S-23-01

Evaluation of drug consumption rooms for drug addicts

N. Scherbaum. Rheinsiche Kliniken Essen, Essen, Germany

Objective: In drug consumption rooms drug addicts are able to use heroin or cocaine in a hygienic environment without fear of prosecution. This study investigates the kind of drug addicts using a drug consumption room and their course.

Methods: During an individual observation period up to six months the course of users of a drug consumption room was evaluated. Clinical interviews were done at onset of the use of the consumption room, and after 1, 2, 3, and 6 months. The clinical interview was based on ASI and on the German documentation standards for addictive disorders.

Results: 129 addicts were included. The majority of them showed risk behavior as currently using non-sterile injection equipment (53%) etc. Most of the addicts (90%) had been in addiction treatment before as methadone maintenance or detoxification treatment. Most addicts used the consumption room only for a few weeks. About I/3 went to addiction treatment, about 1/5 to incarceration.

Conclusion: The evaluated drug consumption room reaches a target population with risk behavior. However, it did attract only in a small proportion addicts with no previous experience with addiction treatment. Long-term use of the consumption room was rare whereas a lot of patients were successfully transferred to addiction treatment.

S-23-02

Results of the dutch heroin trial

W. van den Brink. Academic Medical Center, Amsterdam, Netherlands

Objective: Heroin dependence is a chronic, often treatment resistant disorder, with serious public health implications. Supervised medical prescription of heroin has been proposed to improve the physical and mental health and social condition of those heroin dependent patients not sufficiently benefiting from methadone maintenance treatment. The aim of this study is to test the efficacy and cost-effectiveness of the new approach.

Methods: Two open label randomized controlled trials - one with inhalable heroin (n=375) and one with injectable heroin (n=174) - were conducted, comparing a six month and a 12 month treatment of heroin plus methadone with methadone alone, keeping the psychosocial treatment offer constant. Heroin was offered seven days per week and three times per day, whereas methadone was dispensed 2-7 times per week for daily use.

Results: Adherence was excellent with 12-month outcome data available for 94% of the randomized patients. Using an intentionto- treat analysis, twelve-month treatment with heroin plus methadone was significantly more effective than treatment with methadone alone: inhalable trial response rate 47.9% versus 25.2% (difference 22.7%; OR=2.77); injectable trial response rate 56.6% versus 31.6% (difference 25.0%; OR=2.99). Similar effects were observed with full symptomatic recovery and sustained response as effect parameters. Discontinuation of the co-prescribed heroin resulted in a rapid deterioration in the vast majority (83%) of the treatment completers who responded to the co-prescribed heroin. The incidence of serious adverse events was similar in the treatment conditions. With the exception of previous abstinence oriented treatments, no clinical predictors for response could be identified. A cost-utility analysis showed that heroine prescription was not only efficacious, but also cost-effective.

Conclusion: Supervised co-prescription of heroin is feasible, more effective, more cost-effective and probably just as safe as methadone alone in reducing the many physical, mental and social problems of chronic, treatment-resistant heroin dependent patients.

S-23-03

Drug monitoring during substitution treatment

C. Eap. Unité de Biochimie et Psychoph, Phil-Lausanne, Switzerland

Objective: Among the various drugs used for substitution treatment such as methadone, buprenorphine, codeine or heroin, the usefulness of therapeutic drug monitoring (TDM) has been demonstrated only for methadone. Thus, it is not expected that TDM of heroin or codeine, or of the active metabolite (i.e. morphine) which is a very short acting compound, would be of any help in the clinical management of patients who are prescribed codeine or heroin. No studies have examined yet the usefulness of TDM of buprenorphine but such studies are warranted, at least for a better understanding of the use of very high doses of buprenorphine requested by some patients, and examining whether this could be due in part to a rapid metabolism of buprenorphine. On the other hand, TDM of methadone has shown its usefulness in many situations, such as a non-response due to a rapid metabolism, problems of metabolic interactions or risks of cardiac side effects induced by methadone (i.e. prolongation of the QT interval). This will be discussed in details with practical examples, and the latest data of an ongoing large pharmacogenetic study on methadone examining also the problems of cardiotoxicity of methadone will be presented.