The provision of opioid agonist treatments (OATs), as a standard approach towards opioid dependence syndrome, differs widely between countries. In response to access disparities, in 2014, the Council of Europe's Pompidou Group first brought together an expert group on framework conditions for the treatment of opioid dependence. The group used a Delphi approach to structure their discussions and develop guiding principles for the modernisation of OAT regulations and legislation. The expert group identified some 60 guiding principles, which were then the subject of wide public consultation. Endorsed by Pompidou Group member states, the final report identified four key recommendations: (1) Prescription and delivery without prior authorisation schemes; (2) Effective removal of financial barriers to access to care; (3) Coordination and follow-up by a national consultative body; and (4) Neutral, precise and respectful terminology. During meetings, the expert group hypothesised that inequalities in OAT access are likely to be linked to underlying rationales which in theory are contradictory, but in practice co-exist within the different political frameworks. The present article considers the perceived influence upon different regulatory frameworks. Discussion is centred around the potential impact of underlying rationales upon the effective implementation of a modernised framework.

The European Pain Federation EFIC, the International Association for Hospice and Palliative Care, International Doctors for Healthier Drug Policies, the Swiss Romandy College for Addiction Medicine, the Swiss Society of Addiction Medicine, and the World Federation for the Treatment of Opioid Dependence called on medical journals to ensure that authors always use terminology that is neutral, precise, and respectful in relation to the use of psychoactive substances. It has been shown that language can propagate stigma, and that stigma can prevent people from seeking help and influence the effectiveness of social and public-health policies. The focus of using appropriate terminology should extend to all patients who need controlled medicines, avoiding negative wording. A narrow focus on a few terms and medical communication only should be avoided. The appropriateness of terms is not absolute and indeed varies between cultures and regions and over time. For this reason, it is important that communities establish their own consensus of what is “neutral”, “precise”, and “respectful”. We identified 23 problematic terms (most of them we suggest avoiding) and their possible alternatives. The use of appropriate language improves scientific quality of articles and increases chances that patients will receive the best treatment and that government policies on psychoactive substance policies will be rational.

Journal of Palliative MedicineVol. 21, No. 4 Letters to the EditorThe Use of Terminology Related to Dependence and Dependence-Producing MedicinesWillem Scholten, Olivier Simon, Robert Hämmig, Icro Maremmani, Lukas Radbruch, and Chris WellsWillem ScholtenInternational Doctors for Healthier Drug Policies, London, United Kingdom.Search for more papers by this author, Olivier SimonSwiss Romandy College for Addiction Medicine, Lausanne, Switzerland.Swiss Society of Addiction Medicine, Bern, Switzerland.Search for more papers by this author, Robert HämmigSwiss Society of Addiction Medicine, Bern, Switzerland.Search for more papers by this author, Icro MaremmaniWorld Federation for the Treatment of Opioid Dependence, New York, New York.Search for more papers by this author, Lukas RadbruchInternational Association for Hospice and Palliative Care, Houston, Texas.Search for more papers by this author, and Chris WellsEuropean Pain Federation EFIC, Diegem, Belgium.Search for more papers by this authorPublished Online:1 Apr 2018https://doi.org/10.1089/jpm.2018.0004AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"The Use of Terminology Related to Dependence and Dependence-Producing Medicines." Journal of Palliative Medicine, 21(4), pp. 415–416FiguresReferencesRelatedDetails Volume 21Issue 4Apr 2018 InformationCopyright 2018, Mary Ann Liebert, Inc.To cite this article:Willem Scholten, Olivier Simon, Robert Hämmig, Icro Maremmani, Lukas Radbruch, and Chris Wells.The Use of Terminology Related to Dependence and Dependence-Producing Medicines.Journal of Palliative Medicine.Apr 2018.415-416.http://doi.org/10.1089/jpm.2018.0004Published in Volume: 21 Issue 4: April 1, 2018PDF download

Opioid medicines prescribed on a long-term basis for opioid dependence syndrome have historically been deemed « substitution treatments » and misunderstood as involving the "replacement of an illicit drug by a legal drug". Prior authorisation schemes, in addition to ordinary procedures for authorising medicines and supervising professionals, interfere with access to treatment. In order to guide the countries in their efforts to modernise their regulations, the Pompidou Group mandated a group of health and legal experts, who identified 62 guiding principles and developed four strategic recommendations : 1) the removal of prior authorisation schemes, 2) the removal of financial barriers, 3) supervision by a national consultative body and 4) The adoption of neutral, precise and respectful terminology.

Zusammenfassung Das erste Mal hat sich der Europäische Gerichtshof für Menschenrechte in Strassburg zur Frage geäussert, ob heroinabhängige Personen im Freiheitsentzug ein Anrecht auf eine Substitutionsbehandlung mit Methadon haben. Gestützt auf den Artikel 3 der Konvention, welcher Folter und ­andere unwürdige Behandlungen verbietet, hat der Gerichtshof Folgendes entschieden: Der Staat, der kein Methadon zur Verfügung stellt, muss – anhand eines unabhängigen Gutachtens – beweisen, dass eine andere Behandlung dem Patienten besser hilft als die Substitution mit einem Opiat. Im Folgenden werden die Bedeutung und die Grenzen dieses Entscheides dargelegt.

Background Buprenorphine is a partial µ-opioid receptor agonist used for maintenance treatment of opioid dependence. Because of the partial agonism and high receptor affinity, it may precipitate withdrawal symptoms during induction in persons on full µ-opioid receptor agonists. Therefore, current guidelines and drug labels recommend leaving a sufficient time period since the last full agonist use, waiting for clear and objective withdrawal symptoms, and reducing pre-existing full agonist therapies before administering buprenorphine. However, even with these precautions, for many patients the induction of buprenorphine is a difficult experience, due to withdrawal symptoms. Furthermore, tapering of the full agonist bears the risk of relapse to illicit opioid use. Cases We present two cases of successful initiation of buprenorphine treatment with the Bernese method, ie, gradual induction overlapping with full agonist use. The first patient began buprenorphine with overlapping street heroin use after repeatedly experiencing relapse, withdrawal, and trauma reactivation symptoms during conventional induction. The second patient was maintained on high doses of diacetylmorphine (ie, pharmaceutical heroin) and methadone during induction. Both patients tolerated the induction procedure well and reported only mild withdrawal symptoms. Discussion Overlapping induction of buprenorphine maintenance treatment with full µ-opioid receptor agonist use is feasible and may be associated with better tolerability and acceptability in some patients compared to the conventional method of induction.

Heute wird nur jeder zehnte Patient mit einer Suchtproblematik auch behandelt. Die Interdisziplinäre Fachgruppe für Suchtmedizin Schweiz fordert daher ein System, das Suchtmedizin auf breiter Ebene fördert und alle involvierten Fachbereiche und Institutionen einschliesst. Auch spezifische Aus- und Weiterbildungsprogramme seien nötig.

BACKGROUND/AIMS: Switzerland’s drug policy model has always been unique and progressive, but there is a need to reassess this system in a rapidly changing world. The IMPROVE study was conducted to gain understanding of the attitudes and beliefs towards opioid maintenance therapy (OMT) in Switzerland with regards to quality and access to treatment. To obtain a “real-world” view on OMT, the study approached its goals from two different angles: from the perspectives of the OMT patients and of the physicians who treat patients with maintenance therapy. The IMPROVE study collected a large body of data on OMT in Switzerland. This paper presents a small subset of the dataset, focusing on the research design and methodology, the profile of the participants and the responses to several key questions addressed by the questionnaires. METHODS: IMPROVE was an observational, questionnaire-based cross-sectional study on OMT conducted in Switzerland. Respondents consisted of OMT patients and treating physicians from various regions of the country. Data were collected using questionnaires in German and French. Physicians were interviewed by phone with a computer-based questionnaire. Patients self-completed a paper-based questionnaire at the physicians’ offices or OMT treatment centres. RESULTS: A total of 200 physicians and 207 patients participated in the study. Liquid methadone and methadone tablets or capsules were the medications most commonly prescribed by physicians (60% and 20% of patient load, respectively) whereas buprenorphine use was less frequent. Patients (88%) and physicians (83%) were generally satisfied with the OMT currently offered. The current political framework and lack of training or information were cited as determining factors that deter physicians from engaging in OMT. About 31% of OMT physicians interviewed were ≥60 years old, indicating an ageing population. Diversion and misuse were considered a significant problem in Switzerland by 45% of the physicians. CONCLUSION: The subset of IMPROVE data presented gives a present-day, real-life overview of the OMT landscape in Switzerland. It represents a valuable resource for policy makers, key opinion leaders and drug addiction researchers and will be a useful basis for improving the current Swiss OMT model.

Opioid substitution treatment (OST) for opioid dependence may be limited by adverse events (AEs). Increasing the range of therapeutic options optimizes outcomes and facilitates patient management. An international, multi-center, two-phase study investigated the efficacy and safety of slow-release oral morphine (SROM) versus methadone in patients receiving methadone therapy for opioid dependence. In phase 1 (two way cross-over, 11weeks each period) patients were randomized to SROM or methadone oral solution. In phase 2 (25weeks), patients continued treatment with SROM (group A) or switched from methadone to SROM (group B). In total, 211 out of 276 completed phase 1 and 198 entered phase 2 (n=95 group A, n=103 group B). Treatment with both SROM and methadone was well tolerated. However, the mean QTc-interval associated with methadone was significantly longer than that under SROM. Higher treatment satisfaction, fewer cravings for heroin, and lower mental stress were reported with SROM. This study adds a significant further weight of evidence that SROM is an effective and well tolerated long-term maintenance treatment for opioid dependence with a beneficial risk profile compared to methadone regarding cardiac effects and supports its clinical utility.

Die Komorbidität von Opiatabhängigkeit mit anderen psychischen Störungen (z.B. Depression, Angststörungen, Persönlichkeitsstörungen) sind für Wissenschaft, Versorgung und den klinischen Alltag eine Herausforderung, denn ihr Vorkommen ist hoch, die Unsicherheit in Diagnostik und Indikation gross und die Behandlung meist schwierig. In diesem Beitrag wird zunächst ein Überblick zu Epidemiologie, Diagnostik und Ätiologie (z.B. Selbstmedikations-, Affektregulations- und Supersensitivitätsmodell) gegeben. Danach wird näher auf Beratung, Behandlung und Rehabilitation eingegangen, wobei die Notwendigkeit individualisierter und vor allem integrativer Angebote betont wird. Insbesondere werden die typischen Therapiephasen und die Kernkomponenten einer integrativen Behandlung vorgestellt.

To assess tobacco, alcohol, cannabis and benzodiazepine use in methadone maintenance treatment (MMT) as potential sources of variability in methadone pharmacokinetics.Trough plasma (R)- and (S)-methadone concentrations were measured on 77 Australian and 74 Swiss MMT patients with no additional medications other than benzodiazepines. Simple and multiple regression analyses were performed for the primary metric, plasma methadone concentration/dose.Cannabis and methadone dose were significantly associated with lower 24-h plasma (R)- and (S)-methadone concentrations/dose. The models containing these variables explained 14-16% and 17-25% of the variation in (R)- and (S)-methadone concentration/dose, respectively. Analysis of 61 patients using only CYP3A4 metabolised benzodiazepines showed this class to be associated with higher (R)-concentration/dose, which is consistent with a potential competitive inhibition of CYP3A4.Cannabis use and higher methadone doses in MMT could in part be a response to-or a cause of-more rapid methadone clearance. The effects of cannabis and benzodiazepines should be controlled for in future studies on methadone pharmacokinetics in MMT.

We examined acute effects of intravenous diacetylmorphine (heroin) administration - which induces a characteristic biphasic response: A short rush-sensation associated with intense pleasurable feelings followed by a subjectively different period of euphoria on cerebral blood flow. This was assessed in nine male heroin dependent patients participating in a heroin maintenance program in a setting resembling everyday pattern of heroin abuse. 99mTc-HMPAO was administered 45 s (rush) and 15 min (euphoria) after administration of i.v. heroin and 45 s after administration of saline (placebo). Plasma concentration of diacetylmorphine and its metabolites were measured with high-pressure liquid chromatography (HPLC). Compared to the euphoria condition, rush was associated with blood flow increase in the left posterior cerebellar lobe, left anterior cingulate gyrus and right precuneus. Our results are in line with recent reports indicating that the cerebellum is an important component in functional brain systems subserving sensory and motor integration, learning, modulation of affect, motivation and social behaviour, which all play important roles in reinforcing properties of opioids.

Background: Genetic variations of the dopamine and opioid receptors could influence the response to methadone maintenance treatment (MMT).Methods: We included 238 MMT patients according to their response to treatment and methadone dosing, along with 217 subjects without substance dependence. All were genotyped for polymorphisms of the dopamine D-1, D-2, mu-opioid and delta-opioid receptor genes.Results: The polymorphisms of the mu-opioid (118A > G), delta-opioid (921 T > C), dopamine D-1 (Ddel) and D-2 (TaqI A) receptor genes were not associated with response to MMT and methadone dosing, whereas an association was found with the dopamine D2 receptor (DRD2) 957C > T polymorphism. The 957CC carriers were more frequently non-responders to treatment (OR=2.4; p=0.02) and presented a fourfold shorter period of negative urine screening (p=0.02). No significant differences in allele frequencies were observed between the MMT patients and the control group, suggesting no association of the analyzed polymorphisms with opioid dependence.Conclusions: These results suggest that DRD2 genotype may contribute to the understanding of the interindividual variability to the response to MMT. (c) 2008 Elsevier Inc. All rights reserved.