Opiate replacement therapy
Encyclopedia
Opioid replacement therapy (ORT) 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) 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 sublingual
ly (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 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 diluent
s, 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.)
Law
Law is a system of rules and guidelines which are enforced through social institutions to govern behavior, wherever possible. It shapes politics, economics and society in numerous ways and serves as a social mediator of relations between people. Contract law regulates everything from buying a bus...
opioid
Opioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
drug
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
such as heroin with a longer acting but less euphoric opioid, usually methadone
Methadone
Methadone is a synthetic opioid, used medically as an analgesic and a maintenance anti-addictive for use in patients with opioid dependency. It was developed in Germany in 1937...
or buprenorphine
Buprenorphine
Buprenorphine is a semi-synthetic opioid that is used...
, that is taken under medical supervision. In some countries (e.g. Switzerland, Austria) patients may be treated with slow-release morphine where methadone is deemed inappropriate in the circumstances. In Germany, Dihydrocodeine
Dihydrocodeine
Dihydrocodeine, also called DHC, Drocode, Paracodeine and Parzone and known by the brand names of Synalgos DC, Panlor DC, Panlor SS, Contugesic, New Bron Solution-ACE, Huscode, Drocode, Paracodin, Codidol, Didor Continus, Dicogesic, Codhydrine, Dekacodin, DH-Codeine,...
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
Piritramide
Piritramide is a synthetic opioid analgesic with a potency 0.65 to 0.75 times that of morphine. A common starting dose is 15 mg IV, equivalent to 10 mg of morphine hydrochloride. Piritramide is commonly used for the treatment of postoperative pain...
, extended-release hydromorphone
Hydromorphone
Hydromorphone, a more common synonym for dihydromorphinone, commonly a hydrochloride is a very potent centrally-acting analgesic drug of the opioid class. It is a derivative of morphine, to be specific, a hydrogenated ketone thereof and, therefore, a semi-synthetic drug...
including polymer implants lasting up to 90 days, dihydroetorphine
Dihydroetorphine
Dihydroetorphine was developed by K.W.Bentley at McFarlan-Smith in the 1960s and is a potent analgesic drug , which is used mainly in China...
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
Tablet
A tablet is a pharmaceutical dosage form. It comprises a mixture of active substances and excipients, usually in powder form, pressed or compacted from a powder into a solid dose...
form with the opiate antagonist Naloxone
Naloxone
Naloxone is an opioid antagonist drug developed by Sankyo in the 1960s. Naloxone is a drug used to counter the effects of opiate overdose, for example heroin or morphine overdose. Naloxone is specifically used to counteract life-threatening depression of the central nervous system and respiratory...
to prevent addicts from crushing the tablets and injecting them instead of taking them sublingual
Sublingual
Sublingual, literally 'under the tongue', from Latin, refers to the pharmacological route of administration by which drugs diffuse into the blood through tissues under the tongue...
ly (under the tongue
Tongue
The tongue is a muscular hydrostat on the floors of the mouths of most vertebrates which manipulates food for mastication. It is the primary organ of taste , as much of the upper surface of the tongue is covered in papillae and taste buds. It is sensitive and kept moist by saliva, and is richly...
).
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 from experiencing withdrawal
Withdrawal
Withdrawal can refer to any sort of separation, but is most commonly used to describe the group of symptoms that occurs upon the abrupt discontinuation/separation or a decrease in dosage of the intake of medications, recreational drugs, and alcohol...
symptoms and drug cravings
Craving (withdrawal)
When going through withdrawal, craving is a psychological urge to administer a discontinued medication or recreational drug.-Duration:The duration that cravings last after discontinuation varies substantially between different addictive drugs...
, 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
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...
or Hepatitis C
Hepatitis C
Hepatitis C is an infectious disease primarily affecting the liver, caused by the hepatitis C virus . The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years...
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 diluent
Diluent
A diluent is a diluting agent.Certain fluids are too viscous to be pumped easily or too dense to flow from one particular point to the other. This can be problematic, because it might not be economically feasible to transport such fluids in this state.To ease this restricted movement, diluents...
s, non-sterile
Sterilization (microbiology)
Sterilization is a term referring to any process that eliminates or kills all forms of microbial life, including transmissible agents present on a surface, contained in a fluid, in medication, or in a compound such as biological culture media...
syringes), psychosocial (mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
issues, drug craving
Craving (withdrawal)
When going through withdrawal, craving is a psychological urge to administer a discontinued medication or recreational drug.-Duration:The duration that cravings last after discontinuation varies substantially between different addictive drugs...
and obsession), and legal (arrest
Arrest
An arrest is the act of depriving a person of his or her liberty usually in relation to the purported investigation and prevention of crime and presenting into the criminal justice system or harm to oneself or others...
and imprisonment
Imprisonment
Imprisonment is a legal term.The book Termes de la Ley contains the following definition:This passage was approved by Atkin and Duke LJJ in Meering v Grahame White Aviation Co....
) 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
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
and/or panic and suicidal depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
, 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
Alcoholic beverage
An alcoholic beverage is a drink containing ethanol, commonly known as alcohol. Alcoholic beverages are divided into three general classes: beers, wines, and spirits. They are legally consumed in most countries, and over 100 countries have laws regulating their production, sale, and consumption...
and/or benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
drugs, and a small percentage become addicted to amphetamines, cocaine
Cocaine
Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
, 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
Drug-Related Crime
In the United States, Illegal drugs are related to crime in multiple ways. Most directly, it is a crime to use, possess, manufacture, or distribute drugs classified as having a potential for abuse...
, the prosecution thereof, the spreading of diseases, etc.)
See also
- MethadoneMethadoneMethadone is a synthetic opioid, used medically as an analgesic and a maintenance anti-addictive for use in patients with opioid dependency. It was developed in Germany in 1937...
- Methadone maintenance treatment
- BuprenorphineBuprenorphineBuprenorphine is a semi-synthetic opioid that is used...
- Dependence treatment
- Heroin assisted treatmentHeroin assisted treatmentHeroin assisted treatment, or diamorphine assisted treatment, refers to the prescribing of synthetic, injectable heroin to opiate addicts that do not benefit from or cannot tolerate treatment with one of the established drugs used in opiate replacement therapy like methadone or buprenorphine...