Opioid replacement therapy
Opioid replacement therapy (ORT) or opioid substitution therapy is the medical procedure of replacing an illegal opioid drug such as heroin with a longer acting but less euphoric opioid, usually methadone or buprenorphine, that is taken under medical supervision. In some countries (e.g. Switzerland, Austria, Slovenia) patients may be treated with slow-release morphine where methadone is deemed inappropriate in the circumstances. In Germany, Dihydrocodeine has been used off-label in ORT for many years, however it is no longer frequently prescribed for this purpose. Extended-release dihydrocodeine is again in current use in Austria for this reason. Research into the usefulness of piritramide, extended-release hydromorphone including polymer implants lasting up to 90 days, dihydroetorphine and some other drugs for this purpose is in various stages in a number of countries at present. The prescription of medicinal heroin or morphine for long-term addicts, particularly those having difficulty with methadone programmes, is also done in some countries.
Some formulations of buprenorphine are manufactured in pill form with the opiate antagonist Naloxone to prevent addicts from crushing the tablets and injecting them instead of taking them sublingually (under the tongue).
The driving principle behind ORT is that an opiate addict will be able to regain a normal life and schedule while being treated with a substance that stops him or her from experiencing withdrawal symptoms and drug cravings, but doesn't provide strong euphoria. In some countries (not the USA, UK, Canada, or Australia) regulations require that ORT should be applied for a limited time only, as long as needed for the patient to consolidate his economic and psychosocial situation. (Patients suffering from HIV/AIDS or Hepatitis C are usually excluded from this demand.) In practice, 40-65% of patients are able to maintain complete abstinence from opioids while receiving opioid maintenance therapy, and 70% to 95% are able to reduce their use significantly with a concurrent elimination or reduction in the rate of medical (improper diluents, non-sterile syringes), psychosocial (mental health issues, drug craving and obsession), and legal (arrest and imprisonment) issues that arise from the use of illicit opioids. Less than 2.5 out of every 100 patients is able to maintain abstinence from opioids for one year after discontinuing maintenance therapy (~7% of patients remain abstinent for 90 days), and the risk of fatality climbs 2900% in the first six weeks of discontinuing maintenance due to varied effects, including vastly reduced drug tolerance, extreme anxiety and/or panic and suicidal depression, amongst other opioid withdrawal and protracted withdrawal syndrome symptoms. In the patients that do achieve lasting (longer than six months) abstinence from opioids, over 40% become addicted to alcohol and/or benzodiazepine drugs, and a small percentage become addicted to amphetamines, cocaine, or marijuana, with over 50% of those remaining abstinent from opioids as per the aforementioned criterion becoming addicted to another drug to the degree of significant medical, psychosocial, or legal consequences, often just as bad as if not worse than the situation of the patient who first sought out opioid replacement therapy, in a phenomenon called cross-addiction.
ORT has been shown to be the most effective treatment for improving the health and living condition of patients. It is also the most effective in reducing mortality as well as overall costs for society. (e.g. those caused by drug-related crime, the prosecution thereof, the spreading of diseases, etc.)
Because of the negative prognosis of buprenorphine and methadone treatment described above, since the late 90s in Austria, slow release oral morphine has been used alongside methadone and buprenorphine for OST and more recently it has been approved in Slovenia (marketed as "Substitol") and Bulgaria, and it has gained approval in other EU nations including the United Kingdom, although its use is not yet widespread. The more attractive side effect profile of morphine compared to buprenorphine or methadone has led to the adoption of morphine as an OST treatment option, and currently in Vienna over 60 percent of substitution therapy utilizes slow release oral morphine. Illicit diversion has been a problem, but to the many proponents of the utilization of morphine for OST, the benefits far outweigh the costs, taking into account the much higher percentage of addicts who are "held" or, from another perspective, satisfied by this treatment option, as opposed to methadone and buprenorphine treated addicts, who are more likely to forgo their treatment and revert to using heroin etc., in many cases by selling their methadone or buprenorphine prescriptions to afford their opiate of choice. Driving impairment tests done in the Netherlands that have shown morphine to have the least negative effects on cognitive ability on a number of mental tasks also suggest morphines use in OST may allow for better functioning and engagement in society.
- Heroin assisted treatment
- Richard P. Mattick et al.: National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of Results and Recommendation
- Michel et al.: Substitution treatment for opioid addicts in Germany, Harm Reduct J. 2007; 4: 5.