Opioid replacement therapy
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Opioid replacement therapy (ORT) or opioid substitution therapy (OST) is a medical treatment that involves replacing an illegal opioid, such as heroin, with a longer acting but less euphoric opioid; methadone or buprenorphine are typically used and the drug is taken under medical supervision. Some formulations of buprenorphine incorporate the opiate antagonist naloxone during the production of the pill form to prevent people from crushing the tablets and injecting them, instead of using the sublingual (under the tongue) route of administration.
In some countries, such as Switzerland, Austria, and Slovenia, patients may be treated with slow-release morphine when methadone is deemed inappropriate due to the individual's 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 other drugs for ORT is at various stages in a number of countries. The prescription of medicinal heroin or morphine for people with long-term addictions, particularly those who have difficulty with methadone programs, is also legal in some countries.
The driving principle behind ORT is the program's capacity to facilitate a resumption of stability in the user's life, while the patient experiences reduced symptoms of drug withdrawal and less intense drug cravings; however, a strong euphoric effect is not experienced as a result of the treatment drug. In some countries (not the USA, UK, Canada, or Australia), regulations enforce a limited time period for people on ORT programs that conclude when a stable economic and psychosocial situation is achieved. (Patients suffering from HIV/AIDS or Hepatitis C are usually excluded from this requirement.) In practice, 40-65% of patients maintain complete abstinence from opioids while receiving opioid replacement therapy, and 70-95% are able to reduce their use significantly, while experiencing a concurrent elimination or reduction in medical (improper diluents, non-sterile injecting equipment), psychosocial (mental health, relationships), and legal (arrest and imprisonment) issues that can 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 proven to be the most effective treatment for improving the health and living condition of people experiencing problematic illicit opiate use or dependence, including mortality reduction and overall societal costs, such as the economic loss from drug-related crime and healthcare expenditure.
A 2008 New York Times article announced that methadone would not be legally available in Russia as an option for opiate-dependent citizens. A February 2008 conference, partly organized by Dr. Vladimir D. Mendelevich, director of the Institute for Research Into Psychological Health, discussed the subject, but health officials remained unconvinced "that this [methadone] is effective." Since the demise of the Soviet Union, Russian governments have been struggling with the intravenous use of illicit heroin and, in 2008, the estimated number of opiate-dependent Russians was between three million and six million. Also in 2008, the leading cause of the Russian HIV epidemic was injecting drug use, responsible for around 66 percent of new cases in 2006, and the numbers of new infections were still rising at the time.
In early April 2014, following the official annexation of Crimea, Russian officials informed around 800 methadone recipients that their prescriptions will cease due to the illicit sale of the drug by its users. One methadone user from Sevastopol stated to the media: "It is happening at such a pace that it's going to be a massacre here."
Slow-release oral morphine
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Since the late 1990s in Austria, slow-release oral morphine has been used alongside methadone and buprenorphine for ORT, while more recently it was approved in Slovenia (marketed as "Substitol") and Bulgaria, and has gained approval in other EU nations, including the United Kingdom; however, its use is not widespread. The more attractive side effect profile of morphine, compared to buprenorphine and methadone, has led to the adoption of morphine as an ORT treatment option, and currently in Vienna over 60 percent of substitution therapy utilizes slow-release oral morphine.
Despite the problem of illicit diversion, many proponents of the slow-release morphine option assert that the benefits far outweigh the costs, taking into account the higher percentage of users who are satisfied by this treatment option. This is presented in contrast to methadone and buprenorphine-treated individuals, who are more likely to forgo their treatment and revert to using heroin—in many cases, methadone or buprenorphine prescriptions are sold to fund such drug use.
- 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.
- Michael Schwartz (22 July 2008). "Russia Scorns Methadone for Heroin Addiction". The New York Times. Retrieved 5 April 2014.
- Peter Walker (4 April 2014). "Crimea: no more McDonald's or methadone after annexation". The Guardian. Retrieved 5 April 2014.