Biomedical subjects
Publications and source records attributed to R Stohler.
Indications and contraindications for an alcohol withdrawal treatment of outpatients are presented, with particular reference to the symptoms and the diagnosis of the withdrawal syndrome. The general conditions and the practical process of outpatient detoxification are outlined. At the same time the question of medication of the withdrawal syndrome is addressed.
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The present review focuses on articles dealing with clinical or epidemiological studies on the association between cannabis use and psychoses. Included are all articles published since 1990 that were located by a Medline or Psyclit data-base research and those earlier articles that are needed for a correct understanding of studies published during the index episode. The three main topics found are 1) is there evidence for a so called cannabis psychosis 2) do cannabis users exhibit a higher risk of developing a psychotic disorder or 3) does its use worsen the course in established schizophrenia spectrum disorders. The review concludes that very high doses of cannabis can induce a brief psychosis but that this condition is extremely rare. Therefore, such a diagnosis should only be made after careful exclusion of other etiologies. The actual evidence regarding the impact of cannabis use on persons vulnerable to psychosis is not conclusive. Cannabis use seems to worsen the course of schizophrenia spectrum disorders. Adolescents run a higher risk from using cannabis than older people. They should be strongly advised not to indulge in such behaviour.
Cocaine and the opiates are--together with alcohol--involved in the genesis of the "three great addictions". The medical conceptualisation of the dependence phenomenon has evolved on the grounds of a critical observation of different ways of use and treatment endeavours, mainly during the last three centuries. Whereas the prohibitionists favoured (and still favour) total abstinence from all psychotropic drugs, defect theoreticians emphasise analytically-oriented psychotherapeutic procedures aiming at healing a supposed underlying self-defect. Contrarily, proponents of the "Metabolic Theory" of the addictions suggest a mainly medication-based approach in order to normalise a--in their eyes causal--still in some aspects hypothetical metabolic defect. Based on a short survey of recently emerging trends of consumption patterns (speed-balling, chasing, multi-substance-use) in Europe, the most important newer treatment types and forms are presented. Finally, a multimodal, integrated, and individualized approach is recommended.
To examine possible metabolic frontal lobe alterations in i.v. heroin-dependent patients with different histories of concomitant substance use, N-acetylaspartate (NAA), a putative marker of neuronal viability, was measured by (1)H-MRS. Compared with controls, NAA levels in patients were reduced by 7% in gray matter (p = 0.015) but not in white matter. To what extent comorbid conditions or substance use, including alcohol, contributed to these frontocortical metabolic changes remains to be elucidated.
This study compared the safety and efficacy of sublingual buprenorphine tablets with oral methadone in a population of opioid-dependent individuals in a double-blind, randomized, 6-week trial using a flexible dosing procedure. Fifty-eight patients seeking treatment for opioid dependence were recruited in three outpatient facilities and randomly assigned to substitution with buprenorphine or methadone. The retention rate was significantly better in the methadone maintained group (90 vs. 56%; P<0.001). Subjects completing the study in both the treatment groups had similar proportions of opioid positive urine samples (buprenorphine 62%; methadone 59%) and positive urine specimens, as well as mean heroin craving scores decreased significantly over time (P=0.035 and P<0.001). The proportion of cocaine-positive toxicology results did not differ between groups. At week six mean stabilization doses were 10.5 mg per day for the sublingual buprenorphine tablet, and 69.8 mg per day for methadone, respectively. Patient performance during maintenance was similar in both the groups. The high attrition rate in the buprenorphine group during the induction phase might reflect inadequate induction doses. Thus, buprenorphine is a viable alternative for methadone in short-term maintenance treatment for heroin dependence if treatment induction is done with adequate dosages.
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AIMS: To assess the impact of the closure of an open drug scene on the demand for methadone maintenance treatment (MMT). DESIGN: Interrupted time series analysis of case register-based data of all MMTs performed in the canton of Zurich (Switzerland) between June 16 1992 and July 7 1997. SETTING: Five private and 14 state-controlled institutions as well as 330 general practitioners, 35 psychiatrists, and 79 other specialists offering outpatient MMT. PARTICIPANTS: 5210 opiate users with 9042 MMT episodes. MEASUREMENTS: Monthly number of entries into MMT before, during and after the closure of the Letten scene in February 1995, MMT retention rates, participants' socio-demographic and drug-related data. FINDINGS: ARIMA modelling revealed 68 (95% CI = 31-105; p < 0.001) additional MMT admissions due to the dispersion of the open drug scene without a decrease in MMT retention rates. Socio-demographic and drug-related characteristics of patients entering MMT in the month of the closure did not significantly differ from other admissions. CONCLUSIONS: Law enforcement strategies to eliminate open drug scenes may increase the demand for MMT. Sufficient treatment facilities for opioid dependence should be provided when law enforcement activities against open drug scenes are planned.
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In a cross-sectional multicentre study, we compared the characteristics of heroin chasers and heroin injectors. Subjects were 162 primarily opioid-dependent volunteers for whom either chasing (n = 85) or injecting (n = 77) was the principal route of heroin administration. Each subject was rated by means of the Swiss version of the European Addiction Severity Index. Additionally, subjects completed a questionnaire battery including the Severity of Dependence Scale, the Symptom Checklist SCL-90-R, a self-constructed peergroup questionnaire and a semantic differential list to assess the connotative meaning of heroin chasers and injectors. The heroin injectors were older and more likely to use one or more other drugs besides heroin than the chasers. They had longer heroin-using careers, a longer duration of detention and a higher prevalence of some type of hepatitis. In conclusion, the differences between chasers and injectors were rather related to a longer history of heroin use than to the route of heroin administration.
The short-term effects of intravenous opioids (heroin 20-300 mg, methadone 30-180 mg) on cortical hemoglobin oxygenation were examined by near infrared spectroscopy in ten opioid-dependent subjects and were compared with the effects of saline in ten age-matched normal controls. Heroin and methadone produced a rapid and dramatic decrease in cortical hemoglobin oxygenation. Saline had no effects. Opioid-induced acute deoxygenation of cortical hemoglobin is most likely associated with respiratory depression. Thorough medical monitoring is strongly recommended in intravenous opioid maintenance treatments.
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Since the beginning of the 'Janus' opiate project in Basel in which severely opiate-dependent persons are treated intravenously with heroin, morphine or methadone 11 from 160 participants (to november 1995) were treated in the withdrawal and intervention unit at the psychiatry clinic of the university of Basel. 7 patients sought a total, 4 a partial withdrawal. Whereas the 4 patients wanting withdrawal from consumption of drugs in addition to study drugs all reached their goal 4 of the 7 persons aiming at total withdrawal interrupted treatment prematurely. The 3 patients who were successful are-as far as the authors know-still off opiates. Substitution of intravenous opiates provided by 'Janus' with oral methadone and slow tapering off of the latter over days to weeks occurred mostly without problems. Participants of the 'Janus' project thus desired a withdrawal oriented treatment with equal frequency and had not less success than persons substituted with oral methadone in achieving this goal.
A group of Turkish drug-addicted out-patients (n = 34) is compared to a group of Swiss opiate-addicted outpatients (n = 145) with respect to age, sex, social status, the number of offspring, the age of initiation of drug addiction and the type of the drug used. The results revealed that the Turkish population showed a better prognostic profile when the age of initiation of drug addiction, the familial integration and multiple addiction are taken into account, 97.1% of the Turkish opiate-addicted patients belonged to the second-generation immigrant population. In this group, the median age at immigration to Switzerland was 14.2 +/- 2.1 (excluding the three patients born in Switzerland). The conflict between the group-oriented expectations of their families and the individual-oriented life style of the peer group is the main reason for social role confusion, identity disturbances, for feelings of guilt because of separation or for shame because of dependence from the family. Confusion in social roles as well as in the interpretation of identification and the development and integration of identity permitting the coexistence of both cultures are the main topics of psychotherapy of drug-addicted Turkish immigrants.
The treatment of patients who are dependent on drugs is undergoing a conceptual change, and in this connection more attention is being paid to a qualified withdrawal and weaning. More than 200 withdrawals are being performed annually in the U2 section of the Department of Psychiatry of the University of Basel. The authors report on the composition of the patient groups, their withdrawal symptoms and the therapy offered. In respect of the continually too frequent discontinuations of therapy attention is drawn to the need for a really efficient pharmacotherapy.
The treatment of patients who are dependent on opiates has definitely been including drug substitution besides withdrawal and weaning in the Swiss urban community ("Kanton") of Basel City since 1980. After a significant increase of treatments in 1987 in connection with the spread of HIV infections, more than 800 patients were presently receiving substitution treatment according to a descentralised schedule. The type of long-term treatment is illustrated by sociodemographic and treatment data of 500 substituted individuals who are mostly being looked after always by the same persons entrusted with caring for them. This represents a flexible, economically feasible and highly individual type of care and treatment that can help to reduce illegal drug consumption and hence the undesirable events associated with it in an urban district such as Basel city.
A novel brain-selective acetylcholinesterase inhibitor, SDZ ENA 713, is under development for the treatment of dementia of the Alzheimer type. To determine the threshold dose for central activity, single doses of the compound were administered to 20 young male volunteers in a double-blind cross-over design and the effects on the sleep electroencephalography studied. The first group of eight volunteers received in random order: placebo, 0.5 mg; and 1 mg SDZ ENA 713. The second group of 12 volunteers received: placebo, 1.3 mg; and 2 mg SDZ ENA 713. Sleep quality was not affected by the study medication, which was well tolerated by all subjects. A statistically significant increase in rapid-eye movement sleep density was observed after doses of 1 mg, 1.3 mg, and 2 mg. Rapid-eye movement latency and slow-wave sleep were not altered. The results demonstrate that SDZ ENA 713 is centrally active in man at well-tolerated doses.