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Schwarz T, Anzenberger J, Busch M, Gmel G, Kraus L, Krausz M, Labhart F, Meyer M, Schaub MP, Westenberg JN, Uhl A. Opioid agonist treatment in transition: A cross-country comparison between Austria, Germany and Switzerland. Drug Alcohol Depend 2024; 254:111036. [PMID: 38091902 DOI: 10.1016/j.drugalcdep.2023.111036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND AIMS OAT is a well developed and successful treatment strategy for opioid dependent patients in Europe. It has significantly contributed to the fight against the HIV and HCV pandemics, leading to an increased life expectancy in this population. Building on the OAT experiences in Austria, Germany, and Switzerland and their models of care, the objective of this study is to analyse experiences and changes in patient structures to identify necessary adaptations for the system of care. METHODS We analysed national register-based data from patients receiving OAT during the period spanning from 2010 to 2020 in Austria, Germany (cases), and Switzerland. We examined and compared OAT policies and practice at national levels through a review of literature and publicly available policy documents. RESULTS Across these three countries, the life expectancy of OAT patients increased substantially. The mean age increased from 33.0 in 2010 to 39.1 in 2020 in Austria, from 35.6 years to 41.5 years in Germany (cases), and from 39.6 to 47.1 in Switzerland, respectively. In all three countries, the percentage of patients/cases aged 60 years and older increased more than tenfold between 2010 and 2020. CONCLUSIONS Integrated support models, reliable care structures, internationally comparable high treatment coverage, flexible prescribing practices, and a wide range of available OAT medications are successful strategies. The experiences in these countries indicate that it is possible to address the complex and chronic nature of opioid dependence and its concurrent mental and physical health challenges, resulting in an increasing life expectancy of OAT patients.
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Affiliation(s)
- Tanja Schwarz
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Doctoral Programme Meduni Vienna, Medical University of Vienna, Spitalgasse 23, Vienna 1090, Austria.
| | - Judith Anzenberger
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Martin Busch
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Gerhard Gmel
- Addiction Switzerland, Lausanne, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ludwig Kraus
- IFT Institut für Therapieforschung, Mental Health and Addiction Research, Munich, Germany; Department of Public Health Sciences, Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden; Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary; Centre of Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Krausz
- University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Florian Labhart
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Maximilian Meyer
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Michael P Schaub
- Swiss Research Institute for Public Health and Addiction, Zurich, Switzerland
| | - Jean N Westenberg
- Addiction Switzerland, Lausanne, Switzerland; University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Alfred Uhl
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Sigmund Freud University Vienna, Vienna, Austria
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Westenberg JN, Meyer M, Strasser J, Krausz M, Dürsteler KM, Falcato L, Vogel M. Feasibility, safety, and acceptability of intranasal heroin-assisted treatment in Switzerland: protocol for a prospective multicentre observational cohort study. Addict Sci Clin Pract 2023; 18:15. [PMID: 36906604 PMCID: PMC10007841 DOI: 10.1186/s13722-023-00367-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Heroin-assisted treatment (HAT) is a proven effective treatment option for individuals with severe opioid use disorder (OUD). In Switzerland, pharmaceutical heroin (diacetylmorphine, DAM) is available in tablet form or as injectable liquid. This creates a large barrier for individuals who require the rapid onset of effect but are either unable or do not want to inject, or who primarily snort opioids. Early experimental data has demonstrated that intranasal DAM administration can be a viable alternative to the intravenous or intramuscular route of administration. The purpose of this study is to assess the feasibility, safety, and acceptability of intranasal HAT. METHODS This study will assess intranasal DAM using a prospective multicentre observational cohort study design in HAT clinics across Switzerland. Patients will be offered to switch from oral or injectable DAM to intranasal DAM. Participants will be followed-up over 3 years, with assessments at baseline, and after 4, 52, 104 and 156 weeks. The primary outcome measure (POM) is retention in treatment. Secondary outcomes (SOM) include prescriptions and routes of administration of other opioid agonists, illicit substance use, risk behaviour, delinquency, health and social functioning, treatment adherence, opioid craving, satisfaction, subjective effects, quality of life, physical health, and mental health. CONCLUSIONS The results derived from this study will generate the first major body of clinical evidence on the safety, acceptability, and feasibility of intranasal HAT. If proven to be safe, feasible and acceptable, this study would increase the accessibility of intranasal OAT for individuals with OUD globally as a critical improvement in risk reduction.
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Affiliation(s)
- Jean N Westenberg
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,School of Medicine, University College Cork, Cork, Ireland
| | - Maximilian Meyer
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Johannes Strasser
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kenneth M Dürsteler
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.,Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zurich, Switzerland
| | - Luis Falcato
- Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
| | - Marc Vogel
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.
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Vogel M, Meyer M, Westenberg JN, Kormann A, Simon O, Salim Hassan Fadlelseed R, Kurmann M, Bröer R, Devaud N, Sanwald U, Baumgartner S, Binder H, Strasser J, Krausz RM, Beck T, Dürsteler KM, Falcato L. Safety and feasibility of intranasal heroin-assisted treatment: 4-week preliminary findings from a Swiss multicentre observational study. Harm Reduct J 2023; 20:2. [PMID: 36611162 PMCID: PMC9826580 DOI: 10.1186/s12954-023-00731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Heroin-assisted treatment (HAT) is effective for individuals with severe opioid use disorder (OUD) who do not respond sufficiently to other opioid agonist treatments. It is mostly offered with injectable diacetylmorphine (DAM) or DAM tablets creating a barrier for individuals who need the rapid onset of action but are either unable or unwilling to inject, or primarily snort opioids. To explore another route of administration, we evaluated the safety and feasibility of intranasal (IN) DAM. METHODS This is a multicentre observational cohort study among patients in Swiss HAT. All patients planning to receive IN DAM within the treatment centres were eligible to participate. Participants were either completely switched to IN DAM or received IN DAM in addition to other DAM formulations or opioid agonists. Patients were followed up for four weeks. Sociodemographic characteristics, current HAT regimen, reasons for starting IN DAM, IN DAM doses, number of injection events in the sample, IN DAM continuation rate, and appearance of adverse events and nose-related problems were evaluated. RESULTS Participants (n = 52) reported vein damage, preference for nasal route of administration, and desire of a stronger effect or for a less harmful route of administration as primary reasons for switching to IN DAM. After four weeks, 90.4% of participants (n = 47) still received IN DAM. Weekly average realised injection events decreased by 44.4% from the month before IN DAM initiation to the month following. No severe adverse events were reported. CONCLUSIONS After four weeks, IN DAM was a feasible and safe alternative to other routes of administration for patients with severe OUD in HAT. It addressed the needs of individuals with OUD and reduced injection behaviour. More long-term research efforts are needed to systematically assess efficacy of and patient satisfaction with IN DAM.
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Affiliation(s)
- Marc Vogel
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.
| | - Maximilian Meyer
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
| | - Jean N. Westenberg
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland ,grid.17091.3e0000 0001 2288 9830Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC Canada
| | | | - Olivier Simon
- grid.9851.50000 0001 2165 4204Service of Addiction Medicine, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | | | - Markus Kurmann
- HeGeBe HEROL, Psychiatric Services, Hospitals Solothurn, Olten, Switzerland
| | - Rebecca Bröer
- SuGeBe Gourrama, Psychiatric Services, Hospitals Solothurn, Solothurn, Switzerland
| | | | - Ulrike Sanwald
- Integrierte Suchthilfe Winterthur ISW, Integrated Psychiatry Winterthur, Winterthur, Switzerland
| | | | - Hannes Binder
- Outpatient Clinic for Substance Use Disorders, Psychiatric Clinic Baselland, Reinach, Switzerland
| | - Johannes Strasser
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
| | - R. Michael Krausz
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Thilo Beck
- grid.483175.c0000 0004 6008 5851Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
| | - Kenneth M. Dürsteler
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland ,grid.7400.30000 0004 1937 0650Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Luis Falcato
- grid.483175.c0000 0004 6008 5851Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
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Meyer M, Westenberg JN, Strasser J, Dürsteler KM, Lang UE, Krausz M, Vogel M. Nasal administration of diacetylmorphine improved the adherence in a patient receiving heroin-assisted treatment. Harm Reduct J 2022; 19:63. [PMID: 35672825 PMCID: PMC9171487 DOI: 10.1186/s12954-022-00644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Traditional heroin-assisted treatment in Switzerland consists of oral and injectable diacetylmorphine (pharmaceutical heroin) administration. To date, no suitable treatment option is available for patients who crave rapid onset (“rush”) but are either unable to inject or primarily sniff or inhale illicit heroin. We present a patient who successfully switched to intranasal heroin-assisted treatment following several unsuccessful treatment attempts. Case presentation A 29-year-old male with severe opioid use disorder, injection substance use, and concomitant cocaine use, previously prescribed slow-release oral morphine, was started on intravenous diacetylmorphine. Due to complications and harms associated with intravenous injections, nasal diacetylmorphine was prescribed. With this novel route of administration, the patient who had previously been unable to adhere to other OAT options remained in treatment. Health outcomes improved by reduction of injection-related harms, increased adherence to the heroin-assisted treatment regimen, and increased collaboration with the therapeutic staff. Conclusions Nasal heroin-assisted treatment can be a feasible therapeutic option for individuals with severe opioid use disorder who crave the fast onset of effect of diacetylmorphine but are unable to inject intravenously.
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Meyer M, Eichenberger R, Strasser J, Dürsteler KM, Vogel M. «One prick and then it´s done»: a mixed-methods exploratory study on intramuscular injection in heroin-assisted treatment. Harm Reduct J 2021; 18:134. [PMID: 34922561 PMCID: PMC8684658 DOI: 10.1186/s12954-021-00584-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/09/2021] [Indexed: 12/05/2022] Open
Abstract
Background Intramuscular (IM) injection of drugs is associated with high rates of injecting-related injuries and diseases. However, little is known about the role of this route of administration in heroin-assisted treatment. The aim of this study was to determine the prevalence of IM diacetylmorphine administration and associated complications as well as to explore patients’ views and opinions on the topic and the underlying reasons for this practice. Methods The research site was a Swiss outpatient treatment centre specialised in heroin-assisted treatment. We conducted in-depth interviews with two patients who intramuscularly inject diacetylmorphine. Interviews were analysed qualitatively, and emerging themes were used to develop a 38-item questionnaire on IM injections. We then offered this questionnaire to all patients in the treatment centre. Results Five main themes emerged from the in-depth interviews: poor venous access, side effects, subjective effects, procedure for IM injection, and consideration of alternatives to IM. These themes covered the rationale for using this route of administration, complications, subjective effects of IM diacetylmorphine, hygiene and safety measures as well as alternative routes of administration. Fifty-three patients filled in the questionnaire. The lifetime prevalence of IM injections was 60.4% (n = 32) and 34.4% (n = 11) of the patients stated that IM injection was their primary route of administration. No participant reported using the IM route for street drugs. The main reason for IM injections was poor vein access. Other reasons given were time saving and less risk of injuries. Complications included induration of muscle tissue and pain, whereas more severe complications like thrombosis and infections of the injection site were reported much less often. Conclusion As the population of opioid-dependent individuals is aging and the deterioration of access veins is likely to increase, the frequency of IM injecting will equally increase. Even though our data show that the IM injection of diacetylmorphine in a clinical setting is a common practice and appears to be relatively safe, research on alternative routes of administration is needed to provide potentially less harmful alternative routes of administration in heroin-assisted treatment.
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Affiliation(s)
- Maximilian Meyer
- Division of Substance Use Disorders, University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Ramón Eichenberger
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland
| | - Johannes Strasser
- Division of Substance Use Disorders, University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Kenneth M Dürsteler
- Division of Substance Use Disorders, University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.,Department for Psychiatry, Psychotherapy and Psychosomatic, University of Zurich, Lenggstrasse 31, 8008, Zurich, Switzerland
| | - Marc Vogel
- Division of Substance Use Disorders, University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland. .,Psychiatric Services of Thurgovia, Division of Substance Use Disorders, Seeblickstrasse 3, 8596, Münsterlingen, Switzerland.
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