000 participants represented by the CALDATA study sample in 1992 was $209 million. Each day of treatment paid for itself on the day it was received, primarily through an avoidance of crime. The benefits of alcohol and other drug treatment outweighed the costs of treatment by ratios from 4:1 to greater than 12:1, depending on the type of treatment. Benefits after treatment persisted through the second year of follow-up for the limited number of participants followed for as long as 2 years. This suggests that projected cumulative lifetime benefits of treatment will be substantially higher than the shorter-term figures. The level of criminal activity declined by two-thirds from before treatment to after treatment. The greater the length of time spent in treatment, the greater the percentage of reduction in criminal activity. Declines of approximately two-fifths also occurred in the use of alcohol and other drugs from before treatment to after treatment. Approximately one-third reductions in hospitalizations were reported from before treatment to after treatment. For each type of treatment studied, there were slight or no differences in effectiveness based on gender, age, or ethnicity. Overall, treatment did not have a positive effect on the economic situation of the participants during the study period. 38 tables and 11 figures