Development and evaluation of an evidence-based health information on benzodiazepines and z-drugs

Background

With approximately 1.1-1.4 million people in Germany taking benzodiazepines (BZDs) and z-drugs in a problematic or dependent manner, this is a relevant public health problem which needs to be adressed. However, it is well known that affected individuals do not receive the counseling or treatment they need. One possible solution is preventive education of affected individuals and medical practioners using evidence-based and target-group-health information (HI).The project EDER-MIA aimed to develop and evaluate evidence-based and target-group-related HI.

Methods

With the help of three different focus groups (18-40-years; women: 40-60-years; > 60-year-olds), the information needs of affected individuals were assessed. Based on the results, we developed the HI and received feedback from health experts. The HI was implemented online (http://www.psychenet.de) and evaluated with the ‘Usefulness Scale of Patient Information’ (USE): An assessment was made on 3 subscales with a 10-point scale from ‘1=disagree at all’ to ‘10=agree completely'. By forming a sum score (range: 0-90), an overall assessment was calculated.

Results

The results of the focus group study revealed the persons taking BZDs or z-drugs were in need about informations about sleep problems, the risk of taking BZDs and z-drugs and a better orientation regarding help services. The evaluation of the health information achieved medium acceptance rates of usefulness for affected persons (N = 192, 68.2% female; mean= 54.3, sd = 15.4). A somewhat higher usefulness was recognised by the medical staff (N = 58, 69.0% female, mean=64.7, sd = 17.2).

Conclusions

The development of target group-specific HI with the participation of affected individuals and experts is suitable for topics that are associated with possible experiences of shame and stigma. In addition to providing information about the risks of taking BZDs and z-drugs, screening of problematic BZD and z-drug use is also a matter of concern.

Key messages

• BZDs and z-drug use is a relevant public health concern which needs to be adressed.

• Target-group specific health information for BZD and z-drug use accompanied by a screening-test can encourage affected individuals to seek medical advice.

[Social integration after 4 years of heroin-assisted treatment]

BACKGROUND

Studies from several countries have by now shown the effectiveness of heroin-assisted treatment in comparison to methadone treatment. However, only few long-term results exist, and in particular data with a focus on social integration of the patients are scarce.

OBJECTIVE

The study analyzes the course of long-term social integration among the patients of the German diamorphine study.

METHODS

Individual changes in health, drug use and social integration among patients who had participated in a 4-year diamorphine treatment (n=156) were described and statistically tested by means of repeated measures analyses. The criteria used are based on the instruments OTI-HSS and SCL-90-R, on medical findings, urinalyses, and on variables as well as composite scores from the European Addiction Severity Index.

RESULTS

In all domains significant improvements were found after long-term treatment. The percentage of patients employed or currently working had increased 3-fold up to 40% after 4 years. Moreover, the living situation and leisure behaviour improved, and criminal activities declined markedly. The main influencing factor for successful social integration after 4 years of treatment is the ability to work.

CONCLUSIONS

Heroin-assisted treatment is a long-term effective treatment for severely dependent opiate addicts with respect to stabilization of health, reduction of illegal drug use and improvement of social integration. Furthermore, the results show that processes of social (re-)integration of drug users take time.

[Long-term prescription of benzodiazepines and non-benzodiazepines]

BACKGROUND

The number of persons with a dependence on prescription drugs such as sedatives or tranquilizers in Germany is estimated at between 1.4 and 1.9 million. According to national addiction treatment documentations only very few of them seek help in specialised treatment services. The majority of prescription drug-dependent people use benzodiazepines. This medication is usually prescribed by physicians and according to German guidelines it should be prescribed only for limited, short periods and in low doses.

OBJECTIVE

This study aims to determine the extent of the problematic prescription of benzodiazepines and non-benzodiazepines.

METHODS

We used prescription data from the Northern Germany Computing Centre for Pharmacies registered between 2005 and 2007. For the German regions of Hamburg, Bremen and Schleswig-Holstein, benzodiazepine prescriptions during an individual prospective period of 12 months were analysed.

RESULTS

From July 2005 to June 2006, 294 143 prescriptions of benzodiazepines and non-benzodiazepines were recorded for 78 456 citizens of Hamburg and billed at the expenses of the governmental health insurance funds. In the course of one observed patient year, 51.1% of benzodiazepine prescriptions were in accordance with the German guidelines. 15.6% of the patients were supplied on a long-term basis (0.5-1 DDD during at least 2 months). Prescriptions for women and persons older than 70 years were disproportionately high. Compared with the Federal states of Bremen and Schleswig-Holstein, Hamburg does not show an exceptional position.

CONCLUSION

The prescription of benzodiazepines which is not in accordance with the relevant national guidelines is widespread and calls for discussion and education among physicians and pharmacists. Furthermore, professional addiction services should reconsider ways to help and attract prescription drug-dependent people to cover their needs, as their numbers will grow in an aging society.

Quality of life profiles and changes in the course of maintenance treatment among 1,015 patients with severe opioid dependence

INTRODUCTION

Studies indicate that different areas of mental, physical, social and daily life functioning need to be considered in order to improve intervention outcomes in substance user patients. The aim of the study was to assess health-related quality of life (HRQOL) in patients diagnosed with opioid dependence as compared to healthy controls and patients diagnosed with depression and schizophrenia.

METHODS

A total of 1,015 outpatients diagnosed with opioid dependence were investigated during 12 months of maintenance treatment. HRQOL (MSQoL), addiction (EUROP-ASI), and sociodemographic characteristics were assessed.

RESULTS

HRQOL in opioid dependence improved significantly (p < .001), but was lower as compared to that of healthy controls and patients diagnosed with schizophrenia. HRQOL in opioid dependence comprises addiction-specific aspects, most importantly low material satisfaction, physical health, and social stability.

CONCLUSIONS

HRQOL measurement provides valuable information for course and outcome in opioid dependence treatment.

Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence

BACKGROUND

There is increasing evidence that health-related quality of life (HRQOL) is associated with a successful treatment and better outcome in opioid addiction. The aim of the present study was the longitudinal investigation of HRQOL in patients with severe opioid dependence, who were randomly assigned to four groups of medical and psychosocial treatment: heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively.

METHODS

HRQOL (MSQoL) and physical health (OTI) were investigated in 938 subjects, who participated in the German multi-centre study examining the effects of heroin-assisted treatment in patients with severe opioid dependence. Data for the present analysis were taken from baseline and 12-month follow up.

RESULTS

Under both forms of maintenance and psychosocial treatment HRQOL improved significantly during the observation period. HRQOL improvement under maintenance with heroin exceeded improvement under methadone, especially with regard to subjective physical health. HRQOL improvement was significantly associated with better expert-rated physical health. Further analyses showed significant better improvement of HRQOL in subjects treated with PSE compared with CM.

CONCLUSIONS

The advantage of heroin with regard to the improvement of HRQOL may be partially explained by a better improvement of physical health under maintenance with heroin compared with methadone, which highlights the importance of a comprehensive model of health care for patients with severe opioid dependence. Future studies need to investigate the benefits of PSE for patients in maintenance therapy.

Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial

BACKGROUND/AIMS

Until now, the medical prescription of diamorphine (heroin) has been suggested as suitable for patients who have failed previous maintenance treatments. The aim of this paper is to assess the effects of diamorphine on opioid-dependent patients with no previous maintenance treatment experience (NPME).

METHODS

The German heroin trial compared diamorphine versus methadone maintenance treatment and included 107 patients with NPME. This paper is a sub-analysis of these patients.

RESULTS

When comparing this subsample with the rest of the participants in the study, large baseline differences were found, showing a more severe drug use profile in patients with NPME. However, no differences were found in terms of treatment outcome and treatment retention. In the subsample with NPME, outcome measures on the reduction of illicit drug use were significantly better under diamorphine compared to methadone treatment, while there was no difference in health outcomes.

CONCLUSION

Controlled studies are now necessary to examine whether diamorphine treatment could be considered as one of several options in treating severely opioid-dependent patients, regardless of previous maintenance treatment experience.

Effects of psychiatric comorbidity on treatment outcome in patients undergoing diamorphine or methadone maintenance treatment

BACKGROUND

Comorbid psychiatric disorders among opioid-dependent patients are associated with several negative outcome factors. However, outcomes of maintenance treatment have not been sufficiently established, and no evidence is available with respect to heroin-assisted treatment (HAT).

METHODS

For patients in the German heroin trial outcome measures were analyzed for HAT versus methadone maintenance treatment (MMT) both for patients with and without a comorbid diagnosis according to CIDI.

RESULTS

47.2% of the sample had at least one comorbid psychiatric diagnosis, mainly neurotic, stress-related or somatoform (F4) or affective (F3) disorders. HAT had a better outcome than MMT concerning improvement of health and reduction of illicit drug use in both comorbid and non-comorbid patients, but weaker effects were found in the comorbid group.

CONCLUSIONS

The better outcome of HAT also in comorbid patients suggests that psychiatric comorbidity should be an inclusion criterion for HAT. The weaker advantage of HAT may be due to pharmacological or methodological reasons.

Physical and Mental Health in Severe Opioid Dependent Patients Within a Randomised Controlled Maintenance Treatment Trial

Background:

Injection drug users (IDUs) frequently suffer from somatic and mental co-morbidity. The effects of different opioid maintenance protocols on these parameters have not been systematically studied yet.

Methods:

This study was conducted as a 12-month open-label multi-centre randomised controlled trial to test a heroin- vs. methadone based protocol.

Results:

515 patients were randomised to the heroin-assisted and 500 to the methadone-assisted treatment program. Baseline scores were as follows: OTI-HSS 19.0 (±5.2), BMI 22.6 (±3.5), pathologic electro-/echocardiogram 20.4% (n=582) / 13.9% (n=491), positive HBV-, HCV- and HIV-serology 65.7% (n=863) / 86.5% (n=855) / 9.2% (n=951), positive tuberculin test 9.1% (n=318), KPS 71.4 (±12.9), Global Severity Index (GSI; SCL-90-R) 69.2 (±10.6), GAF 53.6 (±11.7) (all parameters not significant between treatment groups). Improvement after 12 months of treatment differed significantly between treatment groups (heroin vs. methadone): OTI-HSS 8.1 (±5.2) vs. 10.6 (±6.4), BMI 24.5 (±4.3) vs. 23.7 (±4.1), KPS 78.2 (±12.8) vs. 74.2 (±13.3), GSI 58.6 (±13.7) vs. 62.0 (±13.2), GAF 63.0 (±13.3) vs. 56.2 (±15.0) (ANOVA, all p=.000). The frequency of pathologic echocardiograms after 12 months was significantly lower in the heroin compared to the methadone group. Within the heroin group, completers benefited stronger than drop-outs. The remaining parameters did not differ between baseline and 12 months and between treatment groups.

Conclusion:

Integration of severe injection drug users either in methadone or heroin assisted maintenance treatment has positive effects on most change sensitive physical and mental variables. In this patient group heroin assisted treatment showed superior results compared to methadone.

Association of personality disorders, family conflicts and treatment with quality of life in opiate addiction

AIM

The purpose of this study was to investigate the association of the current status and longitudinal changes in different clinical and social variables with quality of life (QOL) in opiate addiction. Our hypotheses were that drug use, comorbid personality disorders and social problems are associated with worse QOL.

METHODS

107 participants with long-term opiate addiction were included and interviewed at entry with the Europ-ASI and the PDQ-R. QOL (SF-36) and changes in different domains of the Europ-ASI were assessed after 2 years.

RESULTS

Personality disorders, interpersonal conflicts with the family or partner and ongoing need for somatic and psychiatric treatment were significantly associated with worse subjective QOL, whereas changes in drug and alcohol use, the economic situation, legal problems and social problems with persons outside of the family showed no relevant association with QOL.

CONCLUSION

Our results provide support for an emphasis in treatment on helping clients to reduce intra- and interpersonal conflicts according to comorbid conditions and among family members and partnerships. In addition, the present data provide further support for the advantages of extended interventions in long-term opiate addiction.

Cocaine use and the utilisation of drug help services by consumers of the open drug scene in Hamburg

In order to describe the patterns of use in the open drug scene in Hamburg, a study was carried out among 616 drug users in the drug scene and in or in the vicinity of low-threshold institutions close to the drug scene in summer 2000. The special focus was on the prevalence of cocaine and crack use as well as on the utilisation of help services for drug users. 80% of the interviewed persons were male, the average age was 32.6 years. They had been using drugs such as heroin or cocaine for an average of 11 years. 84% had used heroin and 74% cocaine within the last 24 h. Use was intravenous for 66%. 57% used cocaine intravenously, the percentage of crack smokers was 22%. Compared to previous studies, an increase in cocaine use can be noted among the scene users in Hamburg, mainly related to intravenous cocaine use. Crack smoking has only increased slightly over the past few years. Based on cluster analysis, four consumption pattern groups can be established. The largest group (38%) mainly uses cocaine and heroin. The second group (26%) consists of polyvalent drug consumers using methadone in addition to heroin and cocaine, as well as, partially, benzodiazepines, cannabis or alcohol. Group 3 (19%) mainly uses heroin only, some of them also using methadone and/or cannabis. The fourth group (17%) is mainly related to alcohol, the greater part of them additionally using heroin. On the whole, it appears that those users who currently do not use cocaine (or crack) are in a better health and social situation. The group using only heroin (cluster 3) also compares favourably with the other three consumption pattern groups with regard to the intensity of use, consumption in public and risk behaviour. Almost all the interviewed persons are in contact with general practitioners. However, the increasing cocaine use has not been met by sufficient intervention and treatment programmes so far.

[Mental disorders and the course of opiate dependence]

OBJECTIVE

The present study investigates the hypothesis of a relationship between mental disorders and symptoms on the one hand and the extent of drug consumption and the addiction-related problems of opiate dependents on the other hand.

METHODS

In a five-year follow-up study in Hamburg among 350 opiate dependents who, at the time of the initial survey, were in contact with the drug help system, 219 clients (63%) could be interviewed at (so far) three different times of investigation. Standardised questionnaires like the EuropASI, CIDI, SCL-90-R, STAI and BDI were used for the interviews.

RESULTS

The general life situation of the surveyed persons has on the whole improved in the course of the last two to three years. Also the average drug consumption clearly decreased. Between mental disorders/disturbances and drug dependence or drug-related problems, a linear correlation could be found: An unfavourable course of mental disorders and symptoms correlates with a problematic current life situation of the client. There is also a global relationship between increased drug consumption and the emergence of mental symptoms like depressiveness and anxiety and the psychosocial functional level.

CONCLUSIONS

The expected relationship between mental disturbances and the extent of drug consumption is not very marked. This is in support of the basic assumption that specific constellations of drug consumption and mental disorders do not exist isolated, but that they are related, as elements of a complex pattern, to the development of other areas of life.

[Use of and participation in self-help groups for methadone substitution patients]

To evaluate the importance of self-help groups and the patients' readiness to participate in such groups a sample of 675 methadone patients in Hamburg was asked by means of questionnaires. 43% of the patients had heard of self-help groups. One quarter of them (10% of the whole sample) had participated in self-help groups at some time. The greatest importance of self-help organisations is attached to a representation of the interests of methadone patients to improve their overall situation. Another important purpose of self-help groups is seen in getting help for legal, financial and social problems. Getting in contact with other clients or offering breakfast/lunch, washing clothes or shower facilities etc. is not evaluated as an important task for self-help organisations. Patients who are working on a regular basis and living in stable conditions are less interested in participating in self-help groups. Thus, the participants in self-help groups can hardly benefit from the experiences of the socially better integrated methadone patients.

Psychiatric comorbidity in opiate addicts

The present study investigates whether a correlation exists between mental symptoms and opiate dependency. During a 5-year follow-up study in Hamburg, of 350 opiate addicts who were in contact with the help system at the time of the initial investigation, 219 (63%) could be interviewed three times at 1-year intervals. The investigation instruments were standardized questionnaires such as EuropASI, CIDI, SCL-90-R and BDI. The general life situation of the investigated persons had, on the whole, improved in the course of the last 2-3 years. Drug consumption had markedly decreased. One third of the opiate addicts were in a comparatively good mental condition on all three survey interviews, for 17% there was a worsening of the condition, and for another 17% the negative mental condition was reinforced. A correlation can be established between mental disorders/symptoms and drug addiction or drug-related problems. The more unfavorable the course of the mental symptoms, the greater the problems of the client's current life situation. There is also an overall relationship between increased drug consumption and mental symptoms like depressivity and anxiety, and the psychosocial functioning level. However, the expected correlations between mental disorders and the extent of drug consumption are not very marked. This indicates that specific constellations of drug consumption and mental disorders are not isolated but are related, as elements of a complex behavioral pattern, to the development of other life areas of the client.

Comorbidity of opiate dependence and mental disorders

In a 5-year-follow-up study of 350 opiate addicts in contact with a drug help system in Hamburg, 272 clients (78%) were interviewed a second time after 1 year. The objective of the study was to examine the correlation between mental disorders and drug consumption and its relationship to clients' general life situation. In the majority of the opiate addicts, a pattern of polydrug consumption was observed, but the amount of drugs consumed was clearly lower after 1 year. In the initial survey, a mental disorder according to ICD-10 could be diagnosed for 55% of the sample. Among groups formed by the severity and course of mental disorders or their symptoms, a significant correlation was observed, particularly at the time of follow-up, between the extent of drug consumption and the course of the mental disorder. Other areas, like physical health or social problems/conflicts, were also related to comorbidity (i.e., heavy drug consumption and/or mental disorder). These interrelationships should be taken into account in treatment, care and guidance to increase the prospects for successful treatment.

Maintenance treatment of opiate addicts in Germany with medications containing codeine--results of a follow-up study

AIMS

Outpatient maintenance treatment of opiate addicts with codeine/dihydrocodeine is a common approach in the treatment of drug addicts in Germany. This study was carried out to assess possible benefits of codeine maintenance in terms of patients' health stabilization, social rehabilitation and drug consumption.

DESIGN

Three-year follow-up study.

SETTING

Three practices of substituting physicians in large-city areas in Germany.

PARTICIPANTS

Of a random sample of 297 people attending for opiate outpatient treatment in 1993, 199 were successfully followed up 3 years later.

MEASUREMENTS

Measures of health, living conditions, employment, criminal activities and drug use were collected at baseline and follow-up. The data were based on standardized interviews and medical examinations by the attending doctors as well as on questionnaires from the patients.

FINDINGS

Based on a 67%-follow-up rate, after 3 years of codeine maintenance there was improvement in general health and mental problems. The living and working situation remained more or less unchanged and stabilized at a satisfactory level. The same applies to the consumption of drugs.

CONCLUSION

The patients' progress shown in this study was comparable to that achieved by methadone maintenance in similar geographical regions. Codeine has a weaker pharmacological effects and our results suggest that codeine maintenance treatment deserves more attention and controlled trials to assess the benefits compared with methadone (or other opioids).

[Prevalence of psychiatric disorders in opiate dependent patients in contact with the drug treatment system]

In the course of a 5-year follow-up study concerning comorbidity in opiate addicts, 350 patients were investigated initially in various addiction centres in Hamburg. More than two thirds of the participants of the study are male, with an average age of 29 years at the time of the investigation. Most of them are receiving methadone maintenance treatment (42%), about one fourth is in residential rehabilitation and another 17% in inpatient detoxification treatment. The patients have been consuming heroin for an average of 9 years. For 55% of the opiate addicts (at least) one more psychic disorder in accordance with ICD-10 has been diagnosed (lifetime prevalence). F6 personality disorders have not been taken into consideration. The 6-month prevalence is 37%, 2-week prevalence 23%. For 43% of the opiate addicts, the predominant disorders belong to the group of neurotic, endurance, and somatoform disorders (F4), and for 32% of the patients to the group of affective disorders (F3). Schizophrenic, schizotypic and delusional disorders (F2) are less frequent (5%). Another 5% of the opiate addicts suffer from eating disorders (F5). These are partly multiple diagnoses cases; there is an average of 1.3 diagnoses per patient. Women are clearly more often affected by comorbidity than men. Most disorders first occur between the age of 18 and 21 years. Therefore, (lifetime) prevalence rates are twice to three times as high as that of the average German population, according to the present state of knowledge. This underlines the great importance of specific diagnostic and explorative methods for the treatment of addiction. Psychic disorders or disturbances that might adversely affect the course of treatment should be given more consideration.

The correlation between everyday stress and angina pectoris: a longitudinal study

The article describes a longitudinal study testing the hypothesis that everyday stress can aggravate angina pectoris (AP). Every weekend for 1 year, 42 patients with coronary heart disease filled out a questionnaire on perceived stress for the preceding week. They also rated AP symptoms, again for the previous week. Within-subject correlation between stress and severity of AP was quite pronounced in some subjects and resulted in a sample mean of 0.38. The distribution of correlation coefficients in the sample was significantly different from a random distribution around 0. Stress values also predicted AP in the week to come. However, this finding was no longer significant when the influence of lag 1 auto-correlations between stress values was eliminated. Our results show that the effect of everyday stress on AP is essentially immediate and that it can be quite important in some subjects.

Opioid addiction and suicidality

The prevalence of suicide attempts among opioid addicts is reported to lie between 8% and 17%, with some studies reporting an even higher rate among special groups of addicts. Yet there is insufficient knowledge about which addicts have a higher risk of suicide and which other factors seem to be involved in the constellation leading to the suicide attempt; the study of different subgroups of addicts is thus necessary. This paper reports a study on suicide attempts among a sample population in a detoxification unit and another group undergoing codeine maintenance treatment. There was a high rate of suicide attempts among both groups (23% of those in the detoxification unit and 28% of those maintained on codeine), but treating physicians tended to underestimate suicidality. The results lead to the conclusion that among a subgroup of addicts suicidality plays a larger role; a greater emphasis should thus be placed on the underlying psychopathology and the treatment needed.

[Drug substitution treatment of heroin dependent patients with codeine preparations--treatment effects from the viewpoint of the physicians and patients]

The controversy caused by the debate on treatment and substitution strategies in drug addiction is unchanged. This is particularly true concerning the use of codein-based drugs in the substitution of heroin abusers. However, only a few studies on the effects of this old and widely used method of substitution have been carried out. This article presents one retrospective and prospective study on the effects of the codein-based substitution in heroin abusers (n = 416). With respect to the issues addressed by this study such as somatic and psychic health, social integration, delinquincy and consumption patterns, patients as well as clinicians report an improvement in general health and fewer of the problems usually associated with heroin abuse, similar to the results from substitution treatment elsewhere.

Results of international and federal German evaluation studies of methadone substitution therapy--an overview

After a brief historical review results of German evaluation studies are contrasted for the first time with international results concerning the efficiency of methadone treatment of heroin addicts. All studies report a fast and obvious improvement of the patients' physical and psychic well-being. Decrease is observed in drug related criminality as well as in its following consequences such as arrests, trials, and inprisonments. Patients distance themselves from the drug-scene and at the same time increase communication with a drug-free environment. One problem persisting for German methadone-patients is the reintegration into their education or job. As to this only minor improvements have been obtained. Already after a short time patients on a methadone-therapy reduce their illicit use of drugs substantially. Especially the consume of heroin is getting reduced if not totally given up. The use of other drugs such as cocaine, tranquilizers and barbiturates gets reduced. For a number of patients the use of benzodiazepines remains a problem. The time patients stay in methadone-therapies (and to a high degree the success of the therapy itself) depends on a well structured arrangement of the methadone program and on the methadone dosage. Long-term follow-up studies abroad show that after methadone treatment the percentage of patients staying abstinent in the long run is almost the same as after drugfree treatment.