Archive for Juni, 2010


Chemical Warfare

The war on the Afghan heroin trade is having some success, with opium production down 22 percent last year. There has also been more attention paid to opium smuggling, as this is a major concern for Pakistan (and its several million opium addicts). Iran has put more troops on their border, for the same reason, and made it more difficult to get opium into the country. The drug gangs have responded by converting more of their opium into heroin and morphine. But that requires more imports of industrial chemicals for the conversion.

Heroin is much less bulky than opium, and easier to smuggle. As a more expensive drug, it finds most of its users in more affluent areas (like the Persian Gulf, Europe and North America). If you can get the needed chemicals, the math works in your favor. Ten tons of opium (worth about $45 a pound) can be refined into  1.3 tons of heroin (worth about $1,600 a pound).

This conversion requires 2.6 tons of acetic anhydride, an industrial chemical. This is a clear liquid that is flammable and poisonous if you inhale it. There is no legal use for acetic anhydride inside Afghanistan. With bribes and transportation costs, the drug gangs pay about $2,000 per ton to get it to Pakistan. Then it has to be smuggled into Afghanistan, by truck. There are a limited number of roads, with the border manned by guards who are accustomed to being bribed. There are several other chemicals needed to refine the opium (to morphine, then to heroin), but acetic anhydride is the hardest to get, and the one needed in the largest quantities. Smaller quantities of hydrochloric acid are also needed, but this is a more common industrial chemical.

Pakistan drove the heroin trade out in the 1990s, in part, by interfering with the supply of acetic anhydride. While there was a market for opium, it was mainly local, and the large amount of opium available drove the price down. The real money was in heroin, where smaller, more valuable amounts, were easier to move out of the country to more lucrative foreign markets.

Now, consider how heroin fits into the worldwide drug market. The most widely used drug is actually marijuana (and it’s refined version, hashish). There are about 170 million users of these products worldwide. Many live in rural areas where marijuana grows wild and legal restrictions are not energetically enforced. But in many urban areas, marijuana is a major source of income for gangsters, and some terrorist groups. Not as profitable as cocaine and heroin, and harder to smuggle (because of the bulk), but it is still a major threat because it has such a large market.

More debilitating drugs like heroin and cocaine are more expensive, more potent and have less than 20 percent of the market of marijuana and hashish. Cocaine and heroin are more likely to disable users, including much higher risk of accidental death. The 30 million cocaine or heroin users (about 60 percent of them prefer the less debilitating cocaine) are actually dwarfed by the slightly larger number of addicts for synthetic drugs (everything from methamphetamine to Ecstasy and especially prescription drugs).

But cocaine and heroin come from farm crops (coca for cocaine, poppies for heroin) that are very profitable for poor farmers in places like the South American highlands (coca) or Central Asia (Afghanistan at the moment). In both these places, the illegal crops account for the majority of the supply for that illegal drug on the planet. In the case of cocaine, the drug is largely produced by gangsters, with some help from political outlaws (mostly leftist groups). There is some terrorism, but it is all local.

The big danger is the heroin trade, where Islamic terrorists have partnered with tribe based drug gangs to produce most of the world’s heroin. This sort of thing is nothing new. For decades after World War II, most of the heroin came   from the remote Burma (now Myanmar)-China border area, where the drug gangs could afford to raise and equip private armies. But both of those nations eventually cracked down on that business, and it moved to Pakistan for a while, but was forced, by a violent government reaction, across the border into Afghanistan. In both earlier cases, controlling the supply of acetic anhydride played a major role in crushing the heroin trade.

The Afghan government is reluctant to shut down the heroin trade, partly because many senior government officials are being bribed, and partly because it would cause more tribal warfare (most of the tribes oppose the heroin trade, and only a few of the Pushtun tribes in the south control most of the heroin production). Moreover, there is the likelihood that the poppy growing and heroin production would just move to another Central Asian nation. The Islamic terrorists would follow. So the problem really is to crush, or otherwise neutralize, the Taliban, al Qaeda and other Islamic radicals who are sustaining their violence via drug profits. The Taliban earns $50-100 million a year from helping protect the drug gangs.

It is interesting that the two major illegal drugs are both produced in small regions, areas that are dominated by outlaw armies and a general absence of law and order. Cocaine is largely from Colombia, where the drug gangs and their political allies (the leftist FARC) almost brought the government to its knees, before politicians, and most of the population rose up and fought back. In Afghanistan, NATO and U.S. commanders have finally convinced their governments to go after the money; the heroin trade.

That means manufacturers and distributors of acetic anhydride have been under scrutiny, and pressure to control the supply of the chemical entering Afghanistan, for nearly a decade. The smugglers have been very resourceful, using bribes and threats to get past government restrictions. The chemical enters Afghanistan from all neighboring countries, except Iran (which has a small army of incorruptible troops on the border trying to keep out the opium and heroin.) The acetic anhydride is often bought in Europe or Russia, labeled as some other product, and sent on its way to Pakistan or one of the Central Asian neighbors of Afghanistan, where bribes or threats are used to get it into southern Afghanistan, where the processing labs are. This smuggling network is now under major attack. Russia is determined to control their growing addiction problem by keeping the smugglers (who bring drugs out and chemicals out) away from the border. But all this effort is crippled by the corruption and lawless nature of the border area. The example of Colombia shows that you can fight back. But it’s not easy, and progress is slow.

ps. the so called „Islamic Terror Groups“ are founded by the US./UK. Secret  Service!

The annual United Nations World Drug report on world drug consumption by region provides some interesting intriguing data on global heroin consumption, but a little math sheds some much needed light on the numbers.

Heroin use is declining in the United States, but rising in Europe, according to the latest report, which noted that European users smoke or inject about 25 percent of the 340 metric tons of heroin consumed worldwide each year.

U.N. officials said that cultivation of opium, the compound used to make heroin, has decreased 13 percent in the last year, to 657 tons.

Especially high demand for heroin, and also for cocaine, in Western European countries such as the UK, Italy and France, has led to the emergence of new trafficking routes in West Africa, the report states.

The Regional Breakdown for Heroin Consumption:

  • Europe – 26% at 88 metric tons
  • Russia – 21% at 70 metric tons
  • China – 13% at 45 metric tons
  • Africa – 7% at 24 metric tons
  • U.S.A. & Canada – 6% at 21 metric tons
  • Pakistan – 6% at 21 metric tons
  • India – 5% at 17 metric tons
  • Southeast Asia – 5% at 17 metric tons
  • Iran – 5% at 17 metric tons

Looks like Europe is the biggest overall consumer of heroin, but which region or country has the biggest heroin problem per capita?

The Math:
Russia’s 141,927,297 people consume 70 metric tons or 70,000 kilos, for a total of .000493 kilos per person. Russia’s per capita heroin consumption is nearly double that of Iran, the runner-up. Iran’s 72,000,000 people consume 17 metric tons or 17,000 kilos, for a total of .000236 kilos per person.

Europe comes in third for global heroin use per capita. Europe’s 710 million people consume 88 metric tons or 88,000 kilos, for a total of .000123 kilos per person.

Pakistan ties Europe for third place in overall per capita heroin use. Pakistan’s 169,869,000 people consume 21 metric tons or 21,000 kilos, for a total of .000123 kilos per person.

Per capita heroin use falls off sharply among the U.S., Canada, and other countries that make up the top ten global heroin consumers. U.S.A. & Canada’s 341 million people consume 21 metric tons or 21,000 kilos, for a total of .000061 kilos per person. China’s 1,324,655,000 people consume 45 metric tons or 45,000 kilos, for a total of 0.0000339 kilos per person.

Africa’s 840 million people consume 24 metric tons or 24,000 kilos, for a total of .0000285 kilos per person. Southeast Asia 593,000,000 people consume 17 metric tons or 17,000 kilos, for a total of .0000286 kilos per person. India 1,182,500,000 people consume 17 metric tons or 17,000 kilos, for a total of .0000143 kilos per person.

See the U.N.’s breakdown of the world’s heroin and other drug consumption by geographical region, here.
For more info: UN

source:http://www.examiner.com/x-8543-SF-Health-News-Examiner~y2010m6d28-Who-uses-most-of-the-worlds-heroin

generally well tolerated and beat out placebo in reducing opioid use and decreasing opioid cravings in opioid-dependent patients, new research suggests. After 24 weeks, the median percentage of opioid-free urine screens was 90% among patients taking extended-release naltrexone, compared with 35% among patients taking placebo (P < .0002).

David R. Gastfriend, MD, vice president of scientific communications for Alkermes, presented the results of the 250-patient, double-blind, placebo-controlled, phase 3 study here at the American Psychiatric Association (APA) 2010 Annual Meeting.

„Despite currently available treatments, more than half of the 1.3 million Americans suffering from [opioid dependence] remain untreated, and the global disease burden is growing. Extended-release naltrexone appears to offer an important alternative treatment strategy that addresses the obstacle of poor patient adherence,“ Dr. Gastfriend said.

„The number of Americans addicted to prescription opioids and heroin has more than doubled since 2000. What’s driving this increase? About 20% is attributable to heroin. The much larger problem is addiction to prescription drugs,“ he told Medscape Psychiatry.

Less Potential for Addiction
Extended-release naltrexone was approved by the US Food and Drug Administration (FDA) for treating alcohol dependence in adults who have completed detoxification treatment in 2006. The FDA recently designated the company’s supplemental new drug application for extended-release naltrexone for opioid addiction as a priority review, Dr. Gastfriend said.
Opioid addiction is typically treated with substitution therapy, typically with methadone or buprenorphine, „agonist medications that bind to opioid receptors and mimic the drug’s effects,“ he said.

This approach carries a host of problems, including access, acceptability, diversion, illicit use, and overdose deaths, he added.
In contrast, naltrexone, including the oral formulation, is an opioid antagonist, preventing opioids from binding to receptor sites. As a result, there is less potential for addiction, he said.

„The once-monthly formulation addresses the added obstacle of adherence,“ said Dr. Gastfriend.

Detox Before Treatment
For the study, 250 patients with opioid dependence recruited from 13 sites in Russia from July 2008 to October 2009 were randomized to 24 weeks of treatment with 380 mg of extended-release naltrexone by intramuscular injection (n = 126) or placebo injection (n = 124), every 4 weeks.
„Patients must be detoxed fully before treatment,“ Dr. Gastfriend said. In this study, patients had not been taking any opioids for 7 to 30 days, and the first dose was administered within 1 week of inpatient discharge.
All patients received biweekly individual drug counseling. No significant differences were found between the treatment groups in demographic or baseline clinical characteristics.

The mean age of patients was 29.4 and 29.7 years in the naltrexone and placebo groups, respectively. A total of 89.7% and 86.3% of patients in the naltrexone and placebo groups were male, and their mean duration of opioid dependence was 9.1 and 10.0 years, respectively. Most (88.1% in the naltrexone group and 88.7% in the placebo group) were addicted to heroin.
The primary endpoint was the response profile based on the rate of opioid-free urine test results from weeks 5 to 24.

Reduced Cravings
In addition to their significantly better median percentage of opioid-free drug screens, patients taking naltrexone fared better on a number of secondary endpoints.

Total abstinence (100% opioid-free weeks) was reported in 45 (35.7%) of treated patients vs 28 (22.6%) of placebo recipients (P = .02).
The median number of days receiving treatment was more than 168 for naltrexone-treated patients vs 96 in the placebo group (P = .004).
Also, significantly more naltrexone-treated patients completed the study: 53.2% vs 37.9% (P = .017). None of the patients in the naltrexone group discontinued treatment because of adverse events; 22 (17.5%) dropped out because of lack of efficacy.

In addition, naltrexone-treated patients showed a 50% mean reduction in cravings from baseline on the visual analog scale craving score, compared with no change for placebo-treated patients (P < .001).
„The placebo group never goes below baseline and bumps up as they leave the study. For the naltrexone group, cravings decreased in the first week, progressively decreased through the eighth week, and [were] significantly different from baseline every week until the end of study,“ Dr. Gastfriend said.

No significant difference was seen in the incidence of clinical adverse events between the groups.
The most common clinical adverse events were nasopharyngitis, seen in 7.1% of naltrexone-treated patients, and insomnia, in 6.3%.
Asked if the drug would be compared against existing treatments for opioid dependence rather than placebo, Dr. Gastfriend said such a study night be difficult to design, in part because of patient preferences.
Extended-release naltrexone „is not intended to take over existing treatments; it’s another tool in the armamentarium,“ he said.

Opioid Dependence Drugs Underused
Commenting on the findings, Petros Levounis, MD, director of the Addiction Institute of New York at St. Luke’s and Roosevelt Hospitals, in Manhattan, said, „It’s encouraging news to have more options in our treatment of opioid dependence.

„But the issue we need to look at is the issue of compliance. How many people…are willing to have shot every month? That’s the idea in my mind. Some people prefer the pill once a day; some would rather have the shot once,“ he said.
He agreed with Dr. Gastfriend that an advantage over agonist medications is that „you certainly have a risk of physical dependence, even addiction at times, with them.“

Dr. Levounis said that in the United States, pharmacologic treatment for opioid dependence is vastly underused.

„The majority of detox centers give people a referral to an outpatient treatment program, sometimes to inpatient rehab. But very rarely do they give them recommendations for medications like these.

„Oral naltrexone and buprenorphine haven’t caught on. That’s [partially] because of physician awareness, [partially] because of tradition, or momentum, if you like. There’s difficulty with reimbursement at times.
„More than anything it’s the culture of detox units. They dictate a nonpharmacology trajectory. They say just come here, we’ll take you off the drugs, and then you go out and should be able [to handle yourself].
„It’s really a shame [that we don’t use pharmacologic interventions as often as we could]. There are a lot of addictions that we don’t have good meds for…but for some, like opioids, we’ve come up with some particularly good medications, and we should use them,“ Dr. Levounis said.
The study was funded by Alkermes Inc. Dr. Gastfriend is an employee of the company. Dr. Levounis has disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2010 Annual Meeting: Abstract NR7-06. Presented May 26, 2010.

source:http://www.medscape.com/viewarticle/722907

Titan Pharmaceuticals, a biopharmaceutical company, has reported that the US Patent and Trademark Office has issued new patent covering Probuphine for the treatment of opiate addiction.

Titan is the assignee of this patent which claims a method for treating opiate addiction with a subcutaneously implanted device comprising buprenorphine and ethylene vinyl acetate, a biocompatible copolymer that releases buprenorphine continuously for extended periods of time.

This patent, which also includes certain additional claims covering the composition and dimensions of the device, will expire in June 2023 excluding any patent term adjustment which is expected to add several months to the life of the patent.

The safety and effectiveness of treatment with Probuphine has been initially established in the three Phase III studies conducted to date, and the company is currently conducting a confirmatory Phase III clinical study in the US which is partially funded through a two-year $7.6 million National Institutes of Health grant being administered by the National Institute on Drug Abuse.

This study is designed to confirm the safety and effectiveness of treatment with Probuphine versus placebo in reducing the use of illicit opioids over the 24 week treatment period, and also to perform a non-inferiority comparison of Probuphine with Suboxone which is the widely used sublingual formulation of buprenorphine approved for the treatment of opiate addiction. This 250-patient three-arm study is currently enrolling patients at 17 sites in the US and is expected to complete enrollment by the end of 2010 with results available in the third quarter of 2011.

Sunil Bhonsle, president of Titan, said: „We are very pleased by the issuance of this patent which is expected to provide exclusivity in the US for Probuphine at least through mid-2023. We are also highly encouraged by the rapid progress in the confirmatory Phase III study.“

Abstract

Untreated opiate addiction remains a major health care crisis in New York and in most other urban centers in America. Optimism for closing the gap between need and demand for treatment and its availability has greeted the recent approval of a new opiate medication for addiction, buprenorphine – which unlike methadone may be prescribed by independent, office-based practitioners. The likelihood of buprenorphine fulfilling its potential is assessed in the light of the massive expansion of methadone treatment more than 30 years earlier. It is concluded that the key, indispensable ingredient of success will be true commitment on the part of Government to provide care to all those who need it.

Commentary

Over thirty years ago an editorial appeared in The New York Times under the headline, „A Drug Success.“ [1] The focus was the New York City Health Department’s Methadone Maintenance Treatment Program, which had expanded „so swiftly and so successfully…that there no longer are waiting lists for admission…“ Recently, another medication – buprenorphine – was approved for treating opiate addiction, [2] and there is hope that it will allow many more patients to receive help. Critical to significant expansion of treatment capacity will be „clinician attitudes and the extent to which they embrace buprenorphine . . .“ [3] However, to gauge the degree to which buprenorphine’s potential will be realized it is important to consider the factors that went into the success of methadone in the early 70s.

New treatment services were being established throughout the country in those days, but the most dramatic increase took place in New York City, and it was due first and foremost to the vision and commitment of one man, Gordon Chase, the City’s Health Services Administrator under then-Mayor John Lindsay. (Chase died in an auto accident in 1980 at the age of 47.) Chase, who had only a bachelor’s degree and had never worked in the field of health care, was determined that every single heroin user would be offered prompt access to treatment; to achieve this goal he concluded that methadone maintenance would have to be the cornerstone of the City’s efforts. He acknowledged readily that he knew very little about methadone (few at the time knew more – methadone had been introduced just five years before [4]); he had been persuaded, however, that without methadone the vast majority of those who needed and were willing to accept help would be abandoned.

Chase peremptorily dismissed the litany of reasons staff gave in urging him to „go slow“: rapid expansion of methadone treatment had never been attempted, and could be a widely publicized disaster that would undermine treatment efforts everywhere; individualization of care and „comprehensive ancillary services“ were considered indispensable components of treatment and required extensive time and staff training to establish; etc. Indeed, virtually every experienced professional in the country rejected the very concept of expansion on a massive scale. This may explain why Chase asked the author to implement his vision of „treatment on request“ for all addicts; I was a resident in Public Health at the time, whose only prior medical training had consisted of two years of general surgery, and whose administrative background was limited to a few months directing the New York City component of a national nutrition survey.

The consistent response by Chase to the nay-sayers within and outside City Government was to ask: „How convincing will your concerns and criticisms be to parents whose children sought help but were turned away, and subsequently died of an overdose?“ His argument was compelling,. In any event, Chase prevailed and within two years the City Health Department had established a program with an active enrollment of approximately 11,000! Concomitantly, the Health Department spurred („shamed“ is probably a more accurate term) other methadone and drug-free providers in New York and elsewhere to increase their own capacity markedly.

The net result for the City of New York was dramatic: a sharp reduction in addiction-related property crime, drug arrests, hepatitis and deaths attributed to drug dependence. [5] As for the Health Department’s new methadone program in particular, whether measured by retention rates, employment, drug use, health status or any other parameter, the extensively documented outcomes were every bit as good as those of other addiction treatment services. [6]

The New York City Health Department program was financed entirely by City and State funds and by Medicaid reimbursement for eligible patients. The Federal Government provided neither fiscal nor moral support for the City’s unprecedented response to opiate addiction, the most important clinical and public health challenge of the day. As for the rest of the country, without the demonstration by New York that massive, rapid expansion was feasible, it is likely that things would have proceeded at a snail’s pace.

Tragically, since the mid-70s there has been little if any further increase in addiction treatment capacity of any kind in America. Roughly the same 20 percent of the estimated heroin addicted population receives care today as did then – before the onset of AIDS. [7] Undoubtedly the greatest obstacle to accommodating more patients has been the absolute monopoly on methadone maintenance that has been given to „programs;“ independent, office-based practitioners are excluded from the field by law – a restriction on prescribing that applies to no other medication in the US pharmacopoeia.

A „new“ treatment option

The New York Times recently reported [8] that an estimated 36,000 patients receive methadone in the City – essentially the same number as three decades ago (according to one source, 34,000 patients were being treated with methadone maintenance in 1974 [9]). At the same time, The Times noted optimistically that prescriptions for buprenorphine are „expected to soar in the coming years“ (one year earlier the paper had run another optimistic story on buprenorphine under the headline, „New drug promises shift in treatment for heroin addicts“ [10]). In fact, however, if the past is prologue, the acceptance and utilization of buprenorphine may be a long time coming. As early as 1978 it had been described as a medication with „a unique pharmacology with immediately obvious therapeutic application as a maintenance drug in narcotic addiction“ [11]. And yet, to make this „immediately obvious“ medication a reality “ . . . took considerable financial commitment from NIDA [National Institute on Drug Abuse], more than two decades of dedicated effort by myriad researchers and practitioners, and the collaboration of a willing and savvy pharmaceutical manufacturer. It also literally took an act of congress“ [3].

The breakthrough itself, when it finally came, was not pharmacological but regulatory. Unlike methadone, buprenorphine could henceforth be prescribed for opiate dependence by any physician who is „certified.“ Certification requires nothing more than an application and demonstration that the physician has completed an eight-hour training course (which also is available on-line). While the demands imposed on „methadone programs“ are undiminished, and office-based physicians continue to be barred from making methadone available to their patients, buprenorphine can be prescribed to a new patient for a full month, and in some states (e.g., New York) the prescription can be refillable without further physician-patient contact for five additional months. Surely not good medical practice – but in contrast to methadone, not illegal! The one restriction that makes treatment with buprenorphine exceptional is that no physician or group practice may treat more than 30 patients at a time (this limit, as it applies to group practices, was eliminated in a bill passed by Congress and signed by the President in August, 2005 [12].

Despite all the hype, the ease of certification and the relative absence of regulatory constraints, there’s little to cheer about. Notwithstanding the very considerable effort of the Federal Government, and the extensive advertising and public relations campaign of buprenorphine’s manufacturer, the percent of previously untreated opiate-dependent individuals that receives this medication appears to be miniscule. Worse, it’s by no means clear that anyone cares; no Federal targets have been announced, and no one seems to be measuring the increment in patient numbers (and if they are, they are not talking, which also bodes ill). Of course, it is likely that the manufacturer is following its sales very, very closely, but it too has released no data.

One major barrier to significant expansion of addiction treatment with buprenorphine is the persistent mixed message sent by Government. We can hardly expect physicians, patients or the public at large to embrace treatment with one medication (buprenorphine), when Government itself continues to reflect and reinforce the stigma towards treatment with another medication (methadone) for the same patients and the same disease. We’ll never see significant numbers of physicians – i.e., „mainstream medicine“ – prescribe buprenorphine when methadone must, by law, be associated with a fully panoply of „comprehensive ancillary services,“ frequent urinalysis, stringent restrictions on „take-home privileges,“ and inspection and approval of all providers by „accreditation agencies.“ In addition, of course, there continues to be an absolute bar, regardless of circumstances, against treatment with methadone by independent office-based practitioners.

The experience three years after buprenorphine was approved speaks for itself. Less than 500 prescriptions for buprenorphine, from all sources, were written in New York City during the month of June, 2005. [13] If each prescription were for an unduplicated individual, the total recipients of this medication would be one-quarter of one percent of the estimated 200,000 untreated heroin-dependent population of the city. [14]

Conclusion

We need Government to give strong, unqualified support to the premise that addiction is a chronic medical condition. It must acknowledge forthrightly that neither buprenorphine nor methadone nor any other treatment modality, medication-based or drug-free, is a „cure.“ At the same time, it must stress the fact that addiction is eminently treatable. (The same reality of „treatable but not curable“ applies to all chronic illnesses.) Above all, however, we need leaders with the commitment, pragmatism and common sense that Gordon Chase personified. Sadly, such traits are rarely evidenced today by those who influence and implement policy – in government, academia or the private sector. Meanwhile, hundreds of thousands of opiate dependent people in New York and throughout the country continue to suffer and die, and society at large bears the associated fiscal and human costs. It is high time to reconsider the rhetorical question Chase posed almost 35 years ago: Are our rationalizations for tolerating the status quo truly persuasive? Would they be accepted by those who are suffering and dying as a consequence of inaction?

In opioid substitution treatment, nursing builds and provides
the primary and main therapeutic relationship and care with patients.
Despite its essential contribution to the treatment of drugdependent
patients, nursing in substitution treatment tends to be
overlooked.

Also, little is known about their work in heroin substitution
in particular. The aim of this article is to describe the nursing
actions provided in the care of patients in the PEPSA (experimental
drug prescription program in Andalusia, Spain) trial, mainly
concerned with patients receiving intravenous diacetylmorphine.
The study was conducted in the Centre for diacetylmorphine prescription
within the context of a heroin clinical trial, Virgen de las
Nieves University Hospital, Granada, Spain.
The nursing team was responsible for overall care for the patient,
focusing on his/her needs. Care provided to each patient
was individualized, with verbal communication being the main
tool to facilitate a two-way exchange of information between the
patient and the nurse providing care.

The protocol for nursing
performance comprised the administration and supervision of the
treatment and other actions aimed at reducing harm, encouraging
healthy habits, monitoring the patient and counseling.

The general process included: admission of the patient; assessment of
his/her general health status; delivery of the treatment; and assessment
of the patient’s response receiving injected diacetylmorphine.
The care of patients who are addicted to drugs provided
calls for a relationship that ensure seamless care. This relationship
should be aimed at fostering and maintaining therapeutic communication.
This relationship involves nurses providing empathy,
active listening, assertiveness, acceptance, respect, offering consistent
information and avoiding a judgmental approach.

In this trial, the nurses attempted to motivate change, detecting and providing
positive reinforcement of any changes made, while always
respecting the patient‘s choices. The fundamental aim was harm
reduction, which involves reducing any adverse consequences aris-
All authors on behalf of the PEPSA Team (Experimental Drug Prescription
Program in Andalusia)

Nice read:  Nursing_in_an_Intravenous_Heroin_Prescription_Treatment

Methadone & Pregnancy
“Is methadone safe for my baby?” is usually the first question  we hear           from women.
Pregnant women have been treated with methadone for more than  25  years          and neither methadone or other opiates have not been  shown to  directly          cause birth defects. However, your baby may  experience some side  effects          from methadone. The most common  are smaller-than-normal head  size, low          birth weight, and  withdrawal symptoms. As babies born dependent  on methadone           grow, they usually will fall in the normal range for size and   development.

Methadone is not the only thing that can cause these symptoms.   Smoking          cigarettes, drug use, your biological makeup,  nutrition, and how  well          you take care of yourself are just a  few examples of things that  can affect          the health of your  baby.
Whether or not you are pregnant, you only get the benefits of   methadone          if you are stable on your dose. There is no ‘magic  number’ of  milligrams          to stay below. If you feel any  withdrawals or cravings to use,  make sure          you talk to your  counselor about adjusting your dose. When you  feel withdrawals,           so does your baby and that can lead to complications and even   miscarriage.

Research does not necessarily show any connection between a mother’s dose and withdrawal symptoms in the baby.

It might seem that the more milligrams a mother is taking, the worse the withdrawal symptom s will be, however this is not the case. That’s why we encourage you to focus on finding a dose that works for you and not to worry about the amount of milligrams. If you are tapering, most clinics will stop your taper and keep you at your current dose. Some women ask about tapering off methadone while they are pregnant. The Government’s Center for Substance Abuse Treatment says this: “Medical withdrawal of the pregnant women from methadone is not indicated or recommended.” and here at methadoneandpregnancy.com agree with them. Remember- If you were not ready to taper before you were pregnant, you are not ready to taper because you are pregnant. Medically, pregnant women have been safely tapered off of methadone, but it’s only been done on an inpatient basis where they can monitor the fetus for any distress. You should never try to detox yourself. This can be very dangerous to you and your baby. This can also put your recovery in jeopardy. Usually when women learn more about methadone use during pregnancy and see other healthy babies at the clinic with their moms, they decide to continue methadone treatment. It’s not uncommon to need a dose increase during your pregnancy. By the third trimester the amount of blood in your body just about doubles! Because of this your dose of methadone may need to be increased to help keep you and your baby free from withdrawal symptoms. In fact, an increase in methadone (if you need it) during this time can help improve growth and reduce risk of premature delivery. We cannot stress it enough; make sure you are stable on your dose! If for some reason you aren’t able to make it to the clinic for one day make sure you call the clinic and let them know you aren’t able to make it in. Do your best to get there the next day as early as possible. If you’re having problems with transportation, talk to your counselor. They will help you to figure out how you can get to the clinic every day. Many people wonder: does methadone use during pregnancy increase the chance of my child becoming an addict? There are not many studies that have looked at long-term effects of babies born depended on methadone. The other problem is that there are so many factors influencing drug use, it would be difficult to pinpoint methadone as the ‘cause’ if a child did start using drugs. We do know that there is a genetic component to addiction, so regardless if you are in methadone treatment or not, if you or the baby’s father has had substance abuse problems, the child may be at an increased risk of being an addict or having problems with drug use. While you are pregnant some clinics require that you meet with the Nurse Practitioner (NP) or other medical staff at least once per month. The medical staff wants to check in with you to make sure your pregnancy is going smoothly and ask about your prenatal visits. This is an excellent time to ask any medical questions. If you have any questions at anytime feel free to talk to your counselor or medical staff at the clinic. Your questions are important and deserve to be answered! Clinic staff may ask you to sign a release so we can speak with your prenatal providers. The release is needed so we can talk with your prenatal provider about your treatment at the clinic. It’s also important to have a release in place so if there are any medical concerns the clinic will be able to assist you. Medications such as Suboxone, Nubain, and Stadol could cause you to have severe withdrawal symptoms if you are taking methadone. Be cautious of medications that you are prescribed or given. You should always check with your medical providers before taking any medication. You should never take anyone else’s prescription medication. And be careful about taking any medications, even if it’s offered to you from a friend or family member. Some people store more than one type of medication in a bottle and you might be given something that could harm you, your pregnancy, or cause you to have a positive drug screen. All of your providers are here to support you and want to help you to have a healthy and safe pregnancy! Let us know what you need and how we can help. 1. Methadone maintenance treatment Methadone maintenance treatment (MMT) is the treatment of choice for opioid dependant pregnant women 2. Methadone is a long-acting opioid that enables women to cease or reduce their heroin use and related behaviours, in accordance with a harm minimization philosophy. MMT throughout pregnancy is associated with improved fetal development, infant birth weight, and reduces the risk of perinatal and infant mortality in heroin dependant women (level III 2, 1). The aims of methadone maintenance treatment are to:
  • Reduce or eliminate illicit heroin and other drug use
  • Improve the health and wellbeing of those in treatment
  • Facilitate social rehabilitation
  • Reduce the spread of blood borne diseases
  • Reduce the risk of death associated with opioid use
  • Reduce the level of crime associated with opioid use 2
  • Withdrawal from heroin, without MMT is associated with risks to the fetus and a high risk of relapse2. Women should be informed of these risks, and if it is to be attempted it should ideally be done in the 2nd trimester, supervised in a specialist unit (Consensus,1). While inpatient supervision of withdrawal is not available at the Women's, WADS clinicians are able to provide outreach services to pregnant women undergoing withdrawal in specialist detoxification units.
2. Methadone stabilisation program Heroin dependant women should have priority access to methadone treatment, which includes admission to an inpatient obstetric unit for stabilization and rapid dose titration, with respite from the external environment (Consensus,1). This service is offered at the Women's, under the supervision of WADS care coordination team inpatient stabilisation brochure, at any gestation. Admission is for 5 days (Monday to Friday). Inpatient admission is necessary as rapid induction onto methadone is required. Legislative requirements must be met, including obtaining a permit for prescribing methadone from DHS before commencing, as per the Women's CPG: Methadone and Buprenorphine Dosing Procedures. Care in pregnancy should be provided as per CPG: Care of Women with Alcohol and Drug Issues in Pregnancy. 2.1 Criteria for methadone stabilisation program Women will be assessed as being
  • dependent on opioids
  • motivated to undertake induction onto MMT
  • willing to comply with the whole program and methadone regime.
Women not suitable for treatment with methadone3:
  • Severe hepatic impairment
  • Hypersensitivity to methadone
  • Unable to give informed consent (eg. Major psychiatric illness) or age under 18, consider jurisdictional requirements for obtaining legal consent
Specialist advice should be sought for clients with severe respiratory depression, acute asthma, acute alcoholism, head injury and raised intracranial pressure, ulcerative colitis, biliary and renal tract spasm, patients receiving monoamine oxidase inhibitors. 3. Methadone induction procedure Women should commence on a dose of methadone that should be titrated to the woman's symptoms with rapid increases1. The starting dose should be 20mg, and is reviewed at 4 hourly intervals or earlier if required. At each review, if the woman has objective signs of withdrawal (eg. Pupils dilated, restless, see short opiate withdrawal scale in appendix of National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn), then give an additional 5-10mg. If there are no signs of withdrawal no extra dose is given until the next scheduled review. The maximum dose in the first 24 hours should not exceed 50mg. Extreme caution should be exercised when assessing the woman's requirements on subsequent days if a dose of over 30mg is used on day 1, in order to prevent accumulation and possible toxicity from methadone. The same process should be repeated on day 2 (when the woman will almost certainly require less methadone), commencing again with 20mg and giving additional doses of 2.5 to 10mg as required, with a maximum dose increase of 50mg. If at any time the woman becomes sedated (small pupils, drowsiness), increase frequency of observation and ensure no further methadone is administered until sedation is reversed. Women should be encouraged to remain on the ward for 30-60 minutes post dose, for observation. Women should be cautioned regarding the use of other drugs whilst on methadone. Urine drug screening is not routine, but may sometimes be requested if there are concerns about harmful concurrent drug use. 3.1 Vomiting Vomiting is a serious concern in pregnant women on methadone. Vomiting of a methadone dose may lead to withdrawal in both mother and fetus (consensus,1). If a methadone dose is vomited (consensus,1):
  • Within 10 minutes of dosing - consider giving a repeat dose
  • Within 10-60 minutes of dosing - consider giving half a repeat dose
  • More than 60 minutes after dosing - consider half a repeat dose if withdrawal occurs
Prevention of vomiting (consensus,1):
  • Women should be discouraged from ingesting methadone on an empty stomach
  • Women should be encouraged to sip their dose slowly
  • If the dose consistently causes vomiting, consider splitting the dose or giving rectal prochlorperazine 30-60 minutes before dosing
  • If woman vomits constantly not in relation to dose, assess and treat according to the Women's CPG: Hyperemesis Gravidarum.
sources: http://www.thewomens.org.au/Methadon...ioninPregnancy Health Conditions of Drug-exposed Infants Birth weight Birth weight is an important factor associated with children’s overall health and development. Children who weigh under five-and-one-half pounds at birth are more likely to have serious medical problems and to exhibit developmental delays. Drug-exposed infants often do not exhibit normal development. Prematurity The risk of prematurity (birth at less than thirty-seven weeks) is higher in drug-exposed infants. Other complications can include an increase in acute medical problems following birth, and extended periods of hospitalization. Birth weight under three pounds has been associated with poor physical growth and poor general health status at school age. Low Birth weight infants also have an increased risk of neurosensory deficits, behavioral and attention deficits, psychiatric problems, and poor school performance. Premature infants may have experienced bleeding of the brain tissue, hydrocephalus, bronchial problems, eye disease, and interferences with the normal ability to feed. Small for Gestational Age (SGA) This term is used to describe infants whose Birth weight is below the third percentile for their gestational age (i.e., 97% of infants the same age are heavier than the SGA infant). It is common for women who abuse cocaine to experience decreased appetite and provide inadequate nutrition for themselves and their baby. Failure to Thrive (FTT) Infants who were exposed to alcohol and/or drugs may exhibit this disorder, which is characterized by a loss of weight, or slowing of weight gain, and a failure to reach developmental milestones. This can be due to medical and/or environmental factors. The infant’s behavior includes poor sucking, difficulty in swallowing, and distractibility. Many of these children live in chronically dysfunctional families which places them at greater risk of parental neglect. Neurobehavioral symptoms Within seventy-two hours after birth, many infants who were exposed prenatally to drugs experience withdrawal symptoms, including tremors and irritability. Their skin may be red and dry; they may have a fever, sweating, diarrhea, excessive vomiting, and even seizures. Such infants may require medication for calming. Other infants exposed to stimulants show a pattern of lethargy during the first few days after birth, are easily overstimulated, and may go from sleep to loud crying within seconds. These behaviors usually decrease over time and subside in toddlerhood. Infectious diseases Infants with prenatal drug exposure may be exposed prenatally or postnatally to infectious and/or sexually transmitted diseases contracted by their mothers. The most common infectious diseases seen in infants are chlamydia, syphilis, gonorrhea, hepatitis B, HIV, and AIDS. Sudden Infant Death Syndrome (SIDS) Children who have been exposed prenatally to alcohol and/or drugs have an increased risk of dying from sudden infant death syndrome. The causes of SIDS are unknown and its occurrence is almost impossible to predict. Apnea/cardiac monitoring is recommended for these infants. Fetal Alcohol Syndrome Mothers who consume large quantities of alcohol during pregnancy may have babies who are born with Fetal Alcohol Syndrome (or FAS). A diagnosis of FAS is based on three factors: 1) prenatal and postnatal growth retardation; 2) central nervous system abnormalities, and, 3) abnormalities of the face. Many of these children display significant disabilities, learning disorders, and emotional problems as they mature. Each of the above conditions associated with prematurity or drug exposure has programmatic implications for caregivers; the children who exhibit these conditions are often referred to as "medically fragile". Developmental Outcomes There are many unknowns involved in trying to predict the outcomes of infants and children exposed to drugs. While we know that there are certain physical problems that may remain with the child, in a structured and nurturing environment, many of these children are able to grow and develop quite normally. A small percentage of children have been found to have moderate to severe developmental problems. But regardless of their health status, all children who have a history of prenatal substance exposure should receive developmental evaluations on a regular basis: at least once during the first six months; at twelve months; and at least every year thereafter until school age. Early identification of social, language, cognitive, and motor development problems is essential. Developmental Patterns in Children Exposed Prenatally to Drugs Birth to fifteen months
  • Unpredictable sleeping patterns
  • Feeding difficulties
  • Irritability
  • Atypical social interactions
  • Delayed language development
  • Poor fine motor development
Toddlers from sixteen months to thirty-six months
  • Atypical social interactions
  • Minimal play strategies
Preschool children from age three to five While average preschoolers are beginning to share and take turns, demonstrate language skills, and increase their attention spans in a group setting, the drug-exposed toddler may be hyperactive, have a short attention span, lose control easily, have mood swings and problems moving from one activity to another. These children may also experience difficulties processing auditory or visual information/instructions. School and teenage years There has not been sufficient research into the long-term biological effects of drug exposure on older children and teenagers, however, we do know that children with the behaviors described above are at greater risk of abuse and neglect, learning disabilities, and behavioral problems. Obviously, it becomes imperative to identify these problems at a very early age, access the necessary resources for the child, and build a team of professionals who regularly monitor the progress of each child. Supporting a drug-exposed child in the course of his life may require advocating vigorously for specialized educational services; providing recreational and employment opportunities that allow a measure of success; educating parents; and providing counseling. Techniques in Working with Drug-exposed Infants and Young Children Respite and crisis care programs working with drug-exposed infants and children may not know the exact drugs to which each child was exposed. A combination of substances, including alcohol and tobacco, may be involved. There are a few techniques, however, which can be used in a general plan of care that may be individualized to meet the specific problems of each child:
  1. Provide a calm environment: low lighting; soft voices; slow transition from one activity to another.
  2. Be aware of signs of escalated behavior and frantic distress states before they occur, e.g., increased yawns, hiccoughs, sneezes, increased muscle tone and flailing, irritability, disorganized sucking, and crying.
  3. Use calming and special care techniques on a regular basis, such as
    • swaddling blankets tightly around the infant
    • using a pacifier even when the infant is not organized enough to maintain a regular suck
    • rocking, holding, or placing the infant in a swing, or Snuggly™ carrier
    • massaging the child
    • bathing in a warm bath, followed by a soothing application of lotion
    • rubbing ointment on diaper area to prevent skin breakdown
  4. Encourage developmental abilities when the infant is calm and receptive using only one stimulus at a time. Look for signs of infant distress and discontinue the activity if this occurs.
  5. Gradually increase the amount and time of daily developmental activities; encourage the child to develop self-calming behaviors and self control of his own body movements.
Behavior Descriptions and Suggested Strategies Feeding problems Feed the baby more often; feed smaller amounts at one time; allow the infant to rest frequently during feeding. Place the infant upright for feeding; after feeding, place the child on his side or stomach to prevent choking; if vomiting occurs, clean the skin immediately to prevent irritation. Irritability/unresponsive to caregiver Reduce noise in the environment; turn down lights; swaddle the infant: wrap snugly in a blanket with arms bound close to the body. Hold the infant closely; put the infant in a bunting-type wrapper and carry it close to your body. Rock the infant slowly and rhythmically, either horizontally or with its head supported vertically, whichever soothes. Place the child in a front-pack carrier; walk with the infant; offer the infant a pacifier or place it in an infant swing. Goes from one adult to another, showing no preference for a particular adult Respond to specific needs of child with predictability and regularity.

May have poor inner controls/frequent temper tantrums


Use  books,  pictures, doll play, and conversation to help the child explore  and express a range of feelings.

Ignores  verbal/gestural  limit setting
Talk  the child  through to the consequence of the action.

Shows decreased   compliance with simple, routine commands
Provide  the child  with explicitly consistent limits of behavior.

Exhibits tremors  when  stacking or reaching
Observe  the child  and note the onset of tremors, their duration, and how the  child compensates for them; provide a variety of materials to enhance  development and refinement of small motor skills, e.g., blocks, stacking  toys, large Leggos™, and puzzles with large pieces. Sand and water play  are soothing and appropriate.

Unable to end or let  go  of preferred object or activity
Provide  attention  and time to children who are behaving appropriately; provide  child with an opportunity to take turns with peers and adults.

Delayed receptive  and  expressive language
Create  a stable  environment where the child feels safe to express feelings,  wants, and needs; use stories/records/songs; use hands-on activities to  reinforce the child’s language abilities.

Expresses wants,  needs,  and fears by having frequent temper tantrums
Remove  and help  calm the child; redirect the child’s attention; verbalize the  expected behavior; reflect the child’s feelings. Praise attempts toward  adaptive behavior. Set consistent limits.

Difficulty with  gross  motor skills (e.g. swinging, climbing, throwing, catching,  jumping, running, and balancing)
Provide  appropriate  motor activities through play, songs, and equipment. Offer  guidance, modeling, and verbal cues as needed.

Over-reacts to  separation  of primary caregiver
Offer  verbal  reassurance; be consistent, and help the child learn to trust  adults.

Withdraws and seems  to  daydream or not be there
Provide   opportunities for contact; move close to the child, make eye contact,  use verbal reassurance; allow, identify, and react to the child’s  expressions of emotions.

Frequent temper  tantrums
Understand  that a  tantrum is usually a healthy release of rage and frustration;  protect the child from harm; remove objects from the child’s path if he  is rolling on floor. Some children do not want to be held during a  tantrum and doing so can cause more frustration. Remain calm, using a  soothing voice; anger will only escalate the child’s frustration. Do not  shout or threaten to spank the child–the adult needs to be in control.  Help the child to use words to describe emotions. Read stories about  feelings. Help the child gain control by making eye contact, sitting  next to the child, giving verbal reassurance, and offering physical  comfort (rubbing back, etc.). Note the circumstances that provoked the  tantrum, and try to avoid such confrontations when possible. Provide a  neutral area for the child to work through the tantrum, (e.g., a large  cushion or bean bag chair). Some children want to work through a tantrum  alone; keep the child in sight, but do not interact until he is calm.

Parent  Involvement
It is critical to the  success  of the drug-exposed infant that the eventual caregiver (parent,  relative, foster parent, respite provider, adoptive parent) learn the  care routine, control techniques, and background of the children for  whom they will be providing care. Understanding the etiology of  drug-exposure, the types of medical problems that arise, the  developmental patterns, and the techniques for handling drug-exposed  infants and toddlers is imperative.

Program social workers,  case  managers, child care staff, and nursing staff must all work  together with the caregiver to offer parent education ("hands-on"  opportunities to provide care under the guidance of professionals), and  encouragement for families who undertake the care of a drug-exposed  infant. The caregiver’s understanding of the child’s behavior, physical  "cues," and developmental problems, goes a long way in helping the  drug-exposed infant, toddler, and teen succeed. It also assists the  caregiver in setting realistic expectations for children who enter the  world battling the the effects of their parent’s addiction.

Many children who were   prenatally exposed to drugs will grow and develop without unusual  problems. However, for those infants who have physical indicators, the  respite and crisis care provider can make a difference by providing,  perhaps, the first stable, nurturing environment. Here, the child can be  observed, positive routines for care can be established, and parents  can receive the critically necessary education and support to enable  them to care for an alcohol or drug-exposed child.

Summary
Staff training, caregiver   training, and parent education are all critical elements of any program  that will be successful with these children. Physical elements of the  environment (lighting, noise, and space) may need to be adjusted to  accommodate their care. The inclusion of medical support, i.e., nurses  and physicians who are familiar with the problems of these children, is  essential. In summary, the care of alcohol and drug-exposed children is a  team effort that requires coordination, case management, special care  techniques, and education to be successful in any respite or crisis care  situation. With these components in place, agencies and families can  witness the positive growth and development of children who have been  greatly at risk.

About the Author: Jeanne Landdeck-Sisco, MSW, is the Executive Director of Casa de los  Niños  in Tucson, Arizona, which was the first crisis nursery in the  U.S., established in 1973. Ms. Landdeck-Sisco served as the first  President of the ARCH National Advisory Committee for Respite and Crisis  Care Programs from 1991-93 and remained on the committee until 1996.
Resources
Center for Substance Abuse   Prevention National Resource Center for the Prevention of Perinatal  Abuse of Alcohol and Other Drugs, 9302 Lee Highway, Fairfax, VA 22031,  (800) 354-8824.
National Organization on  Fetal  Alcohol Syndrome, 1815 H Street, N.W., Suite 710, Washington, DC  20006, (202) 785-4585.
References
Besharov, Douglas J. When   Drug Addicts Have Children. Washington, DC: Child Welfare League  of America, 1994.
Hargrove, Elisabeth, et  al. Resources Related  to Children and Their Families Affected by  Alcohol and Other Drugs. Chapel Hill, NC: NEC*TAS, 1995.

Special acknowledgment is  given to Rosemarie Dyer, R.N., Nursing Supervisor at Casa  de los Niños, who has developed the agency’s program for drug- and  alcohol-exposed infants and from whose training material many of the  techniques and caregiver responses have been drawn; and to Anna  Binkiewicz, M.D., Casa de los Niños Board Member and Medical  Director, who has provided on-site medical treatment of Casa’s medically  fragile children.
Why is it that only some drug users become addicts? This is the question that has been addressed by the teams of Pier Vincenzo Piazza and Olivier Manzoni, at the Neurocentre Magendie in Bordeaux (Inserm unit 862). These researchers have just discovered that the transition to addiction could result from a persistent impairment of synaptic plasticity in a key structure of the brain. This is the first demonstration that a correlation exists between synaptic plasticity and the transition to addiction.

The results from the teams at Neurocentre Magendie call into question the hitherto held idea that addiction results from pathological cerebral modifications which develop gradually with drug usage. Their results show that addiction may, instead, come from a form of anaplasticity, i.e. from incapacity of addicted individuals to counteract the pathological modifications caused by the drug to all users.

This research is published in the journal Science on 25 June 2010.
The voluntary consumption of drugs is a behaviour found in many species of animal. However, it had long been considered that addiction, defined as compulsive and pathological drug consumption, is a behaviour specific to the human species and its social structure. In 2004, the team of Pier Vincenzo Piazza showed that the behaviours which define addiction in humans, also appear in some rats which will self administer cocaine*. Addiction exhibits astonishing similarities in men and rodents, in particular the fact that only a small number of consumers (humans or rodents) develop a drug addiction. The study of drug dependent behaviour in this mammal model thus opened the way to the study of the biology of addiction.

Now, the teams of Pier Vincenzo Piazza and Olivier Manzoni are reporting discovery of the first known biological mechanisms for the transition from regular but controlled drug taking to a genuine addiction to cocaine, characterised by a loss of control over drug consumption.

Chronic exposure to drugs causes many modifications to the physiology of the brain. Which of these modifications is responsible for the development of an addiction? This is the question the researchers wanted to answer in order to target possible therapeutic approaches to a disorder for which treatments are cruelly lacking.

The addiction model developed in Bordeaux provides a unique tool to answer this question. Thus it allows comparing animals who took identical quantities of drugs, but of which only few become addicted. By comparing addict and non-addict animals at various time points during their history of drug taking, the teams of Pier Vincenzo Piazza and Olivier Manzoni have demonstrated that the animals which developed an addiction to cocaine exhibit a permanent loss of the capacity to produce a form of plasticity known as long term depression (or LTD). LTD refers to the ability of the synapses (the region of communication between neurons) to reduce their activity under the effect of certain stimulations. It plays a major role in the ability to develop new memory traces and, consequently, to demonstrate flexible behaviour.

After short term usage of cocaine, LTD is not modified. However, after a longer use, a significant LTD deficit appears in all users. Without this form of plasticity, which allows new learning to occur, behaviour with regard to the drug becomes more and more rigid, opening the door to development of a compulsive consumption. The brain of the majority of users is able to produce the biological adaptations which allow to counteract the effects of the drug and to recover a normal LTD. By contrast, the anaplasticity (or lack of plasticity) exhibited by the addicts leaves them without defences and hence the LTD deficit provoked by the drug becomes chronic. This permanent absence of synaptic plasticity would explain why drug seeking behaviour becomes resistant to environmental constraints (difficulty in procuring the substance, adverse consequences of taking the drug on health, social life, etc.) and consequently more and more compulsive. Gradually, control of the taking of the drug is lost and addiction appears.

For Pier-Vincenzo Piazza and his collaborators, these discoveries also have important implications for developing new treatment of addiction. „We are probably not going to find new therapies by trying to understand the modifications caused by a drug in the brains of drug addicts,“ explain the researchers, „since their brain is anaplastic.“ For the authors, „The results of this work show that it is in the brain of the non-addicted users that we will probably find the key to a true addiction therapy. Indeed,“ the authors estimate, „understanding the biological mechanisms which enable adaptation to the drug and which help the user to maintain a controlled consumption could provide us with the tools to combat the anaplastic state that leads to addiction.“

ScienceDaily
June 24, 2010
http://www.sciencedaily.com/releases…0624140912.htm

KABUL – Antonia Maria Costa, head of the United Nations Office on Drugs and Crime (UNODC), last month informed the world that Afghanistan’s expected opium harvest for the 2010 season will be three-quarters of last year’s output – a substantial reduction of 2,600 tonnes. Afghanistan produces over 90% of the world’s illicit supply of opiates, the key ingredient of heroin, and has produced more than 6,000 tonnes of opium a year since 2006.

A ravaging naturally occurring blight exacerbated by climatic conditions is behind this season’s failed harvest, according to UN forensic findings. In the case of Kandahar, Helmand and Urozgan provinces, which collectively produced 80% of the total amount of opium in Afghanistan last year, the blight was further spread by aphids, small plant-eating bugs that can carry fungi and viruses.

The UN estimates that up to 50% of Afghanistan’s opium crops
have been affected. Following Costa’s announcement, Taliban insurgents and angry farmers in southern Afghanistan were quick to blame international forces for „aerial spraying“ their fields to disrupt this year’s harvest. Farmers claim unconfirmed spraying of their fields has also sickened livestock, children and hurt production of legal crops like fruit and nut trees. The UN, the North Atlantic Treaty Organization and US officials deny the claims.

Taliban insurgents, who have a high influence throughout the south, have already started exploiting the spray theory, with statements to the local population blaming international forces for spraying unknown chemicals over southern Afghanistan. „The people believe that this disease is sprayed by ISAF [International Security Assistance Force] onto the crops,“ a source in Helmand province told Asia Times Online. “Farmers claim to have some evidence, saying ‚when we get up early in the morning after a night’s sleep, we have seen some white powder-like residue in our fields and even in our homes which are near the field‘.“

Anecdotal claims of usage of chemicals also have been made in neighboring Uruzgan province. „There are strong rumors among the people that foreign forces sprayed drugs with a virus from the air onto their poppy fields,“ Murad, a resident of Tarin Kowt, Uruzgan province, said. “Some of them say that they have found white material that looks like poppy seeds, but there is not clear evidence.”

The Taliban’s insistence on ISAF involvement and claims by farmers have been galvanized by a previous UNODC program funded by the United States that sought to „weaponize“ fusarium oxysporum, a plant fungus capable of devouring coca bushes, poppy fields and marijuana plants.

Uzbekistan served as the test-bed for the project although at least two Central Asian states refused to participate, opting to manually eradicate their poppy fields, and the project was ultimately terminated in 2002 without the fungus ever being used. Efforts to deploy the virus to South America were blocked by Colombia and Peru and even the United States prohibited aerial dispersal of the fungal agent against marijuana fields in the state of Florida following warnings from scientists that the fungus could mutate into a hardier-strain capable of attacking non-targeted crops and livestock.

The Taliban-perpetuated propaganda machine, however, is having an impact among conspiracy minded communities in southern Afghanistan who are adamant that international forces are responsible for the destruction of their crops.

A much less nefarious culprit may bear ultimate responsibility for the wide-scale destruction of the opium poppies: Mother Nature. Although the UNODC is currently testing samples from the badly damaged opium crop, physical evidence points to a fungus, possibly macrosporium papaverus, a blight that causes root and capsule rot, resulting in little to no opium latex for extraction by farmers.

Enyathullah, a landlord from Arghandab district of Kandahar province, shed light on the decrease in opium production in Kandahar. „Farmers used to receive 140 kilograms of opium while they now yield 14 kg from the same land,“ he said. Countering Taliban claims of a conspiracy, Enyathullah supports the physical evidence that the poppy blight is natural occurring. „Last year, pomegranates were affected by a virus; whereas this year, poppy plants suffer from such problem. A limited number of farmers cultivated opium in Arghandab last year since it was very costly to pay high bribes to the police, bear very low prices of opium, and deal with increasing raids by local security forces,“ said Enyathullah.

The poppy plant blight has already hurt general markets and businesses in Kandahar city because the income of farmers from the poppy fields has been slashed, he said. The several highly destructive funguses, viral diseases and forms of blight that affect poppy plants can be exacerbated by excessive moisture, high humidity and overly watered poppy crops. For example, pleospora calvescens, a type of leaf blight harmful to poppy varieties, is worse in times of heavy rainfall or high humidity.

„Beginning in early March, the temperature range between day and night was substantially high so it caused dew in the field. Although dew is good for poppy plants during maturation, this year the increase in dew and high temperature during the day coupled with low temperatures during the night at the growing and blooming stage caused an aphid infestation,“ a source from Helmand familiar with poppy cultivation explained to Asia Times Online. „This aphid infestation causes different problems for different crops, and this year it came late in the season so it helped destroy large plots of poppy crops in southern Afghanistan.“

Costa of the UNODC told participants at an anti-drug forum held in Moscow on June 9 that Afghanistan was entering its third year of substantial decrease in opium output. „This downward trend will continue in 2010 but for a different reason: a natural occurring blight, or plant disease. The same amount of hectares was cultivated as last year but with a drastically different opium output. The blight is caused by a known fungus that has been recorded in Afghanistan over the past 35 years.“

International forces in Afghanistan have adopted a less aggressive opium poppy eradication campaign in favor of increased focus on interdiction and disrupting drug-processing workshops. Widespread destruction will create a new cycle of indebtedness for farmers, raising tensions between rural communities and the Afghan government, and has drastically driven up prices for opium. Opium prices have surged to nearly $115-125 per kilogram from a stable US$25-$35 in some areas.

„The price of opium has gone up because every farmer thinks that this year the opium production was low, so they keep their opium and do not sell it because they hope that the prices will go up,“ Ahmad Jawed, a resident from Helmand province, told Asia Times Online.

„I heard that the opium price is around 65,000 [US$720] to 75,000 Pakistani rupees per seven kilograms, right now. But it was around 10,000-25,000 Pakistani rupees. The quality of the opium is important regarding the price,“ Murad told Asia Times Online.

The UNODC estimates that upwards of 12,000 tonnes of opium are currently in storage and held by a collection of farmers, drug traffickers and insurgents. The soaring prices of raw opium will lead to windfall profits for those wealthy enough to hold onto their caches and sell at times they can make most profit.

The underwhelming 2010 opium harvest will likely lead to farmers planting more in hopes of a bumper crop next year, boosting the profits that anti-government groups like the Taliban and Hezb-i-Islami make from taxing the cultivation and trafficking of narcotics. Rising profits will also threaten the success of the UNODC-sponsored poppy-free province initiative that gives incentives to provinces that wipe out their illicit opium production. Currently 17 of the country’s 34 provinces are poppy-free, a decrease of three from last year, according to UNODC statistics.

Despite the Barack Obama administration’s overhaul of the Afghan war effort beginning last year, little if any meaningful commitment has been made toward curbing the industrial-scale production of narcotics in Afghanistan.

Earlier this year, the UNODC released a long-awaited Afghan cannabis survey that confirmed suspicions that Afghanistan is now the world’s number one producer of two illicit narcotics: opiates and cannabis resin, known better as hashish. Gross misunderstanding of the narcotics problem plaguing Afghanistan has festered for almost nine years under the international community’s watch. The problem has soared to epidemic proportions, causing a tidal wave of legal, health, economic and security problems from Southwest Asia to Europe.

Although corruption has been identified by the ISAF and the US as a bigger challenge than the insurgency in Afghanistan, little has been done to recognize the source of this corruption: the entrenched narco-economy and its penetration of the Afghan state.

Russian government officials have been quick to criticize the ISAF and the US for failure to tackle the burgeoning drug trade as each year an estimated 30,000 Russian youths perish from overdosing on heroin that originated in Afghanistan.

„How are we supposed to take on the drug trade when Afghan government officials cannot explain where the bulk of international financial assistance is and how it was spent?“ asked Rudik Iskujin, head of the Group on Cooperation between the Federation Council of the Russian Federation and the National Assembly of Afghanistan. „Nearly 50% of the international financial aid [given to Afghanistan] is processed by Afghan government entities. The sad fact is only 2% of international monetary assistance is visible by Afghan government entities.“

As thousands of international and Afghan security forces prepare to pacify large swathes of Taliban-occupied and Taliban-influenced territory throughout southern Afghanistan this summer, Afghan farmers will be preparing for a possible record-breaking opium poppy planting season beginning in mid-September, 2010.

The invariably harmful effects of the drug industry on governance, stability and its perversion of the local economy will continue to haunt the international community’s efforts in Afghanistan and thwart progress toward a stable and self-sustaining state until the problem is finally recognized as a key source of the current political and economic instability.

Matthew DuPee and Ahmad Waheed are research associates at the Naval Postgraduate School in Monterey, CA. Matthew is an Afghan specialist who focuses on the Southwestern Asia narcotics industry. Ahmad was awarded the J William Fulbright Scholarship and received his master’s degree in international policy studies, with a specialization in international development, at the Monterey Institute of International Studies.

source: http://www.atimes.com/atimes/South_Asia/LF22Df03.html

Mittlerweile sind 10.000.000 Kinder und Jugendliche in den USA permanent unter den Einfluss von Drogen wie Ritalin, Prozac, Valium und anderen Medikamenten!

Das ist Wahnsinn, zeigt aber auch die verbrecherischen Machenschaften des US-Amerikanischen Systems!

oder auch hier in der Vollversion:

http://www.cinepx.com/2009/12/generation-rx-2008.html

Here in the first Picture we can see that Methadone need a few Days to build up a „Plasma-Level“!

In the next Pic. we will see the „normal decrease in a 24h. Period:

Am 02.12.1999 fand in der Psychiatrischen Klinik der Universität
München unter dem Vorsitz von PD Dr. M. Soyka
eine Konsensus-Konferenz zur Anwendung von Buprenorphin
in der Substitutionsbehandlung opiatabhängiger Patienten
statt. An ihr nahmen Experten aus Deutschland, Österreich
und der Schweiz teil (Teilnehmerliste am Ende des Beitrags).
Hintergrund war die kurz bevorstehende Einführung von
Buprenorphin in der Substitutionsbehandlung Drogenabhängiger
in Deutschland. Ziel der Konsensus-Konferenz war es,
praktische Hinweise für den Einsatz von Buprenorphin zu
geben, um mögliche Indikationen und Kontraindikationen herauszuarbeiten.
Dabei war es hilfreich, daß die Substanz in
Österreich und der Schweiz schon in einigen Therapiezentren
eingesetzt wurde. Im übrigen liegen breite Erfahrungen, vor
allem aus Frankreich, aber auch den USA vor.
Die von den Experten vorgenommene Einschätzung ist Basis
des erarbeiteten Konsensuspapiers gewesen. Einige wenige Punkte
sollen hervorgehoben werden, da sie im Rahmen der Konferenz
etwas breiter diskutiert wurden. Dies betrifft zum einen
die in der Substitutionsbehandlung mit Buprenorphin gewählte
Eingangsdosis. Während in vielen Publikationen und Therapieempfehlungen
eine Dosis von 2 mg Buprenorphin initial für ausreichend
gehalten wird, deuten insbesondere die Erfahrungen
aus Österreich und der Schweiz darauf hin, daß in Regel 4 mg,
gelegentlich sogar 8 mg Buprenorphin eine geeignete Eingangsdosis

sein könnte. Zu niedrige Dosierungen führen offensichtlich

gehäuft zum Abbruch einer solchen Therapie. Als wenig

problematisch wurde die Applikation von Sublingualtabletten

angesehen, die nach den vorliegenden Erfahrungen von Patienten
gut toleriert werden. Auch wenn in den meisten Fällen das
Vorliegen einer Schwangerschaft sowie Stillen eine Kontraindikation
für eine Substitutionsbehandlung darstellt, so haben doch
Erfahrungen, insbesondere aus Österreich, gezeigt, daß in Einzelfällen
die Gabe von Buprenorphin auch bei Stillenden und
Schwangeren indiziert sein kann. Die diesbezüglich vorliegenden
klinischen Erfahrungen sind offensichtlich gut, allerdings
liegen hier noch keine kontrollierten klinischen Prüfungen vor.
Insofern ist die üblicherweise angegebene Gegenanzeige für die
Behandlung mit Buprenorphin „Stillen von Neugeborenen“ mit
einem gewissen Fragezeichen zu versehen.
Buprenorphin stellt heute, zumindest in Frankreich, das Mittel
der Wahl in der Behandlung Drogenabhängiger dar. In Deutschland
sollen in den nächsten Jahren breiter angelegte Studien zum
Einsatz von Buprenorphin, das im Sicherheitsprofil einige Vorteile
gegenüber reinen Opioidagonisten aufweist, durchgeführt
werden. Dies betrifft auch den Einsatz bei speziellen Subgruppen,
wie zum Beispiel bei Frauen oder Patienten mit komorbiden
psychischen Störungen. Nach der erst wenige Monate zurückliegenden,
erheblichen Revision der „Richtlinien über die Einführung
neuer Untersuchungs- und Behandlungsmethoden und
über die Überprüfung erbrachter vertragsärztlicher Leistungen“
(vormals NUB-Richtlinien) in Deutschland stellt die Einführung
von Buprenorphin eine weitere Neuerung in der Therapie Drogenabhängiger
dar. Sie wird hoffentlich zu einer Diversifizierung
und Verbesserung des therapeutischen Angebots bei Drogenabhängigen
führen. Das erarbeitete Konsensus-Papier soll dabei
die Basis oder genauer gesagt einen Leitfaden für dessen klinischen
Einsatz sein.

Weiter geht es mit den link:

636

Table of contents
EXECUTIVE SUMMARY…………………………………………………………………………..1
INTRODUCTION ……………………………………………………………………………………..2
Medico-legal issues …………………………………………………………………………………………………………………….. 2
OPIOID DEPENDENCE AND PREGNANCY……………………………………………….3
Opioid use during pregnancy ………………………………………………………………………………………………………. 3
Pregnancy outcomes…………………………………………………………………………………………………………………. 3
Neonatal abstinence …………………………………………………………………………………………………………………. 5
OPIOID SUBSTITUTION IN PREGNANCY …………………………………………………6
Objectives of opioid substitution ………………………………………………………………………………………………….. 6
Opioid substitution during pregnancy………………………………………………………………………………………….. 6
Objectives of opioid substitution in pregnancy……………………………………………………………………………… 7
Management of opioid substitution during pregnancy and perinatally ………………………………………….. 8
Assessment of pregnant women………………………………………………………………………………………………….. 8
Maintenance treatment ………………………………………………………………………………………………………………. 8
Breastfeeding ………………………………………………………………………………………………………………………….. 9
Other management approaches for the treatment of heroin dependence during pregnancy………….. 10
BUPRENORPHINE ………………………………………………………………………………..11
Registration and listing of buprenorphine ………………………………………………………………………………….. 11
Literature summary: clinical studies of buprenorphine and pregnancy……………………………………….. 13
Concerns regarding the use of buprenorphine in pregnancy ……………………………………………………….. 17
Monitoring of women for pregnancy while on buprenorphine programs……………………………………… 19
Use of buprenorphine in pregnancy……………………………………………………………………………………………. 20
Transfer from buprenorphine to methadone………………………………………………………………………………. 22
Management with buprenorphine during pregnancy ………………………………………………………………….. 23
Management of dependence……………………………………………………………………………………………………… 23
Management of opiate dependence with buprenorphine……………………………………………………………. 23
Notification of buprenorphine pregnancy ……………………………………………………………………………….. 23
Frequency of review………………………………………………………………………………………………………… 23
Management of heroin use ……………………………………………………………………………………………….. 24
Dose adjustments……………………………………………………………………………………………………………. 24
Monitoring…………………………………………………………………………………………………………………….. 24
Dose reductions or detoxification during pregnancy…………………………………………………………….. 24
Turing Point Alcohol and Drug Centre and The Royal Women’s Hospital
______________________________________________________________________________
ii
Frequency of dosing ………………………………………………………………………………………………………… 24
Use of other substances ……………………………………………………………………………………………………. 24
Dispensing Issues ……………………………………………………………………………………………………………. 25
Poor progress on buprenorphine ……………………………………………………………………………………………. 25
Direct transfer from methadone to buprenorphine……………………………………………………………………… 26
Induction onto buprenorphine after diagnosis of pregnancy ……………………………………………………….. 26
Management of obstetric care ……………………………………………………………………………………………………. 27
Management of ante-natal care …………………………………………………………………………………………………. 27
Frequency of review ……………………………………………………………………………………………………………. 27
Multidisciplinary team approach …………………………………………………………………………………………… 27
Monitoring of pregnancy ……………………………………………………………………………………………………… 27
Timing of delivery ………………………………………………………………………………………………………………. 27
Care in labour………………………………………………………………………………………………………………………… 28
Induction …………………………………………………………………………………………………………………………… 28
Analgesia during labour and caesarean section ……………………………………………………………………….. 28
During labour ………………………………………………………………………………………………………………… 28
Postpartum…………………………………………………………………………………………………………………….. 29
Caesarean section ……………………………………………………………………………………………………………. 29
Use of buprenorphine post-partum…………………………………………………………………………………………….. 29
Management of neonatal care ……………………………………………………………………………………………………. 30
Neonatal Withdrawal Syndrome ……………………………………………………………………………………………….. 30
Breast feeding and buprenorphine……………………………………………………………………………………………… 32
Recommendations ………………………………………………………………………………………………………………….. 32
Prescribing requirements………………………………………………………………………………………………………….. 33
APPENDIXES………………………………………………………………………………………..34
APPENDIX 1: PATIENT CONSENT FORM FOR BUPRENORPHINE
TREATMENT DURING PREGNANCY / BREASTFEEDING ………………………..35
APPENDIX 2: LETTER FROM OBSTETRIC SERVICE TO GENERAL
PRACTITIONERS…………………………………………………………………………………..36
APPENDIX 3: NEONATAL ABSTINENCE SCORE – FINNEGAN SCORE…….36
APPENDIX 4: ISSUES FOR CLINICAL DISCUSSION………………………………..38
APPENDIX 5: CONTACT PHONE NUMBERS …………………………………………..39
REFERENCES ………………………………………………………………………………………41

Please read more:CTG_Bup_Pregnancy_060104

Raw Opium

The opium poppy is botanically classified as Papaver somniferum. The genus is named from the Greek noun for a poppy, the species from the Latin word meaning ’sleep inducing‘: it was Linnaeus, the father of botany, who first classified it in his book Genera Plantarum in 1753. Like many of his contemporaries, and generations before him, he was well aware of its capabilities.

The plant has a dubious history. Some horticulturists consider it evolved naturally, but there are others who claim it is a cultivor developed by century upon century of careful human cultivation. Another theory is that it is a naturally mutated plant which evolved because of a quirk of climate or altitude. This is not far-fetched for plants will take on atypical forms in unique conditions: the cannabis trees of Bhutan prove the point. No one can be certain.

Although there is no positive proof, it is thought P. somniferum may have evolved, or been generated, either from the wild poppy, Papaver setigerum, which contains small amounts of opium and which indigenously grows throughout the countries bordering the Mediterranean Sea, or from a poppy native to Asia Minor.

To many not specifically engaged in its cultivation, the poppy is either an ornamental flower with a delicate beauty or a simple, scarlet blossom growing wild in the cereal fields of Europe, an image for the blood spilled in the trenches of the First World War. In fact, it comes from a large botanical family of 28 genera and over 250 individual species, most of which grow in the temperate and sub-tropical regions of the Northern Hemisphere. Many popular varieties have been specifically cultivated: the bush and tree poppies, the Welsh poppy, the blue and Syrian tulip poppies, the alpine poppy, the sub-arctic Iceland poppy, the Californian poppy. Even the opium poppy itself may be found in borders and displays in well-kept gardens, albeit illegally in most countries. In its wild state, the poppy is a single bloom but double flowers and specialist blooms with serrated and fringed petals have also been bred in a multitude of colours: the most exquisite are two variations of the opium poppy, the Pink Chiffon and the Paeony-flowered Mixed. Several species, such as the Oriental poppy from Asia Minor, are perennials.

Of all these species, only P. somniferum and P. bracteatum produce opium in any significant amount, although the latter is not used at present as a commercial drug source but is sometimes grown as decorative blossom from which a number of hybrids have derived.

Papaver somniferum is an annual with a growth cycle of approximately 120 days. It requires a rich, well-cultivated soil and, in the wild, is more likely to flourish in recently dug or ploughed ground, hence its presence in farm fields and, traditionally, by cart tracks and animal droves. The best growing climate is temperate, warm with low humidity and not too much rainfall during early growth. Ideally, although it will grow in clay or sandy clay, the best soil is a sandy loam which retains nutrients and moisture and is not too hard for the delicate early roots to penetrate. Both excessive and insufficient rainfall affect growth: too much moisture causes waterlogging and, if the soil is not properly drained, the plants will quickly die whilst dull, cloudy weather or excessive rain in days thirty to ninety of the growth period will reduce the opium-producing capabilities. Sunlight is especially important. The opium poppy is a ‚long day‘ photo-responsive plant which means it will not produce blooms unless it has grown through a period of long days and short nights, preferably with direct sunlight at least twelve hours daily.

These requirements aside, the plant is easy to grow. It does not require irrigation unless it is in danger of drying out, demands no expensive fertilisers, has few pests or ailments and, therefore, requires no insecticides or fungicides.

The seeds (about the size of a pin-head) are naturally sown by the pod blowing in the breeze and shaking like a pepper-pot, the contents scattering. When deliberately set, they are either broadcast or dropped in rows of shallow holes made by a stick or dibber, the timing of the sowing depending heavily upon local seasonal and climatic conditions. About 500 grams of seed are sown to half a hectare. The seeds may range over a wide variety of colours from white through yellow to brown, grey or black, the coloration not being relevant to the eventual blossom. Other cash crops, such as beans, peas or tobacco, may be planted alongside the poppy: these do not hinder it and are usually only a means of obtaining a higher return from the same area of land.

The seeds germinate quickly in warm, moist conditions and, within six weeks, the plant is established by which time it vaguely resembles a young cabbage with glaucous, green leaves with a dull grey or bluish tint. By eight weeks, it reaches a height of about 60 centimetres and consists of a main stem the upper portion of which (the peduncle) bears no leaves or secondary stems. Below the peduncle, secondary stems (called tillers) may appear from leaf bases where they join the main stem. Apart from the peduncle, the stems are frequently covered with hairs.

As the plant matures, it grows to a height of between 90 and 150 centimetres, the leaves appearing alternately, those on the main stem being oblong, tooth-edged and between 10 and 40 centimetres long. The main stem and each tiller ends in a single flower bud. As these develop, the ends of the peduncle and tillers extend and bend over to form a distinctive hook shape, the young buds suspended upside down. However, as the buds mature the stems straighten, the main bud at the head of the peduncle pointing upwards. Within two days of becoming vertical, the sepals of the bud – which are the same colour as the leaves – open and the flower blooms. In ideal conditions, the main blossom appears around the ninetieth day from germination.

At first, it appears crumpled, like a butterfly emerging from its chrysalis, but the four petals quickly expand and smoothen, each marginally overlapping the other. Their colour may vary from plant to plant. Traditionally, opium poppies are white but they may just as readily be pink crimson, weakly purple or a variegation of these with the colour darker at the petal base. Inside the flower is a ring of anthers on top of what will become the pod. Fertilisation is carried out by insects.

The flower is short-lived. In two to four days the petals drop, exposing a small, round pod the size of a large pea. This rapidly grows and may become ovoid or globular: when mature, it is the size of a small hen’s egg with a diameter of between 5 and 7.5 centimetres. It is bluish green with a slightly waxy appearance, the top surrounded by a small crown from which the stigmas rise. Where the pod joins the peduncle is a ring of petal base scars.

The pod is made of an outer skin enclosing the wall of the ovary, which is made up of three layers, and cavities or segments separated by seed-producing walls. The seeds, of which one pod may produce over 1000, are reniform in shape with distinct reticulations. When mature, they are loose in the pod before dispersal through small holes which open just under the crown.

The opium poppy has two main products: one, the seeds, is quite innocuous whilst the other, opium, is infamously insidious.

The word ‚opium‘ is misleading, implying the substance is a single chemical compound whereas it is an elaborate cocktail containing sugars, proteins, ammonia, latex, gums, plant wax, fats, sulphuric and lactic acids, water, meconic acid and a wide range of alkaloids. The significant parts are the alkaloids.

An alkaloid is a highly complex organic base (an alkali) with the common characteristic properties of containing nitrogen, of being basic and forming salts and water with acids, found in plants and having a characteristically bitter taste. Over fifty have been identified in opium, the most important being morphine (from which heroin can be made noscapine, papaverine, codeine and thebaine. They appear partially or loosely chemically bonded to meconic acid, the presence of which can be used as a test to detect opium.

In its raw state, opium is the dried latex or juice of the seed pod which is also known as the capsule, bulb or poppy-head. It is an opaque, milky sap which, although found throughout the plant, concentrates the active ingredients in the pod.

Until recently, it was unknown how the poppy manufactured such a complex chemical as an alkaloid. It is now accepted that the substances are actually created in the lactifers (cells which produce the latex), possibly from the synthesis of albumen: the mechanism, however, is still undiscovered. Furthermore, opium is only produced during a ten-to-twelve-day period when the pod is ripening. Once it has reached maturity, the alkaloids are no longer made and are broken down in time.

Why the plant goes through such a process is unknown. Theories abound. One suggests the alkaloids are essential to the formation of the seeds. Another proposes they are a form of deterrent against animal pests. The most intriguing propounds that the plant has developed opium simply to ensure humans maintain it in cultivation, an elaborate and incredibly ingenious example of symbiosis.

Harvesting opium is an exhausting, back-breaking and labour-intensive process which can really only be done by hand and requires knowledge, experience and dexterity. Little changed for centuries, it is obtained by tapping the individual pods.

The harvest begins about two weeks after the petals have dropped. The opium farmer first examines the pod and erect crown. By now, the pod will have lost its grey-green colour and darkened. If the points of the crown are standing straight out or curving upwards, the pod is ready. Not all the pods in a field will mature at the same time so the farmer has to keep a close daily eye on his whole crop over a period of some weeks.

Today, the tapping tool is generally a specialised knife consisting of a set of three or four parallel steel or glass blades mounted on a handle. This is run vertically over two or three sides of the pod. If the blades cut too deeply into the pod wall, the opium will flow too quickly and drip to the earth where it will be lost. Furthermore, deep incisions will cause it to weep internally and injure the pod, cutting off production will the lactifers and preventing the seeds from developing. The will then shrivel and die. If the cuts are too shallow, the flow be too slow and harden on the pod wall, sealing the cut like a scab. The ideal depth for a cut is 1-1.5 millimetres, achieved by setting the tapping knife blades.

The tapping (also known as scoring or lancing) is sometimes carried out in the late afternoon in the hope that the opium will ooze out overnight and coagulate slowly on the surface of the pod. If the tapping is carried out when the sun is still high, the heat of the sunlight can dry up the first sap to appear which then closes the wounds: however, in some countries, the collection of sap is done at midday, the sun’s heat actually encouraging the milky sap to trickle out.

When the opium first appears, it is a cloudy, white, fairly mobile substance but on contact with air it oxidises, turning into a dark brown, viscous substance, sticky to the touch with a distinctive delicate perfume. The opium, now a resinous gum, is carefully scraped from the pod with a short-handled blunt iron blade about 10 centimetres, long. In order to prevent the blade from becoming covered in gum, the farmer wets it between plants. Poppy growers working on licensed farms, where poppies are cultivated for the pharmaceutical industry, do this by dipping the blade in water, peasant farmers, who are the vast majority of the world’s poppy growers, often simply lick the blade. Needless to say, this addicts the farmers to their crop.

A pod will continue to secrete opium for some days and may be tapped up to half a dozen times. The opium yield varies according to the size of the pod and the efficiency of the farmer. The average is 50 milligrams per pod, a hectare of poppies providing, between 8 and 15 kilograms of raw opium.

The farmers work their way backwards across the fields, tapping lower mature pods before the taller ones so as not to spill the opium inadvertently. This is collected in a container hanging around the farmer’s waist. As they go, they mark the larger or more potent pods with coloured yarn. This directs the farmer to the pods on subsequent harvesting sessions and indicates which are eventually to be gathered in whole. These will be opened, dried in the sun and the seeds collected for the next season’s planting.

In gum form, raw opium contains a high percentage of water so it is sun-dried for several days until the mass is reduced by evaporation to a sticky, dark brown substance with a strong odour and the consistency of warmed beeswax. The freshness of raw opium is judged by its pliability: when fresh, it is putty-like. It is then beaten into an homogeneous mass and moulded into cakes, balls or blocks which can be stored for months, wrapped in plastic or leaves and stacked on shelves in a shady place. As it dries, it hardens. Excessive moisture or heat during drying or early storage will cause it to deteriorate but, once dried, it is stable and will gain in value for the older it is the less water it contains and the more concentrated it becomes by weight. In some cases, harvested pods are gathered and pulped in warm water which is then sieved and simmered over a fire, resulting in a poor quality opium which is not traded but may be retained by the farmer for personal use.

Raw opium, which is slightly granular, contains more than just the coagulated latex. In the scraping of the pod, pieces of the outer wall may be removed and up to 7 per cent by weight of raw opium may consist of extraneous plant matter. What is more, it can be deliberately adulterated by the farmer with sand, tree sap or ash, although a trained opium buyer can spot these tricks and few farmers dare resort to such chicanery.

Before the opium can be smoked or further processed, it has to be cooked. As traders usually prefer it somewhat improved from its rough state, cooking also prepares it for market.

The cooking is done by adding the raw opium to boiling water. It dissolves, any impurities such as pod fragments floating to the surface with heavier adulterates sinking to the bottom. The solution is passed through cheesecloth or a fine sieve to remove impurities then brought to the boil again and reduced. It is now a clean, brown, mobile fluid known as liquid opium. Very slowly, it is left to simmer until all that remains is a thick, brown paste known as prepared, cooked or smoking opium. This is pressed into moulds or trays and dried once more in the sun until it takes on the consistency of dense modelling clay which will harden as it matures. Much purer than raw opium, the cooked opium is now ready for the addict, the trader or the drug baron’s laboratories.

The remainder of the plant is not discarded. Once ripe, the seeds contain no dangerous substances whatsoever and are edible. Black, blue and grey seeds are frequently used as a decoration for cakes and bread whilst brown seeds are used in Turkey to make halva and to give the typical crunchiness to such traditional Turkish pastries as silgin boereghi and hashash coereghi. In India, yellow seeds are milled and added to sauces as flavouring or thickening agents.

Ripe poppy seeds yield about 50 per of a fixed oil made up of the glycerides of linolic, oleic, palmitic and stearic acids. Poppy seed oil has a straw-yellow colour, is odourless and tastes vaguely of almonds. It may be employed in cooking and as a salad dressing and it has been used as an adulterate of olive oil. Other uses are in the manufacture of perfumes and, because of its drying properties, as a base for expensive artists‘ oil paints.

In the nineteenth century, Turkish growers wasted little of the plant. Seeds were pressed to give both vegetable and lamp oil, the residual seed cake, stems and leaves being used as cattle fodder. This was historically an important factor in dairy produce, for cows fed on the detritus of poppies were said to provide the milk which made the finest yoghurt. Mixed with flour, the residuals also made a coarse bread. Seed was also sold to merchants in Smyrna who traded it on to Marseilles, where it was used in soap factories, whilst poppy heads were infused to make a traditional sedative drink.

Today, in most areas where the plant is commercially and legally grown, the opium producing stage is bypassed and the dried capsules, known as poppy straw, are milled and processed for the extraction of their alkaloids. Very large quantities of poppy straw have to be processed, but morphine, codeine and thebaine are recoverable. The seeds, which have almost as much value, are used in the food industry.

Although poppy straw morphine was extracted first in 1823 by a French chemist called Tilloy working in Dijon, it was not until 1928 that a factory was built when Janos Kabay, an Hungarian, developed a commercially feasible extraction process. During the Second World War, poppy straw processing began under German control as a source of opium during the Allied blockade. Since then, refinements to extraction techniques, and agricultural development have greatly increased yields, so that today more than 50 per cent of the world’s legal annual morphine demand of about 230 tonnes is derived from this source which, in some countries such as Australia, is a highly mechanised agricultural procedure.

The traditional growing, harvesting and preparation of opium however is and always has been essentially a peasant-farming activity, although there have been variations according to time and place. In Bengal, for example, it was customary to incise the pod with a sharpened mussel shell whilst elsewhere the extruded juice was placed upon a lower leaf of the plant to dry, a practice which lingers in parts of Afghanistan. However, from the late eighteenth century and with the expansion in world trade promoted by Europeans, opium growing and production became in places a highly organised, efficient and lucrative industry.

In India in the nineteenth century, opium growing was far from being a peasant-run operation. Admittedly, smallholders produced the opium but it was sold through a structured market and was big business, employing tens of thousands of growers and workers, many of whom became habituated to the drug.

As a commercial commodity, opium was an extensive branch of Indian agriculture. Grown mostly on the Ganges plain between Patna and Benares (now known as Varanasi), it was a major revenue source for the Indian economy. Its importance is reflected in the substantial records compiled about the business which afford a fascinating glimpse of how the industry began in modern times.

Sown early in November, the crop was harvested from early February the following year. The tapping tool (known as a nushtur) was of similar design to that used today, whilst the collecting blade was an iron scoop (a sittooha) and the collecting vessel an earthenware pot called a kurrace. This was emptied into a shallow tilted brass dish (a thallee) which allowed the water content (pusseewah) to drain away. The raw opium was allowed to dry for several weeks, being turned and stirred daily, before being stored in clay pots in godowns, or warehouses. Once weighed, tested and valued, it was thrown into vast vats, kneaded and subsequently pressed into spheres the size of small cannon balls.

This process was an important part of opium manufacture. The factory hands sat in rows in the godown, each man in front of a tagar, a tin vessel holding enough opium to make three to five balls. A basin containing water, a supply of poppy flower petals, a cup of lewah (inferior opium) and a brass cup in which the ball was shaped made up the rest of a worker’s equipment.

Taking the cup, the worker placed a petal in the base and smeared it with lewah. Another petal was added overlapping the first until the receptacle was lined by opium-soaked petals. An opium ball was rolled and placed in the cup so the dome protruding from the top was the same size as that contained by the vessel. This was then covered in poppy petals and lewah, the petals at the rim carefully interwoven to make a seal. When completed, the ball was about 15 centimetres in diameter and covered in a shell of petals. It weighed about 1.5 kilograms.

Once the ball was formed, it was placed on lattice-work racks in a drying room, a warehouse with open ends to allow the wind to pass through. Checked and turned daily by small boys, who ensured no insects were damaging the opium, it was kept until sufficiently dry then packed into mango-wood chests with two fitted trays, each chest containing forty balls in individual compartments, twenty to a tray. The chests were sealed with pitch, sewn into gunny or hides and sent for trading or to market. In Ghazipur, the centre of India’s modern legal opium production system, some opium-making equipment a century old is still in use in technique which have not significantly changed for 200 years.

The size of the opium industry can be judged from contemporary accounts. The area under poppy cultivation in 1870 was 560,608 acres. In the financial year of 1871-72, the number of chests sold was 49,695 at a trade price of 139 [pounds sterling] each. The net profit per chest was 90 [pounds sterling]. The opium revenue came to 7,657,213 [pounds sterling]. At 1996 currency rates, equates to approximately 612 [pounds sterling] million or $950 million.

The product and the style of marketing varied from place to place. While Indian opium was sold in forty-ball chests in the nineteenth century, Turkish opium from Smyrna – upon which was based a speculative commodities market – was packed in grey calico bags in oblong wicker baskets, the strength and quality of the goods being measured in carats on a 1 to 24 unit scale like gold: under 20 carats, the standard was considered poor and the opium discarded. The opium was blackish-brown, waxy to the touch, wrapped in poppy leaves and sold in irregular, flattened oval cakes weighing between 250 gram and a kilogram. The surface of each was sprinkled with the winged seeds of a species of sorrel to prevent them from sticking together. When shipped, it was transported in hermetically sealed, zinc-lined wooden cases, each sufficiently large to take an entire basket.

An alternative Turkish opium from Constantinople was a redder brown and sold in small lens-shaped cakes covered with poppy leaves whilst Persian opium from Yezd and Isfahan, where the Persian trade was centred, was usually dark brown and came in the form of sticks wrapped in grease-proof paper and tied about with cotton twine, or cones weighing 200-400 grams. Egyptian opium was formed into round, flattened cakes like ice hockey pucks, was reddish in colour and quite hard.

Aficionados, dealers, merchants and users were expert at assessing quality and strength in each and every variety and cargo. Opium was judged with all the finesse of a tea or coffee blender, the pertinent factors being its colour, weight, density, water content and granularity. Many traders could identify and judge the quality of individual samples just as experienced wine tasters can tell the vintage of a bottle of claret and from which vineyard it comes.

When and how man first discovered the potency of opium is hard to ascertain: he has been familiar with it since prehistoric times. The nineteenth century botanist, George Watts, suggested man came upon the poppy’s secret by stages of gradual awareness. Watts conjectured that humans aesthetically appreciated the poppy for its flower before they came to use it as a vegetable: certainly, it was eaten in salads in India as recently as the 1890s, although this may have been for its medicinal qualities. The juice was then found to make a refreshing drink when diluted with water and, eventually, the neat juice would be discovered to have narcotic effects inducing feelings of contentment and capable of numbing pain.

However that first discovery might have been made, today it is known that opiates can be swallowed, smoked, injected, sniffed, inhaled or absorbed through mucous membranes. How it is taken affects the intensity and speed with which it has an effect upon the brain and the whole body.

Historically, there have been only two basic ways to indulge in opium: one was to eat it, the other to smoke it.

Opium eating refers, in effect, to the general swallowing of it for as well as eating it in solid form it is also possible to drink raw opium dissolved in a variety of liquids. Opium in solution might well have been the first common method of taking it as, before the technique of cutting the pods to allow the sap to ooze out, the whole poppy head was crushed and mixed with wine or honey and water. Such a solution served more than one purpose for raw opium has a bitter taste and eating it neat would not have been easy: indeed, raw opium can induce severe vomiting.

Despite this, it was taken orally in India for over 1500 years, the dictum going that efficacy improved with unpalatability. In 1687, it was recorded the Turks ate opium for pleasure but disguised the bitterness with nutmeg, cardamom, cinnamon or mace and served it with saffron or ambergris. Even then, it was essentially a medicine and regarded as an aphrodisiac. In Europe, opium was mixed with wine or wine and sugar or honey.

Smoking opium was chiefly confined to China, the East Indies, the eastern seaboard of Indo-China (particularly Vietnam) and Taiwan (formerly Formosa). It had to be concentrated before it could be used. A method of preparing opium for smoking was published in the British Pharmacopoeia in the early nineteenth century:

Take of opium in thin slices, 1lb; distilled water 6 pints. Macerate the opium in 2 pints of water for 24 hours, an express the liquor. Reduce the residue of the opium to a uniform pulp, macerate it again in 2 pints of water for 24 hours, and express. Repeat the operation a third time. Mix the liquors, strain through flannel, and evaporate by a water-bath until the extract has acquired a suitable consistence for forming pills.

Once the extract was produced, the opium mass had been reduced by about 50 per cent, the concentration more or less doubled. Known in China as chan du, the pills were round, pea-sized, dark-coloured and stiffly malleable.

A traditional opium pipe was quite unlike that used by tobacco smokers. There were variations but basically it consisted of a broad tube (often made of a length of bamboo about 5 centimetres in diameter and perhaps 50 centimetres long) with a smaller, usually metal, tube protruding about two-thirds of the way down, ending in a tiny cup or bowl up to 2 centimetres across. In typical Chinese pipes, the bowl was a hollow chamber with a tiny hole in the roof.

The would-be smoker reclined on his side and held the pipe in one hand. With the other he took a thin metal spike or needle about 15 centimetres long, impaling the pill of opium on the end. This task of preparing the pill was traditionally carried out in opium dens by small boys who were, on occasion, also catamites. If the pill was too moist, it was dried over the flame of a small, specifically designed spirit lamp which produced a fierce hot spot above a toughened glass cowl. With the desired consistency achieved, the opium was spread around the base of the bowl or placed over the hole of the hollow bowl by inserting the spike into the hole and pulling it free, the index and second fingers of the pipe hand holding it in place. The bowl was then inverted over the spirit lamp until the opium pill melted and began to vaporise. At this moment, the smoker took a very deep breath and sucked air rich with opium fumes through the main tube. Some early Chinese pipes were similar to hookahs, the fumes drawn through water or scented liquid before inhalation.

The action was ideally done in one large inhalation for the opium was quick to vaporise: a pipe took between fifteen and thirty seconds to run its course. The pipe characteristically whistled while the opium was drawn in. As the smoker inhaled, he sometimes manipulated the opium with a needle-like probe to keep an air-hole open and to force the opium into the chamber of the bowl. Unvaporised opium, or vapour which had not been inhaled, solidified on the interior of the pipes: needless to say, old pipes had a value because they were coated with a residue of raw opium which could be recycled. Known as ‚dross‘, it was a mixture of charcoal, empyreumatic oil and opium and was sold as pills to the poor or mixed with tobacco, tea or some other material smoked by them.

The inhaled fumes were retained as long as the smoker could hold his breath, exhalation made only through the nostrils to gain the best advantage of the fumes: what the lungs did not absorb, the nose might take in. A first-time user was usually nauseated by his pipe but this effect passed after two or three further pipes, diminishing with each. Experienced smokers would take three or four pipes in quick succession, a pipe consisting of one pill.

His smoking over, the smoker fell into a deep but not refreshing sleep which could last from fifteen minutes (with one pipe) to several hours. Upon waking, there were no after-effects, such as a hangover. The smoker was subdued and calm, in a state of extreme lassitude.

The habit of reclining to smoke opium had its origins in China but was not essential: it was, however, convenient for the smoker would quickly fall asleep after his pipe, the effects of which were quite rapid. As Jean Cocteau, the French writer and opium addict, observed: ‚Of all drugs „the drug“ is the most delicate. The lungs instantaneously assimilate its smoke. The effect of a pipe is immediate.‘ He called opium ‚the ultimate siesta‘.

The method of smoking opium has not changed and, in the few places were it is still smoked today, such as the Shan states of north-east Burma (now called the Union of Myanmar), China, Laos and Thailand, the technique and paraphernalia survive. Opium smoking is in fact legal in some countries, notably in the Middle East, where it is sold as sticks about the size of a hot dog sausage.

One does not have to be an addict, or an eater or smoker, to come under the effect of opium: passive consumption is possible. Walking through a field of incised pods can induce mild effects and poppy farmers can tell when the time to harvest is nigh because they wake in the morning with severe headaches and even nausea. Harvesters may absorb opium through their skin and excise officers and traders who come into frequent contact with it can also be affected.

Opium is still consumed by the traditional means of eating and smoking in Third World countries, especially in those where it is produced, but in more technologically advanced nations opium is not widely used today. Its derivative, heroin, is the main opiate of addiction and there are several ways in which that drug can be taken. Unlike opium, heroin is rarely swallowed because this is an ineffectual method of consumption but it is frequently smoked, either mixed with tobacco in a hand-rolled reefer or ‚joint‘, or inserted into a cigarette filter tip.

Smoking is, however, a relatively inefficient way of taking heroin and requires a high purity to be effective. The best non-injectable way to use heroin is to sniff it in powder form through the nostrils – a method known as ’snorting‘ – which allows absorption into the bloodstream through the nasal mucous membranes.

The quickest, most effective way to take heroin is to inject it. This requires certain equipment: a cooker (usually a large spoon), a source of flame and a hypodermic syringe. The addict mixes heroin in the spoon with water, or glucose and water, in order to dissolve it. Lemon juice, citric acid or vitamin C may be added to aid dissolving. This cocktail is heated until it boils, drawn into the syringe through a piece of cotton wool or a cigarette filter to remove solid impurities and injected whilst still warm. An addict calls his equipment his ‚works‘ or ‚kit‘.

Subcutaneous injection is known by addicts as ’skin-popping‘, whilst intravenous injection – injecting straight into the vein – is called ‚mainlining.‘ The mainliner also requires a tourniquet of some sort to distend veins. When the tourniquet is released, the effects of the heroin are almost instantaneous. Most heroin is taken by injection: however, since the arrival of AIDS and the risk of cross-infection through shared needles, the habit of smoking and snorting heroin has been on the gradual increase.

Whatever the means of consumption, whatever methods of taking the drug have become tenable or fashionable, the fact remains that, well before man had developed into a civilised, social being, he had discovered the precarious magic of poppy sap

Rationalization and denial are key concepts in addiction treatment. To recover, addicts admit they have rationalized their habit („I use so much less than my friends.“) and denied they have a problem („I can handle it. It’s not affecting my job.“)
Here’s another barrier to recovery from addiction: „I’m too smart for this to become a problem.“

This week’s Journal of the American Medical Assn., contains a sad essay from a medical researcher who made headlines last year when his fiancee, also a medical researcher, died after the two injected themselves with what they thought was the narcotic buprenorphine for kicks.

The author of the essay, Clinton B. McCracken, a former pharmacologist at the University of Maryland, describes how he became a user of marijuana and intravenous opioids (morphine and oxycodone) over a decade while building his career as a successful neuroscientist who studied the effects of drugs on the brain.

He notes that people who work in medicine have addiction rates that are equal to, if not higher than, rates among the public. Drugs are easier to get, McCracken said. But he said an attitude of arrogance led him, as a medical professional, to believe that he could enjoy dangerous drugs and avoid serious consequences. For example, he was careful to schedule his opioid use to prove to himself that he did not need it to get through the day, made sure he was tending to his responsibilities at work and reviewed the criteria for drug dependence to assure himself that he was not an addict.

„By intellectually addressing the official criteria for abuse and dependence, I provided myself with the illusion of total control over the situation and was able to confidently tell myself that no problems existed,“ he wrote in the essay.

His world came crashing down last fall when his fiancee died while injecting Drugs with him. When the police arrived, they discovered McCracken’s Mariuhana plants. He was arrested and jailed, and he later agreed to a plea bargain to avoid more serious charges. Besides losing his girlfriend, he has since lost his career, his reputation and, as a citizen of Canada and convicted felon, he expects to be deported.

Addiction may look different in different people, but it seems that, in the end, everyone, no matter the level of intelligence, looks the same — ruined.

„The transition from my drug use having no apparent negative consequences, to both my personal and professional life being damaged possibly beyond repair, was so fast as to be instantaneous, highlighting the fact that when it comes to drug use, the perception of control is really nothing more than an illusion,“ he wrote.

— Shari Roan
May 20, 2010

Here is the „sad essay“ :

Health care professionals and physicians in particular have rates of substance abuse that are equal to and often exceed those observed in the general public.These estimates may even be low, as many studies rely on self-reported data. Health care professionals presumably use drugs for many of the same reasons as those of the general population.

Nonetheless, given the intelligence, years of education, and high levels of achievement found in this group, the relatively high incidence of substance abuse may be somewhat surprising. Ease of access to drugs is commonly cited, particularly with respect to the high rates of drug abuse among anesthesiologists; however, given the complex nature of addiction, the underlying causes are assuredly myriad.

One possible contributing factor that may receive insufficient attention is the ability of highly educated professionals to intellectualize their drug use, minimizing in their mind the potential disastrous consequences, both personal (eg, the possibility of death or serious harm due to factors such as overdose or toxicity, among others) and professional (ranging from a tarnished reputation to a ruined career). This intellectualization is particularly insidious because due to its very nature, it prevents the person from realizing the scope of the problem, or even admitting a problem exists. Thus, it is related to, yet distinct from, the phenomena of rationalization and denial. Rationalization and denial are universal components of substance abuse and unaffected by education or training.

By contrast, intellectualization actually relies on advanced education and training, particularly with respect to the effects of drugs and addiction, also incorporating confidence in one’s intelligence and abilities, and no small measure of arrogance, to provide the illusion of control or mastery. The end result of this intellectualization is the manifestation of hubris that produces blindness to the devastating consequences of drug abuse and addiction.

Here, I draw on my experience as a drug abuser who for years maintained a relatively successful career as a basic biomedical scientist studying the neuroscience of addiction and compulsion to present a cautionary tale regarding the extreme dangers of intellectualizing drug use. No matter how well versed one may be in pharmacology or the addictive process, the fact remains that severe problems due to drug abuse can arise almost instantly, and no matter how in control one may believe himself to be, these problems can lead to tragic and irreversibly life-altering consequences.

In my case, this intellectualization occurred on three main levels.

The first related to my drug use patterns. I was a daily user of cannabis for most of the past decade, and an intermittent user of opioids, primarily via the intravenous route, for approximately three years. This use occurred while I pursued a career in basic science research, with a heavy focus on addiction. Consequently, I was intimately familiar with the drug abuse literature and psychiatric diagnostic manuals such as the DSM-IV. I was able to finish my doctorate and conduct research at a high level at the same time I was a regular drug user.

Mindful of the DSM-IV criteria for substance abuse and dependence, I was able to rationalize my drug use in a number of different ways, all with the similar end result of deluding myself into thinking I did not have a problem. First among these was that I was able to maintain a high level of professional achievement while using drugs. In addition, I was able to form and maintain a number of fulfilling personal relationships over this time period. As such, I felt that I was not suffering dire consequences in my personal and professional lives. I was able to tell myself that those items on the DSM-IV clearly did not apply to my situation, and hence no problem existed. I used similar reasoning for other items on the DSM-IV checklists for substance abuse and dependence.

I identified my daily marijuana use as „stable“ for some time (ie, years), and I was able to cease use for weeks at a time without any serious difficulty. Thus, any worries of tolerance (ie, increased use over time) or dependence (ie, withdrawal symptoms upon cessation of use) were minimized. With respect to opioids, I was keenly aware of the potential for these drugs to produce tolerance and dependence and thus restricted my use to no more than two consecutive days spaced no closer than 2 or 3 months apart.

By intellectually addressing the official criteria for abuse and dependence, I provided myself with the illusion of total control over the situation and was able to confidently tell myself that no problems existed. This was in spite of the fact that my ongoing drug use was jeopardizing not only my health, but my career.

I was also able to intellectually justify using opioids via the intravenous route. My first experience with opioid medication came after they were prescribed for pain following an injury. I enjoyed the effects and began to seek other sources to attain these drugs. Although I was acutely aware that these drugs had strong potential to cause tolerance and dependence, I was secure in my ability to control the situation. So why inject? I initially began using these drugs via the IV route primarily to maximize bioavailability.

Many opioids, and morphine in particular, possess only a fraction of their IV bioavailability when taken orally. The euphoria due to rapid drug onset via the IV route (ie, the „rush“) was another attractive factor. While I was aware that IV use presented dangers when compared with oral administration, such as increased risk of overdose, infection, or embolism, I was confident that my technical experience (having performed injections into small-animal blood vessels) and access to sterile needles, sterile syringes, sterile saline as a diluent, and alcohol swabs would allow me to circumvent many of the typical problems associated with IV administration. In hindsight, in my overconfidence I minimized one of the key dangers of IV use—the fact that the extremely rapid onset can lead to irreversible effects if things should happen to go wrong.

The final method by which I was able to intellectualize my drug use dealt with the means by which I obtained drugs. I rationalized that small-scale marijuana cultivation was less risky than purchasing it and was associated with a relatively minimal risk of discovery and associated arrest. I obtained opioids (primarily morphine and oxycodone) from an overseas online pharmacy. In addition to less risk of arrest, I made the assumption that dosage would be more consistent and the chance of adulteration much lower than drugs purchased on the street, thus reducing the risk of possible overdose. Furthermore, in the initial stages of opioid use, I proceeded extremely cautiously to ensure the drugs I received from overseas were what they purported to be. After satisfying myself that this was indeed the case, at least at the beginning, I assumed that this form of quality control was no longer necessary.

There were no acute problems stemming from my drug use for approximately three years. My fiancée, a successful scientist in her own right, and with whom virtually all of my intravenous drug use occurred over the previous three years, lost her life after injecting a product that produced severe anaphylaxis, most likely due to some form of contamination. While waiting for the paramedics to arrive I tried unsuccessfully to resuscitate her. Despite heroic efforts, neither the paramedics nor the emergency department physicians were able to revive her.

As a consequence of her death, our house was searched by police, who then discovered the ongoing marijuana cultivation. I was immediately arrested, jailed, and charged with a number of felonies; then, in the space of a few days, my employment as a postdoctoral fellow was summarily terminated and I was evicted from my residence.

The impact of these events on my life has been enormous. First and foremost is the loss of the woman I loved, my best friend and partner, with whom I had planned to spend the rest of my life. Not only were we a team in the sense of personal life, but also professionally. We worked in the same field, attended the same meetings, and were well known as a couple in our part of the scientific community. Thus, my relationship with her came to define all aspects of both my work life and my home life.

Coming to terms with her loss has proven to be extremely challenging and will likely remain so for a long time. While paling completely compared to the loss of my fiancée, I face a number of other consequences. For one, my career as an academic research scientist has been undeniably derailed, if not destroyed. Reputation is critical in my field, and mine is likely to be damaged for the foreseeable future. I originally faced substantial time in prison; I was able to agree to a plea bargain whereby I avoided any additional incarceration. However, I have now been convicted of a felony, which will undoubtedly have a severely negative effect on any future job prospects and international travel. Finally, as a Canadian citizen, my ability to live in, work in, and even visit the United States, my home for the last ten years, is also compromised; I face imminent deportation with almost no hope of reentry in the future.

The transition from my drug use having no apparent negative consequences, to both my personal and professional life being damaged possibly beyond repair, was so fast as to be instantaneous, highlighting the fact that when it comes to drug use, the perception of control is really nothing more than illusion. Had these events not occurred as they did, it is possible, even probable, that my drug use would have escalated until it precluded a normal personal or professional life.

However, it is important to note here that problems associated with drug abuse can arise with devastating effects even in the apparent absence of many diagnostic criteria, such as overt tolerance and dependence.

Neither advanced education nor knowledge of pharmacology nor familiarity with the addictive process was able to prevent tragic consequences for me. It is my sincere hope that my experience may serve as a warning, help illuminate the dangers of intellectualizing drug use and abuse, and prevent similar tragedies in the lives of others.

Additional Contributions: I thank Lawrence R. Fishel, PhD, and Anthony A. Grace, PhD, for their comments and assistance with this article.

Opium as Folk Pharmacopoeia

by Alfred W.. McCoy

Regardless of level of development, most societies have used drugs for religion, recreation, and medicine. Discovered and domesticated during prehistoric times in the Mediterranean basin, opium became a trade item between Cyprus and Egypt sometime in the second millennium B.C.

The drug first appeared in Greek pharmacopoeia during the 5th Century B.C. and in Chinese medical texts during the 8th century A.D. Inferring from such slender evidence, it appears that opium farming first developed in the eastern Mediterranean and spread gradually along Asia’s trade routes to India, reaching China by the eighth century A.D. Once introduced into China, opium gained a significant role in formal pharmacopoeia.

It was not until the 15th Century that residents of Persia and India began consuming opium mixtures as a purely recreational euphoric, a practice that made opium a major item in an expanding intra-Asian trade. Indeed, under the reign of Akbar (1556-1605), the Mughal state of north India relied upon opium land as a significant source of revenue. Although cultivation covered the whole Mughal empire, it was concentrated in two main areas–upriver from Calcutta along the Ganges Valley for Bengal opium and upcountry from Bombay in the west for Malwa opium.

The persistent role of opiates as folk medicine and recreational euphoric for nearly 4,000 years raises very real questions about the enormous difficulties in effecting its eradication. Through interaction with opiate receptors in the brain, opium and heroin may well have an inherent biological logic that makes their mass abuse a likelihood at most times, in most societies, where ample supply of the drug is available. Historically, every society that has been introduced to opium as a commercial euphoric has consumed the entire supply made available to it.


Early European Opium Trade (1640-1773)

The earliest European expeditions to Asia also mark the start of their involvement in the region’s opium trade. As Portuguese captains first ventured across the Indian Ocean during the early 16th century, they realized the potential of opium. If your Highness would believe me, Affonso de Albuquerque, the conqueror of Malacca, wrote to his monarch from India in 1513, I would order poppies…to be sown in all the fields of Portugal and command afyam [opium] to be made…and the laborers would gain much also, and people of India are lost without it, if they do not eat it.. From their ports in western India, the Portuguese began exporting Malwa opium to China, competing aggressively with Indian and Arab merchants who controlled this trade.

Eager for a commodity to barter for Chinese silks, the Portuguese imported tobacco from their Brazilian colony half a world away. Although the Chinese frustrated the Portuguese by growing their own tobacco, the pipe itself, which had been introduced by the Spanish, turned out to be the key to China’s markets. Indian opium, mixed with tobacco and smoked through a pipe, was somehow pleasing to the Chinese palate. By the early 18th century, opium smoking was spreading across China, prompting the empire’s first attempt at suppression in 1729 when the Emperor Yung Cheng issued an edict banning the smoking of opium.

Arriving in Asia a century after the Portuguese, the Dutch soon became active in the region’s opium commerce. Instead of trading directly with China like the Portuguese, the Dutch established a permanent port at Jakarta in 1619 and began purchasing opium from Bengal in 1640 to supply Java’s limited demand. As Dutch colonials won monopoly rights for Java’s populous districts, their Company’s opium imports from India rose dramatically from 617 kilograms in 1660 to 72,280 kilograms only 25 years later.

Dutch profits from the opium trade were spectacular. Buying opium cheap in India and selling high in Java allowed the Company a 400 percent profit on shipments in the 1670s. Opium, moreover, proved to be a key trade good that drew Asian merchants to Jakarta. By 1681, opium represented 34 percent of the cargo on Asian ships sailing out of Jakarta. No longer a lightweight luxury or medical item, opium was on its way to becoming a commodity.

Although the last of the Europeans to enter the trade, it was the British who finally completed the transformation of opium from luxury good into bulk commodity. The British East India Company had acquired coastal enclaves at Calcutta in 1656 and Bombay in 1661, but it did not become a major factor in the opium trade for another century. In the interim, a syndicate of Indian merchants up the Ganges River at Patna held a monopoly over the Bengal opium trade, making cash advances to peasant farmers and selling the processed opium to Dutch, British and French merchants. Marching inland from their port at Calcutta, the British conquered Bengal in 1764 and soon discovered the financial potential of India’s richest opium zone.

In this period, the major change involved a shift from a limited trade in opium though intra-Asian networks to an expanding European commerce that stimulated both supply and demand. In the 16th century and earlier, there had been a pre-existing, modest demand for opium in China and Southeast Asia, and low-level production of opium in India.

Working separately, European mercantile companies commercialized both opium cultivation and commerce, making it the basis of a profitable long distance trade in low-weight, high-value goods. At first, the Portuguese transported Indian opium to China. Then the Spanish developed a way to mix tobacco with opium so it could be smoked. Finally, the Dutch took advantage of this rising demand for opium, but their main market was limited to Java and some re-export to China. Through these European efforts, the problem of opium addiction became so serious in China that the Emperor had it banned in 1729.

The extraordinary profitability of this low-weight, high-value commodity was a key incentive for escalating European involvement in the Asian opium trade. In particular, the Dutch V.O.C. made a 400 percent profit on its 1679 shipments.

Increase/decrease in World Opium Production:

–Dutch East India Company (VOC) imports from India rose at a rate of 1.5 per annum during the 1660s–rising from 0.6 metric tons in 1660 to 72.3 tons only 25 years later.

–In 1699, the Dutch imported 87 tons of Indian opium for distribution to Java and the Indies.

–British exports of Indian opium to China increased from 15 tons in 1720 to 75 tons in 1773.

Changes in Opium Cultivation by Region:

Indian production increased by unknown amounts in response to stimulus of European and Indian opium traders.

Changes in Quantity of Opium Consumption by Region:

For the first time in its history, China experienced a significant, but unquantified, level of mass opium addiction.

Summary and Analysis of Trends within Epoch:

In this period, opium entered a proto-modern phase in which its capacity for growth as a major commodity first became evident. Significantly, European and Indian merchants played a catalytic role in commercializing and expanding the India-China opium trade.

It is during this era that opium’s extraordinarily profitability becomes manifest. Through its peculiar properties, opium is the ideal trade good during this epoch. As an addictive drug, opium requires a daily dose giving it the inelastic demand of a basic foodstuff. Long distance sea-trade in bulk foods was beyond the capacity of current maritime technology, but opium had the low weight and high mark-up of a luxury good like cloves or pepper. In the early modern era, opium combines the reliable demand of a basic food with the logistics of a luxury good. Compounding its profitability, the Chinese emperor reacted to the rise of mass addiction by banning opium and thus denying China the opportunity to produce opium locally to undercut the high price of Indian imports.


European Mercantilism (1773-1858)

The modern era in the global opium trade began in 1773 when the British Governor-General of Bengal established a monopoly on the sale of opium. Over the next 130 years, Britain actively promoted the export of Indian opium, defying Chinese drug laws and fighting two wars to open China’s drug market for its merchants.

Under the British, Indian opium became a major global commodity, giving this modern commerce a scale and organization that distinguishes it from earlier forms. When the East India Company conquered Bengal, it took control of a well-established opium industry involving peasant producers, merchants, and long-distance traders.

In 1773, the British Governor abolished the Indian opium syndicate at Patna and established a colonial monopoly on principles that operated for the next half-century. Under the new regulations, the Company had the exclusive right to purchase opium from Bengal’s farmers and auction it for export. Realizing that opium was illegal in China, the Governor barred the Company’s ships that called at Canton to load tea from carrying opium, leaving actual sale of the addictive drug to the private European merchants who bid at the Company’s Calcutta auctions.

In 1797 the Company eliminated the local opium buyers in Bengal and established a system of direct collection that lasted for over a century. Under the new procedures, the Company, and the colonial state that succeeded it, controlled opium cultivation, processing, and export. At its peak in the late 19th century, Bengal’s opium country stretched for 500 miles across the Ganges River Valley, with over a million registered farmers growing poppy plants exclusively for the company on some 500,000 acres of prime land.

From their factories at Patna and Benares in the heart of opium country, senior British officers directed some 2,000 Indian agents who circulated through the poppy districts, extending credit and collecting opium. Processed under strict supervision at the two Company factories, the opium was packed into wooden chests, each containing forty balls and weighing 140 pounds. Bearing the Patna and Benares trade-marks, the chests were sent down to Calcutta under guard and sold at auction to private British merchants.

Since the Chinese state had damned opium as a destructive and ensnaring vice and banned all imports in 1799, British sea captains bribed Canton’s mandarins and smuggled the chests into southern China where the Bengal brands commanded twice the price of the inferior local products. For its first quarter century, this system assured prosperity for British India and a stable opium supply for China. Not only did opium solve the fiscal crisis that accompanied the British conquest of Bengal, it remained a staple of colonial finances, providing from six to fifteen percent of British India’s tax revenues during the 19th Century.

More importantly, opium exports were an essential component of a triangular trade that was central to England’s position as a world power. Trade figures for the 1820s, for example, show that the triangular trade was large and well balanced: 22 million pounds sterling worth of Indian opium and cotton to China; next, 20 million pounds worth of Chinese tea to Britain; and, then, 24 million pounds of British textiles and machinery back to India.

In managing this trade, the Company prized stability above profit, and for over twenty years it held India’s opium exports at 4,000 chests–or 280 tons, just enough to finance its purchase of China’s tea crop.

The system’s success was the cause of its downfall. The vast profits of the Britain’s opium trade attracted competitors. Moreover, the Company’s steadfast refusal to raise Bengal’s opium exports beyond the quota of 4,000 chests per annum left a vast unmet demand for drugs among China’s swelling population of opium smokers. As demand drove the price per chest upward from 415 rupees in 1799 to 2,428 rupees just 15 years later, the Company’s monopoly on Bengal opium faced strong competition from Turkey and west India.

Britain’s most daring rivals were the Americans. Barred from bidding at the Calcutta auctions, Yankee traders loaded their first cargoes of Turkish opium at Smyrna in 1805 and sailed them around the tip of Africa to China. Through these efforts, Turkish opium remained an alternative to the Bengal brands until 1834 when the Yankee captains were finally allowed to bid at the Calcutta auctions and abandoned the long haul around Africa.

The major threat to the Company’s monopoly, however, came from Malwa opium grown in the princely states of west India. Malwa opium captured 40 percent of the China market by 1811. Determined to defend their trade, the Company’s directors decided to promote unlimited production in Bengal. In 1831 the Governor-General of India, Lord William Bentinck, toured the upper Ganges with revenue officers to explore new areas for poppy farming and within the decade cultivation doubled to 176,000 acres.

After the East India Company lost its charter in 1834, its informal regulation of the China opium trade collapsed, allowing profit-hungry American and British captains to take control. Indeed, the Company’s demise launched a fleet of new opium clippers to tack to China against the monsoon winds. As the Company loosened its restrictions in the 1820s and then lost its monopoly in 1834, China’s opium imports increased nearly ten fold–from 270 tons in 1820 to 2,558 tons twenty years later. Opium addiction spread rapidly, reaching some three million Chinese addicts by the 1830s.

In defense of its commerce, Britain fought two wars along the China coast in 1842 and 1858, forcing the empire to open itself to unrestricted opium imports. In 1838, the Emperor’s launched a moralistic anti-opium campaign that threatened Britain’s China trade, and London dispatched a fleet of six warships, capturing Canton in May 1839. The First Opium war ended in 1842 with the Treaty of Nanking which required China to cede Hong Kong, and open five new ports to foreign trade. But China still refused to legalize opium.

The fifteen years following the First Opium War brought a new peak in the China trade. Illicit imports of Indian opium nearly doubled, rising to 4,810 tons in 1858. At the Calcutta auctions, frenzied bidding drove opium prices and profits to new heights, making a fast run to the China coast essential and launching 48 new clippers for the opium fleet. Among the 95 clippers in the fleet, the Calcutta’s Cowasjee family owned six, the Americans of Russell & Co. had eight, and the British giants, Dent and Jardine, operated a total of 27.

The era of the opium clipper ended when China finally legalized the drug trade after its defeat in the Second Opium War (1856-1858). In negotiations over the tariff provisions of this new treaty that ended the war, the British emissary Lord Elgin forced the Chinese to legalize opium imports.

In the aftermath of legalization, Chinese officials began encouraging local production, and poppy cultivation spread beyond the country’s southwest. As addiction spread throughout China, imports of Indian opium rose from 4,800 tons in 1859 to 6,700 tons twenty years later. After peaking in 1880, Indian imports declined slowly for the rest of the century as cheaper, China-grown opium began to supplant the high-grade Bengal brands.

Demand Increasing Ahead of Production:

It appears that opium, once commercialized as recreational euphoric, produces a disproportionate demand that soon exceeds the original supply. In this case, the carefully controlled number of chests from Bengal soon proved insufficient for the demand in China. The result was stimulation of production in other opium regions.

Thus, Malwa and Turkish production increased to help meet China’s growing demand. In the end, England capitulated to market pressures, abandoned its self-imposed restraint, and encouraged an expansion of opium production in India.

Once introduced, commercial opium stimulated demand in China beyond supply, encouraging thereby increased cultivation back in India; which, in turn, stimulated more demand in China, sparking, yet again, higher poppy plantings in India. In effect, even in this earliest era of commoditized opium trading, demand and supply increase through a process of reciprocal stimulation that makes it difficult, analytically, to determine which is the dominant cause.

During the 18th and 19th Centuries, China had a limitless capacity for opium consumption that continually outstripped all production, both local and global.

Changes in Shipping Technology:

Since there was now an unlimited amount of opium that could be grown in India, improvements in shipping technology were needed to move greater amounts to China. Hence, a competition and the appearance of the clipper ship. Speed now determined profitability in the opium trade.

Chinese Government Policy:

The Chinese Imperial decrees of 1729 and 1799 banning opium smoking and importation did not restrain the rising addiction problem. However, the legalization of opium consumption in 1858 encouraged a sharp rise in both production and consumption. With legalization, domestic opium superseded imports, making speed less important in the shipping of opium and allowing steamships to replace the clippers.

Thus, we must conclude that China’s policy of prohibiting opium consumption and cultivation from 1729 to 1858 assured the East India Company a de facto monopoly over this fast growing market and created the basic underlying conditions for the hyper profitability of the India-China opium trade.

Without this prohibition on cultivation, China could have reacted the Company’s aggressive exports of Bengal opium by encouraging local opium harvests and destroying both market and profits for the Indian imports. As it was, China’s addicts and their near insatiable demand for the illicit drug created high profits and inspired ferocious competition among merchant captains competing for a share of this lucrative market–English out of Calcutta, Indian and English out of Bombay, and Americans out of Smyrna, Turkey.

Nature of Chinese Demand:

In the midst of the acute demographic and caloric crisis of southeastern China in the late 18th and early 19th Centuries, opium attributes as a appetite suppressant may have increased its appeal to users at a time of scarcity and high food prices. At certain periods, the use of opium may have suppressed appetite sufficiently to make its addiction economical in comparison to the cost of eating a normal diet.

Economics of European Mercantilism:

In colonial Asia of this period (1773-1858), all successful European economic initiatives involved commercialization of drugs in some form–caffeine, nicotine, or opiates. This 18th century trade transformed these drugs from luxury goods into commodities of mass consumption, making them integral to the economies and lifestyles of both Asian and Atlantic nations.

In Java after 1720, the Dutch V.O.C. collected a tax in coffee in the Priangen region of west Java and made vast profits through sales in Europe and America, becoming the globe’s greatest coffee broker and gaining thereby a substitute for its substantial share of the China opium trade lost to Britain after 1720.

Consciously imitating the V.O.C., Bourbon Spanish reformers in Manila established the Tobacco Monopoly in the 1782 and, for the next century, financed their colonial administration from their exclusive control over the cultivation and sale of this addictive drug to Filipinos.

In Bengal, the British East India Company imposed a monopoly over opium in 1773 and used its sale to China to finance purchase of caffeine, in the form of tea, for export to Europe and North America. Within the monopolistic logic of mercantilism, the East India Company achieved the highest profits from opium because, from 1773 to 1830, its strong controls over key aspects–production, export, and sales.

Increase/decrease in World Opium Production:

–The area under cultivation in Bengal, India increased from 90,000 acres in 1830, to 176,000 by 1840, and, finally, a peak of 500,000 acres by 1900.

Changes in Opium Cultivation by Region:

–Reflecting directly increases in production, Indian opium exports to China rose from 75 tons in 1773 to 4,810 tons in 1858–a sustained, high-level of growth over the space of 75 years.

–Again reflecting increases in production, Turkish exports to China increased from 7 tons in 1805 to 100 tons in 1830–creating another instance of steady, high-level growth in production over a protracted period.

Changes in Quantity of Opium Consumption by Region:

–Rising from insignificant levels in the early 1700s, by the 1830s China had an estimated 3 million opium smokers.

–US imports of opium rose 8 tons in 1840 to 62.7 tons in 1858.

Summary and Analysis of Trends within Epoch:

From the late 18th century onward, opium became a major trade commodity. Under the British East India Company (BEIC), centralized controls accelerated the export of Indian opium to China–from 13 tons in 1729 to and 2,558 tons in 1839. Using its full military and mercantile power, Britain played a central role in making China a lucrative drug market.

The Company’s steadfast refusal to raise Bengal’s opium exports beyond its self-imposed quota of 4,000 chests per annum left a vast unmet demand for drugs among China’s swelling population of opium smokers. When demand drove the price per chest upward from 415 rupees in 1799 to 2,428 rupees just 15 years later, the East India Company’s monopoly on Bengal opium faced competition from Turkey and west India.

As the Company loosened its restrictions in the 1820s and then lost its monopoly in 1834, China’s opium imports increased nearly ten fold–from 270 tons in 1820 to 2,558 tons twenty years later. Opium addiction grew rapidly, reaching some three million Chinese addicts by the 1830s. Simultaneously, China’s illicit imports of Indian opium nearly doubled, rising to 4,810 tons in 1858.


Joshua Foust is an American military analyst. He blogs about Central Asia and Afghanistan at Registan.net . Reuters is not responsible for the content – the views are the author’s alone.

It would be an understatement to call opium cultivation in Afghanistan America’s headache. The issue of illegal drug cultivation and smuggling has vexed policymakers for three decades, and led to a multi-billion dollar campaign to combat the phenomenon.

Opium causes all of our problems, so they say—according to  a factsheet at the U.S. Embassy in Kabul (pdf), opium creates instability, funds the insurgency, and wreaks havoc on the government. They’re not alone –  entire books have been written on the subject.

The blame game on opium, however, ignores a critical – and quite uncomfortable – fact: it misses the point. The reality is, while the cultivation of opium does not help matters from a Western perspective, in Afghanistan it is actually a healthy economic activity. The concerns over its cultivation, too, are overblown: even a brief look at the numbers show it to be at best a trailing indicator of insecurity, insurgency, corruption, and economic malaise. Opium, therefore, is only an indicator of other, more substantial problems.

Consider, for example, what I call The Nangarhar Swing. According to the United Nations Office of Drugs and Crime, in 2005 Nangarhar produced nearly 1/5 of Afghanistan’s opium, but was virtually poppy-free in 2006.  2007 saw a 285 percent increase (pdf) in cultivation, making the province one of the country’s top poppy producers. Yet in 2008, it was  once again virtually poppy-free (pdf). This shift cannot be tied only to security, as many like to claim: according to the violence statistics compiled by the Long War Journal, even as Nangarhar has stopped the large scale cultivation of opium, it has become steadily more violent. Moreover, there are many other areas of the country, like Khost province along the border with Pakistan, or Kunar province further north, where the insurgency has become worse even as those provinces were emptied of opium.

The discrepancy is really a trick of language: When the UNODC declares a province poppy-free, what they mean is, production there is “negligible”, not non-existent. Whether that is in the context of total production, other provinces, or some sort of absolute number (a percentage of arable land or total worldwide opium production) isn’t really clear. In Nangarhar, several times declared “poppy free” by the UNODC, there remain active opium eradication missions in outlying districts such as Sherzad. What’s noteworthy about it is not the presence of some fairly smallish opium farms in southwestern Nangarhar, as most opium farms are small family affairs. What is interesting is the density of the farms. In a single 5 km stretch of the countryside, teams found and destroyed 100 poppy fields. For a supposedly poppy-free province, that is simply stunning.

It also covers up the substantial effect of destroying the opium economy. In many parts of Afghanistan, opium is the economy, and the World Bank estimated in 2008 it accounts for 1/3 of the country’s economy. In opium-adjacent communities, opium funds underpin the entire local economy: especially in the opium “heartland” in the South, the only way for small farmers to get microcredit loans or deal with exporters is through opium traders. Through a system of loans called salaam, they in essence create informal futures markets on crops… but only opium. Cereal crops and fruits, or other licit agriculture, are not included in this system (even though it is possible for other actors, whether the government or NGOs, to provide this service). In fact, the ways these markets have developed in the south is remarkably similar to how informal credit markets formed in rural medieval Europe. It is normal. The West just happens to dislike the crop.

But even in opium “success stories”, there are significant problems to simply removing the crop. In Nangarhar, the wild swings in opium prices and cultivation crashed the rural economy again and again. Most of the microcredit salaam loans farmers take out are not denominated in any currency – they pay in opium. So, when prices crash or an eradication team sweeps through, farmers become trapped in a horrendous debt cycle where the only means of escape is to grow yet more opium. There are even rumors of farmers selling a daughter or son to the traffickers in payment, and many families have fled to either Iran or Pakistan to avoid reprisals for unpaid opium debt.

There is a more fundamental economic problem to growing poppy, however: areas that grow opium actually tend to be the wealthiest. Sherzad District in Nangarhar, where there is still opium cultivation and eradication, actually has relatively high income compared to the rest of Nangarhar.  According to the International Monetary Fund (pdf), when Nangarhar province saw a huge drop in opium cultivation in 2005/6, province-wide GDP was about $1.3 billion (which was a big drop from the year before, when there was much more opium). The next year, 2006/7, when opium production spiked 285%, province-level GDP rose to $3.2 billion, only to fall the next year to $1.8 billion as the UNODC declared it poppy-free.

So what is to be done? The Obama administration has wisely recognized that opium eradication is a non-starter, and does far more harm than the marginal good of destroying some opium crops. UNODC Chief Antonio Maria Costa recently agreed, and suggested a “flood of drugs” in its place. Under this plan, somehow the borders of Afghanistan would be sealed so that no drugs can “escape”, in their words, thus crashing the price of opium. Feasible or not, Costa’s idea at least tries to examine other ways of reducing the need for opium cultivation. Looking at opium cultivation as an economic factor, however, leads one to many other conclusions that are inconvenient for a political and military apparatus designed to oppose the very idea of drug cultivation.

If opium is an economic puzzle, and not a political-military one, then there should be an economic (or at least non-military) solution to it. Several years ago, the Afghan Research and Evaluation Unit published a study (pdf) comparing the factors behind the cultivation of opium in adjacent provinces in the “poppy-free” north. Water shortages, soil moisture and salinity, severe socioeconomic inequality driving food insecurity, a poor presence of formal institutions, all have decisive impacts on a household decision whether or not to cultivate opium.

More recently, a team of Norwegian researchers has noted a strong causation between violence and opium cultivation, but not in the way most think:  in their research paper (pdf), they assert that opium follows conflict, and not the other way around. In other words, opium cultivation is simply a feature of ungoverned conflict zones, and especially in Afghanistan, something people do as a last resort when other economic activities fail to provide for their families.

Taken together, these studies (and the many others like them—this is a growing field of study) point to a counterintuitive conclusion: do nothing. That is, focusing only on opium misses the point, and doesn’t address the reasons why it is grown. If opium cultivation were an indicator of an ungoverned or contested space, then that would indicate that making that space governed and uncontested would also address the opium.

There are a few examples even within Afghanistan where governance and security came first, and then opium cultivation simply dropped off. Badakhshan province was the only province in the country that was completely Taliban-free in 2001, and as a result was the only one to grow opium in any really measurable amount during the Taliban’s prohibition. Since the American invasion, it has remained mostly quiet, and has seen a growing success in both trade connections to neighboring areas and better governance by multiple levels of officials. As an aid worker active there told me recently, “the price of poppy has fallen fastest in the north (where the poppy has a lower morphine content), and in Badakhshan, farmers can already make more from okra or onions than opium.” Selling vegetables is relatively low risk and carries a good profit margin – something that cannot be said for the majority of Afghanistan’s non-subsistence farmers.

Drug traffickers have taken enormous measures to lower the risk of drug cultivation, but the development community has not taken the time to do so for legal agriculture. It remains prohibitively expensive to ship anything out of Afghanistan, and border politics especially with Pakistan (one worker recently complained that difficulties in crossing the border into Pakistan meant an entire crop of potatoes from Khost province rotted at the border crossing, unsold) keep export-driven agriculture uncertain and extremely risky. By focusing so much of its energies onto eradication or somehow controlling the cultivation of opium, both the International Community and the government of Afghanistan have ignored providing other ways for farmers to make money legally – even when Alternative Livelihood programs exist in an area, they’re poorly administered and often barely make a dent in the local economy.

So why not do nothing? Opium is not Afghanistan’s biggest problem – it is horrendous poverty, bad infrastructure and no security. When it comes to all three problems, Afghanistan faces two major hurdles – underinvestment (money, equipment, education, health, and security) and corruption-driven illegitimacy. Making matters worse, the overwhelming majority of aid in the country flows outside government channels or oversight, which undercuts Kabul’s legitimacy even among the people it helps.

Focusing only on opium, therefore, doesn’t actually focus on the more fundamental problems facing the country. It is an obsession on symptoms, while the causes go unaddressed. The missing piece of governance, and with it the development of the necessary institutions of society and economy, is the critically ignored piece of almost all plans to eliminate opium in Afghanistan. And as examples like Badakhshan have shown, when even moderate progress is made on these fronts, people will voluntarily switch to growing other crops, and they will make enough money to support themselves. It’s enough to make one wonder just why there needs to be a plan in the first place. It’s counterintuitive, but scrapping the West’s counternarcotics policies is surest way to actually achieve the counternarcotics goal of a poppy-free Afghanistan.

(Reuters photos: Opium fields in Farah province/Goran Tomasevic)

Auf angemessene Behandlung haben Schmerzpatienten einen klaren Anspruch. Ärzte befürchten jetzt, dass eine neue medizinische Leitlinie ihre Arbeit erschweren könnte.

29. März 2010

Schmerzpatienten müssen geduldig sein. Oft vergehen leidvolle Jahre mit einer Odyssee von Arzt zu Arzt, bis sie endlich eine angemessene Behandlung erfahren. Aber auch die Geduld von Schmerztherapeuten wird strapaziert. Nachdem Pioniere wie Thomas Flöter in Frankfurt am Main und Dietrich Jungck in Hamburg vor fast dreißig Jahren die ersten kassenärztlichen Praxen für Schmerztherapie eröffnet hatten, war es noch ein steiniger Weg zu der Einsicht in der Ärzteschaft, dass Schmerz als eigenständige Krankheit auftreten kann.

Nun sehen Schmerztherapeuten neues Unheil heraufziehen. Anlass ist eine im vergangenen Herbst vorgelegte Leitlinie mit dem Kürzel „Lonts“, in der die Langzeit-Anwendung von Opioiden bei nicht tumorbedingten Schmerzen in Frage gestellt wird. „Über drei Monate hinausgehende Daueranwendungen opioidhaltiger Analgetika haben keine nachgewiesenen anhaltenden Schmerzlinderungen erbracht“, lautet eine der Schlussfolgerungen. Auf dem Deutschen Schmerz- und Palliativtag vergangene Woche in Frankfurt am Main sorgte dieses Papier für Empörung. Man ging mit ihm hart ins Gericht.

Vor gar nicht langer Zeit herrschte unter Ärzten noch die Ansicht vor, Schmerzen seien stets eine Begleiterscheinung von „echten“ Erkrankungen. Die Schmerzbekämpfung galt gewissermaßen als Nebentätigkeit des jeweiligen Facharztes. Rückenschmerzen etwa fielen klar in die Zuständigkeit des Orthopäden. Besondere Kenntnisse schienen nicht nötig zu sein: bei leichten Beschwerden ein leichtes Mittel wie Paracetamol, bei starken Leiden notfalls ein Opioid.

Sind die Studien tatsächlich aussagekräftig?

Unermüdlich haben Ärzte, die über Erfahrung in spezieller Schmerztherapie verfügen, mit wissenschaftlicher Unterstützung gegen dieses Schubladendenken angekämpft – mit Erfolg. Inzwischen orientieren sich informierte Therapeuten nicht mehr nur an der Stärke des Schmerzes, sondern vor allem an den von Patient zu Patient oft recht unterschiedlichen Mechanismen. So kann es angebracht sein, das Stufenschema auf den Kopf zu stellen und auch bei nicht tumorbedingten Schmerzen gleich ein Opioid anzuwenden, damit die Beschwerden nicht chronisch werden. Chronischer Schmerz kann sogar Hirnstrukturen verändern und ist schwer auszulöschen. Soeben ist in den „Proceedings“ der amerikanischen Nationalen Akademie der Wissenschaften (doi: 10.1073/pnas.1001504107) der Bericht einer finnischen Forschergruppe um Sanna Malinen erschienen, dem zufolge chronischer Schmerz auch bei ruhenden Patienten mit einem auffälligen Aktivitätsmuster im Gehirn einhergeht.

Ungezählte Patienten mit chronischen Schmerzen haben von der dauerhaften Opioidanwendung schon profitiert. Diesen Erfolg sehen viele Therapeuten durch die neue Leitlinie gefährdet, und entsprechend harsch fiel die Kritik aus. Der Psychologe Hardo Sorgatz von der Technischen Universität Darmstadt, unter dessen Leitung „Lonts“ im Auftrag der Deutschen Gesellschaft zum Studium des Schmerzes erarbeitet wurde, versuchte in Frankfurt einen verbalen Präventivschlag zur Verteidigung der Leitlinie. Diese genüge strengsten methodischen Kriterien und beruhe ausschließlich auf den Ergebnissen der wissenschaftlich aussagekräftigsten Studien. Doch Michael Überall vom Nürnberger Institut für Qualitätssicherung in Schmerztherapie und Palliativmedizin förderte hinter der Glanzfassade des Wissenschaftsgebäudes etliche Risse zutage. Er attestierte „massive methodische Schwächen bei der Analyse von wissenschaftlichen Studien“, die „zu falschen Schlussfolgerungen für die Langzeit-Therapie mit Opioiden“ führten.

Das Grundrecht auf Behandlung

Aufwendige Studien zur Wirkung von Opioiden und anderen Schmerzmitteln stammen häufig aus den Zulassungsverfahren für neue Medikamente. Diese erstrecken sich aber kaum über mehr als drei Monate, so dass man ihnen tatsächlich nichts über eine längere Anwendungsdauer entnehmen kann. Für den Präsidenten der Deutschen Gesellschaft für Schmerztherapie, Gerhard Müller-Schwefe aus Göppingen, steht der Nutzen für viele Patienten gleichwohl außer Frage. Nur lässt er sich schwer wissenschaftlich dokumentieren, denn dazu müsste man einigen Patienten die Opioide vorenthalten, was ethisch kaum zu rechtfertigen wäre.

So hilfreich Opioide sind – sie bergen auch Risiken. Das zeigt sich an der sogenannten Hyperalgesie, dem Phänomen, dass nach einiger Zeit die Schmerzempfindung sogar verstärkt werden kann. Gefördert wird dieser Effekt durch einen abrupten Entzug. Eine Gruppe um Jürgen Sandkühler von der Medizinischen Universität Wien hat herausgefunden, dass hierbei Kalzium-Ionen über bestimmte Rezeptorkanäle in die Nervenzellen der Schmerzbahn im Rückenmark strömen. Möglicherweise verursachen auch starke Schwankungen des Opioidspiegels während der Therapie eine Hyperalgesie. „Darum ist der Einsatz retardierter Darreichungsformen, die den Wirkstoff gleichmäßig über einen längeren Zeitraum abgeben, besonders wichtig“, sagte Sandkühler.

Patienten, die wegen Schmerzen in die Sprechstunde kommen, haben mehr Rechte, als sie und die Ärzte oft glauben. Darauf wies Klaus Kutzer, ehemals Vorsitzender Richter am Bundesgerichtshof, in Frankfurt hin. Er verdeutlichte, „dass es ein allgemeines Menschenrecht ist, von Schmerzen befreit zu werden und, wo dies nicht möglich ist, Schmerzlinderung zu erfahren“. Zudem gebe es hierzulande ein Grundrecht auf eine entsprechende Behandlung. Unter Bezug auf das jüngste Urteil zur Sicherung des Existenzminimums von Hartz-IV- Empfängern sagte Kutzer, die Bekämpfung schwerer Schmerzen sei „genauso ein Aspekt des menschenwürdigen Existenzminimums wie der Erhalt der zum Lebensunterhalt benötigten Geldmittel“. Unterlassene Schmerztherapie könne sogar Körperverletzung sein, denn „das Unterlassen ist dem Tun gleichzustellen, wenn die Pflicht besteht, Schmerzen zu beseitigen“.

Eine Vorreiterrolle beim konsequenten Schmerzmanagement will jetzt die Stadt Münster einnehmen. Dort wurde an diesem Dienstag ein Forschungsvorhaben der Paracelsus Medizinischen Privatuniversität Salzburg vorgestellt, das auf die umfassende Dokumentation und Verbesserung der stationären sowie ambulanten Versorgung zielt. Das Projekt „Aktionsbündnis Schmerzfreie Stadt Münster“ ist auf drei Jahre angelegt.

Text: F.A.Z.
Bildmaterial: Mark Nesbitt and Delwen Samuel, 1988

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Wie stellt sich die aktuelle Situation der Substitutionsbehandlung in Österreich dar? Im Rahmen einer umfangreichen Querschnittstudie erörterten Univ.Prof. Dr. Alfred Springer, Pionier der österreichischen Suchtforschung, und Dr. Alfred Uhl, Koordinator des Forschungsbereiches „Epidemiologie / Sozialwissenschaften“ sowie des Bereiches „Suchtpräventionsdokumentation – Alkohol“ am Anton Proksch Institut (API) in Wien, Themen wie das Ausbildungsniveau und die Arbeitsweise der Ärzte, die Zufriedenheit der Patienten sowie die Bewertung der verschiedenen Substanzen, die für die Substitution zur Verfügung stehen. Die Daten repräsentieren signifikant die Situation des Landes: Die Ergebnisse beruhen auf den Aussagen von etwa zwei Drittel der gesamten Substitutionspatienten in Österreich. Im Gespräch mit drogensubstitution.at bietet Alfred Springer Einblick in die wichtigsten Erkenntnisse der Studie.

Wie steht es aktuell um die Substitutionsbehandlung in Österreich?

Springer: Im Großen und Ganzen lässt sich aus der Studie ableiten, dass die Substitutionsbehandlung sowohl aus der Sicht der Ärzte wie auch der Patienten recht gut und zufriedenstellend funktioniert. Allerdings konnte keine Information darüber gewonnen werden, in wie viel Fällen die Substitution nicht angenommen wurde oder abgebrochen wurde. Die zur Verfügung stehenden Mittel werden differenziert und diversifiziert eingesetzt, wobei im Zeitraum in dem die Untersuchung stattfand, bereits die Verschreibungsregeln der neuen Substitutionsverordnung umgesetzt wurden.

Welche Substanz wurde am häufigsten verschrieben?

Springer: Die zumeist verschriebenen Substanzen waren Morphinzubereitungen mit verzögerter Freisetzung der Wirksubstanz gefolgt von Methadon und Buprenorphin. Die Morphinpräparate wurden sowohl von den Ärzten wie auch den Patienten am positivsten bewertet. Allerdings wurde ihnen von den Ärzten ein relativ hohes Missbrauchspotential zugeordnet. Das geringste derartige Risiko wurde dem Buprenorphin zugeschrieben. Methadon schnitt sowohl in der Bewertung durch die Patienten wie auch durch die Ärzte am schlechtesten ab.

Unter welchen Bedingungen wurde welche Substanz eingesetzt?

Springer: Die positiven Bewertungen ergaben ein differenziertes Bild. Die Ärzte gaben an, dass sie das Morphin insbesondere bei somatisch kranken Patienten, schweren psychischen Komorbiditäten und langer Substitutionsdauer bevorzugten, während das Buprenorphin vorrangig jüngeren Patienten mit relativ kurzer Suchtanamnese verordnet wurde. Auffallend war, dass Methadon überzufällig häufig in niedriger Dosierung verschrieben wurde. Die Bedingung einer täglich oder mehrmals wöchentlich kontrollierten Einnahme wurde am häufigsten im Falle der Morphin-Verschreibungen umgesetzt.

Welche Kritik üben die Patienten?

Springer: Kritik wurde von den Patienten hauptsächlich an den Mitgaberegeln geäußert, wobei diese Kritik auch in der Bewertung der Substanz Niederschlag fand. Der Wunsch nach Umstellung des Mittels wurde am häufigsten von Methadon-Substituierten geäußert, am seltensten von den Morphin-Klienten.

Was bedeuten die Ergebnisse für die Praxis der Substitutionsbehandlung?

Springer: Wie auch aus internationalen Studien bekannt ist, funktioniert die Substitutionsbehandlung besser, wenn nur solche Regeln den Behandlungsablauf beeinflussen, die sowohl für den Arzt wie für die Patienten verständlich und notwendig sind. Auch unsere Ergebnisse sprechen dafür, dass eine patientengerechte Dosierung und eine minimal beschränkende Mitgaberegelung zu höherer Patientenzufriedenheit führen und damit sicherlich auch zu besserer Compliance beitragen. Aufklärungsbedarf besteht, warum Methadon so häufig in niedriger Dosierung (eventuell sogar unterdosiert) verschrieben wird. Eine Begriffsklärung scheint notwendig, was für Ärzte als „Missbrauchspotential“ bedeutet. Wird darunter lediglich die Bereitschaft zu verschreibungswidrigem intravenösem Gebrauch verstanden, oder gibt es weitergehende ordnungs- und sicherheitspolitische Bedenken? Ohne eine derartige Begriffsklärung wird man wohl kaum zu Maßnahmen gelangen, die eine Optimierung der Situation versprechen.

Im Gegensatz zu Morphin retard und Buprenorphin schneidet Methadon in der Bewertung sowohl bei den Ärzten, als auch bei den Patienten schlechter ab.

Springer: Methadon schneidet in der Bewertung schlechter ab, allerdings sind die Unterschiede auch wieder nicht so gravierend, weil die Zufriedenheit mit der Substitutionsbehandlung auch bei Methadonklienten überwiegt. Überhaupt sollte man dieses Phänomen differenziert und nicht auf Substanzniveau allein beschränkt untersuchen. Die Bewertung einer Substanz hängt nicht nur von ihren pharmakologischen Eigenschaften ab, sondern ist weitgehend auch von den Bedingungen ihrer Abgabe und anderen sozialen und psychologischen Faktoren mitbestimmt.

Was kann die Politik in Hinsicht auf das aktuelle Suchtmittelgesetz daraus lernen?

Springer: Für die politische Bewertung ist sicher wichtig, dass sich erweist, dass die Ärzte differenziert und problembewusst handeln. Die neu geschaffenen Konditionen und Restriktionen haben gegriffen, allerdings leider nicht nur zu den erwünschten Ergebnissen geführt. Insbesondere ist der Beigebrauch nicht unter Kontrolle gebracht worden und scheint insbesondere bei Methadonklienten eine recht hohe Bereitschaft zu bestehen, andere Opioide, die illegal erworben werden, zu gebrauchen. Genauere Forschung müsste sich der Frage widmen, ob diese Bereitschaft auch etwas mit der Zubereitung der Substanz zu tun hat. Zu hinterfragen ist auch, ob die Erschwerung, Methadon intravenös zu gebrauchen, dazu führt, dass andere Substanzen für den intravenösen Gebrauch erworben werden. Dieser Missbrauchssituation kann offenkundig weder durch Verbote noch durch restriktive Verschreibung und der Forderung nach Weiterbildung des Arztes wirksam begegnet werden.

Auf jeden Fall sprechen die Ergebnisse dafür, dass eine hohe Kompetenz der substituierenden Ärzte besteht, die Behandlungsmethode gut etabliert ist und von jener Klientel, die sich mit den Bedingungen, unter denen sie umgesetzt wird, abfindet, gut angenommen wird. In  der Zukunft  sollte dafür gesorgt werden, dass die Kompetenz genutzt wird und dass die drogenpolitische Regulierung den Zugang zur Substitutionsbehandlung erleichtert. Es sollte ein flächendeckendes Angebot ermöglicht werden, das auch für jene Teilpopulation der Morphinabhängigen attraktiv ist, die bis jetzt nicht den Zugang zu dieser Versorgung gefunden hat.

Herzlichen Dank für das Gespräch.

Die Studie zum Downloaden: (PDF, Querschnittstudie)

source: http://www.drogensubstitution.at/expertenmeinung/aktuelle-situation-der-substitutionsbehandlung-in-oesterreich-eine-querschnittstudie.htm

von Hans Cousto

Erstmals haben Forschende der Schweizerischen HIV-Kohortenstudie auf molekularer Ebene rekonstruiert, wie sich der AIDS-Erreger HIV in den letzten 30 Jahren in der Schweiz ausgebreitet hat. Die Daten zeigen, dass die 1986 eingeführte Abgabe von sterilen Spritzen an Drogenabhängige auch viele Menschen vor der Krankheit bewahrt hat, die keine Drogen konsumiert haben. Eine Botschaft, die insbesondere auch für Länder wichtig ist, wo die Abgabe von sterilen Spritzen noch nicht eingeführt ist und für Länder wie u.a. Deutschland, wo in Justizvollzugsanstalten Spritzenautomaten wieder entfernt wurden. Spritzenaustauschprogramme schützten also die gesamte Gesellschaft. Dies ist eine international wichtige Botschaft. Denn obwohl Spritzenabgabe-Programme weltweit inzwischen in 77 Ländern vorhanden sind, bleibt sie in vielen Ländern umstritten und wurde etwa in Island, in der Türkei und im Kosovo immer noch nicht eingeführt. Zudem muss hier bedacht werden, dass auch Hepatitis durch unsauberes Spritzbesteck übertragen wird und in Gefängnispopulationen Hepatitis C um ein vielfaches mehr verbreitet ist als im Durchschnitt der Bevölkerung.

Im Widerspruch zu jeder Vernunft durften in Zürich bis September 1986 keine Spritzen an Heroinabhängige abgegeben werden. Im Jahr 1985 drohte der damals noch amtierende Kantonsarzt Gonzague Kistler, unterstützt vom kantonalen Gesundheitsdirektor Peter Wiederkehr, Ärzten und Apothekern mit „patentrechtlichen Maßnahmen bis hin zum Bewilligungsentzug“, falls sie sich nicht an das Verbot der Spritzenabgabe halten würden. Erst im September 1986 änderte der Zürcher Regierungsrat die Heilmittelverordnung und gab den Spritzenverkauf frei.

Schon lange vor dem Aufkommen von AIDS war bekannt, dass durch den Gebrauch von unsterilen und verunreinigten Spritzen tödliche Infektionskrankheiten wie Hepatitis C sehr leicht übertragen werden können, doch erst AIDS hat die Tragweite der Problematik des absurden Verbotes der Spritzenabgabe in das Bewusstsein der Öffentlichkeit gerufen. Noch heute löst die Weigerung des Zürcher Kantonsarztes Mitte der achtziger Jahre, die Spritzen zur AIDS-Prävention freizugeben, Wut und Ärger aus. Seine Argumente gegen die Spritzen waren die Argumente der Drogenprohibition: mit dieser Maßnahme setze man „falsche Zeichen“ und Leute würden durch die Erhältlichkeit von Spritzen zum Drogenkonsum aufgefordert. Diese Argumente wirken, beachtet man die günstige Entwicklung auf die Verbreitung von HIV durch Spritzenaustauschprogramme, zynisch. Glücklicherweise wurde die Politik geändert.

Vom Standpunkt der Ethik aus betrachtet war das Verhalten des Kantonsarztes Gonzague Kistler und des kantonalen Gesundheitsdirektors Peter Wiederkehr in jeder Beziehung inakzeptabel und vom medizinischen Standpunkt aus stand es im krassen Widerspruch zur ärztlichen Verpflichtung, Gesundheit zu fördern und Leben zu erhalten. Vom sozialen und gesellschaftspolitischen Standpunkt aus betrachtet kann so ein uneinsichtiges Verhalten nur als kriminell bezeichnet werden, denn wohl niemand in der Schweiz hat billigend so viele Menschenleben aufgrund eines abstrakten Abstinenzparadigmas geopfert wie diese fundamentalistischen Amtspersonen.

Im Oktober 1984 betrug der Anteil intravenös drogenkonsumierender Personen an der Gesamtzahl der gemeldeten AIDS-Erkrankungen in Europa gerade einmal 2% aller Fälle. Nach einem Jahr, im Oktober 1985 betrug dieser Anteil bereits 8%. Innerhalb eines Jahres wuchs dieser Anteil um 6% an. Die Schweiz hatte Mitte der achtziger Jahre die höchste Häufigkeitszahl an AIDS-Erkrankungen in Europa zu verzeichnen. Mit 11,8 Fällen pro Million Einwohner lag die Schweiz im Herbst 1985 vor Dänemark (11,2) und Frankreich (8,5). Ein Jahr später, im Herbst 1986 hatte die Schweiz mit 21,2 Fällen pro Million Einwohner wiederum den höchsten Wert aller Staaten Europas. Die Gründe für diesen hohen Wert seien nicht bekannt, vermeldete seinerzeit das Bundesamt für Gesundheitswesen (BAG) in Bern. In Zürich erkannten jedoch mehr als 300 Ärzte die Gründe für die rasche Ausbreitung von AIDS in der Schweiz. Nachdem der Regierungsrat des Kantons Zürich sich hinter den Kantonsarzt stellte und eine Aufsichtsbeschwerde gegen ihn ablehnten, unterzeichneten sie 1985 eine Erklärung, wonach sie auch weiterhin Spritzen abgeben würden. Engagiert für die ethischen Grundsätze der Ärzteschaft und mit Zivilcourage setzten sie sich über das Verbot hinweg und gaben weiterhin sterile Spritzen an Fixer ab und retteten so vielen von ihnen das Leben.

Erst im September 1986 änderte der Regierungsrat die Heilmittelverordnung und gab den Spritzenverkauf frei. Eine prohibitive Maßnahme wie das Verbot der Spritzenabgabe führt unweigerlich zu einer Schadensmaximierung mit unabsehbaren Schäden für betroffene Individuen und die Gesellschaft.

Die Zahl der AIDS bedingten Todesfälle von drogeninjizierenden Personen hat sich innerhalb von fünf Jahren mehr als verzehnfacht. 1985 wurden 13 Fälle registriert, 1990 waren es 158. Bis 1994 musste eine zunehmende Tendenz festgestellt werden, danach setzte glücklicherweise ein Abwärtstrend ein. Mit Sicherheit wären es weniger Opfer gewesen, hätte man in Zürich eher auf den Rat der Ärzte gehört und schon früher das Abgabeverbot für sterile Spritzen an Fixer aufgehoben.

Die Übertragung von Viren über unsteriles Spritzbesteck ist ein vermeidbarer Infektionsweg. Stetiger Gebrauch steriler Spritzen mindert die Wahrscheinlichkeit einer Infektion bei der intravenösen Applikation gegen Null. Allein in den Jahren 1989 bis 1996 hätte durch vernünftiges Handeln in der ersten Hälfte der achtziger Jahre das frühzeitige (vorzeitige) Ableben von mehr als 1.400 Menschen zu großen Teilen vermieden werden können. Anders ausgedrückt: etwa 40 Prozent der „AIDS-Toten“ in der ersten Hälfte der neunziger Jahre waren in der Schweiz gemäß Ursachenprinzip „Prohibitionstote“.

In der Medienmitteilung des Schweizerischen Nationalfonds (SNF) heißt es u.a.: „Seit dem Auftreten der ersten Fälle in den frühen 1980er-Jahren rollt eine Infektionswelle über die Schweiz. Jahr für Jahr stecken sich mehrere hundert Menschen mit dem HI-Virus an, das die Immunschwächekrankheit Aids auslöst. Folgt diese Ausbreitung irgendwelchen Mustern? Unterscheiden sich diese Muster zwischen verschiedenen Übertragungsgruppen wie Drogensüchtigen, Homo- oder Heterosexuellen?

Diesen Fragen gingen vom Schweizerischen Nationalfonds (SNF) unterstützte Forschende mit Hilfe modernster molekularer Methoden nach. Bei ihrer soeben im Fachmagazin «The Journal of Infectious Diseases» publizierten Untersuchung konzentrierten sie sich auf den HIV-1 Subtyp B, der in der Schweiz etwa 70 Prozent aller Fälle ausmacht. Sie bestimmten das HIV-Erbgut bei 5.700 anonymisierten Menschen, die sich zwischen 1981 und 2007 mit dem Erreger infiziert hatten. Ihre Idee: Je ähnlicher die Viren von zwei Patienten, desto größer ist die Wahrscheinlichkeit, dass diese sich beieinander angesteckt haben. So bestimmten die Forschenden in Zusammenarbeit mit Kollegen der ETH Zürich so genannte Übertragungsketten, in denen das Virus von einem Patienten auf den nächsten weitergegeben wurde.

Insgesamt fanden die Forschenden 60 verschiedene Übertragungsketten, in denen sich mindestens je zehn Menschen mit HIV angesteckt hatten. Doch alle diese Ketten gehörten einem von nur zwei Kettentypen an: Einerseits Übertragungsketten, die sich hauptsächlich aus suchtkranken Menschen, die sich Heroin oder andere Drogen in die Blutgefäße spritzen, und aus Heterosexuellen zusammensetzen; und andererseits der Kettentyp, in dem sich das Virus vorwiegend unter homosexuellen Männern verbreitet. Die Ketten mit Drogensüchtigen und Heterosexuellen umfassten im Schnitt 144 Patienten; in der größten Übertragungsgruppe infizierten sich sogar 1.051 Menschen. Studienleiter Huldrych Günthard vom Universitätsspital Zürich führt dies vor allem auf die einfachere Verbreitung im Drogenmilieu zu Beginn der Epidemie zurück: «Das Virus gelangte durch den Austausch verseuchter Spritzen von ein paar anfänglich infizierten Personen rasch vom Blut eines Drogensüchtigen in das des nächsten», sagt er. Bei Homosexuellen dagegen, wo das Virus durch Geschlechtsverkehr übertragen wird, erfolgt die Ausbreitung in viel kleineren Ketten: In den Übertragungsketten der Homosexuellen steckten sich weniger Partner – durchschnittlich 29 Menschen – an“.

Vergleiche hierzu auch: Daten und Fakten zur Drogenpolitik um die Jahrtausendwende – Drogenstatistiken einmal genauer betrachtet. Eine Auswertung und Zusammenstellung von Hans Cousto. Herausgeber: Eve & Rave e.V. Berlin

The drug subculture which developed as part of the rise in narcotic drug use in the
1960s has received much attention. Academic sociologists and the media found this, as
an area of deviant behaviour, a subject of considerable intellectual interest and also of
popular fascination. Drug taking as an alternative way of life, where, as Jock Young
puts it, „drug use is given a different meaning from that existing previously“, has
become part of the sociology of deviance. Issues such as the formation and role of the
altemative subculture, the social reaction against deviant drug use, and the particular
importance of the changing social class of drug takers as providing justification for a
moral response, have attracted attention. The transformation of the typical drug user
in the 1960s from a middle-class middle-aged female into a young working-class male
had, it is argued, much to do with the social reaction evoked, and the type of legal and
social controls put into effect.‘ In the 1980s, the link with unemployment has again
been stressed; and the reappearance of cocaine as a „smart“ drug has also provided
another source of sensationalism for the popular press. However, the widespread
assertion that drug taking has now become more „normal“ would seem to downgrade
the ’60s emphasis on drug use as a subcultural activity.2 Certainly, the „junkie“
stereotype is less prominent in media coverage.

Read more:medhist00064-0055

Im Interview mit der Plattform http://www.drogensubstitution.at kritisiert Günther Zäuner, Autor des jüngst erschienenen „Drogenreport Österreich“, scharf das österreichische Pharmaunternehmen Mundipharma und im speziellen sein Substitutionsmedikament Substitol. Nun nehmen DI Dietmar Leitner, Geschäftsführer von Mundipharma, und Univ. Prof. Dr. Ulrich Ganzinger, Internist und Leiter der Medizinischen Abteilung von Mundipharma, Stellung zu den Vorwürfen und klären missverständliche oder falsche Aussagen zur Zulassung und Sicherheit des Medikaments im Wege einer Gegendarstellung auf.

Wo liegen Ihre Hauptkritikpunkte gegenüber dem „Drogenreport Österreich“?

Leitner: Prinzipiell ist es begrüßenswert, wenn man sich wie im „Drogenreport Österreich“ mit dem Themenkomplex Drogenprävention, –therapie und –missbrauch auseinandersetzt. Weite Teile des Buches entsprechen auch grundsätzlich der Sachlage. Was uns fehlt, ist ein medizinisch-wissenschaftlicher Anspruch – besonders bei jenen Kritikpunkten, die speziell unser Unternehmen und das Produkt Substitol betreffen. Hier sehen wir großen Aufklärungsbedarf.

Was sind die wesentlichsten Punkte, die Ihrer Meinung nach zu wenig klar herauskommen?

Leitner: Es ist vielfach nicht bewusst, dass die Substitutionsbehandlung von der WHO als wirksamste Therapie von Heroinabhängigkeit eingestuft wird. Wobei auch anzumerken ist, dass die Substitutionsbehandlung keine Heilung, sondern eine Stabilisierung dieser äußerst schweren psychiatrischen Erkrankung erreichen kann. Wichtig ist auch zu bedenken, dass Drogenabhängige – trotz Therapie – verschiedene krisenhafte Lebensphasen durchmachen, die ihre Gesundheit gefährden. Dazu gehört beispielsweise ein gleichzeitiger Beikonsum von anderen legalen und illegalen Substanzen wie Nikotin, Alkohol und Beruhigungsmittel, aber auch von Kokain und Opiaten. Wesentlich dabei ist die Reduktion des Beikonsums bzw. des Missbrauchs der Substitutionsmedikamente.

Welche Substitutionsmedikamente werden missbräuchlich verwendet?

Leitner: Neueste Studien zeigen, dass der Missbrauch von Substitutionsmedikamenten in allen Ländern ein Problem darstellt, unabhängig davon, welche Medikamente eingesetzt werden. Der Missbrauch ist also unabhängig von der Substanz. Es ist nicht gerechtfertigt, die Diskussion über den Missbrauch an nur einer Substanz aufzuhängen und damit eine wichtige Therapieform zu gefährden. Außerdem ist erwiesen, dass mit steigendem Therapieangebote für Opiatabhängige der Missbrauch von Substanzen – auch während einer Substitutionstherapie – abnimmt. Hier besteht in Österreich noch Handlungsbedarf, zumal nur ca. 8.000 von den geschätzten 30.000 Opiatabhängigen in Österreich in Therapie sind.

Ist nun speziell Substitol ein Gesundheitsrisiko – wie im Buch dargestellt?

Leitner: Prinzipiell ist klarzustellen: Substitol ist eine von mehreren Substanzen, die sich zur Substitutionstherapie bei Opiatabhängigkeit eignen. Bei einer ordnungsgemäßen, d.h. oralen, Einnahme ist Substitol eine wirksame Substanz mit bekanntem Nebenwirkungsprofil, das auch in der Fachinformation beschrieben ist. Substitol wurde für die orale Einnahme entwickelt, und nicht für die intravenöse und damit missbräuchliche Verabreichung.

Laut „Drogenreport Österreich“ stellt speziell ein Bestandteil des Substitols, das so genannte Talkum, ein großes Sicherheitsrisiko dar. Intravenös verabreicht führt es laut Buch zu Venen- und Arterienverstopfungen, Herzklappenveränderungen bis hin zum Tod. Gibt es Studien zu den gesundheitlichen Risiken von Talkum?

Ganzinger: Jedes Medikament, das anders als vorgeschrieben angewendet wird, birgt ein klares Gesundheitsrisiko. Werden Medikamente, die Talkum als Hilfsstoff enthalten, aufgelöst und missbräuchlich intravenös verabreicht, kommt es zu Gesundheitsschäden. Schweregrad und Häufigkeit dieser Gesundheitsschäden nehmen mit der zunehmenden Dauer und Menge des so in den Körper gelangten Talkums zu. Das gilt für jeden Hilfsstoff, der nicht vom Körper abgebaut, sondern eingelagert wird. Diese Gesundheitsschäden sind seit Jahren bekannt und betreffen eine Vielzahl von Medikamenten. Sie treten aber nur in Einzelfällen auf, wie der medizinischen Fachliteratur zu entnehmen ist. Es ist wichtig, auf diese Zusammenhänge hinzuweisen, um somit einen Beitrag zur Verringerung des Missbrauchs zu leisten.

Besteht ein derartiges Risiko auch beim IV-Missbrauch von Substitol?

Ganzinger: Aus rein medizinischen Überlegungen ja, allerdings gibt es für Substitol keinen bestätigten Fall. Unbestätigte Meldungen über Ablagerung von Talkum in Herzklappen sind medizinisch nicht nachvollziehbar. Wir haben alle heimischen herzchirurgischen Abteilungen angeschrieben, wir haben bei der Statistik Austria über Entlassungsstatistiken recherchiert. Das Ergebnis: Schädigungen durch Talkum nach nichtordnungsgemäßer Anwendung von Substitol konnten bisher in keinem einzigen Fall in Österreich medizinisch bestätigt werden.

Zäuner kritisiert, dass Substitol in Tablettenform hergestellt wird, wo Talkum automatisch mit dabei ist. Er schlägt vor, Substitol in flüssiger Form anzubieten. Warum tun Sie das nicht?

Ganzinger: Zuerst muss klargestellt werden, dass Substitol eine Kapsel und keine Tablette ist. Die richtige Galenik für ein Medikament zu finden, ist eine Wissenschaft für sich. Hier greift Mundipharma auf seine über 30-jährige Erfahrung im Umgang mit Morphin in der Schmerztherapie zurück. Erst mit der Entwicklung einer 24-Stunden-Retard-Galenik für Morphin erfüllt Substitol die Anforderungen an ein für die Substitution geeignetes Medikament. Die Beimengung von Talkum erfolgt aus Qualitätsgründen. Es stellt u. a. sicher, dass die Kapseln bei der großtechnischen Produktion gleichmäßig mit Pellets, kleinen Kügelchen, befüllt werden, die den Wirkstoff tragen und die 24-Stunden-verzögerte Wirkstofffreigabe – das Grundprinzip der „Retard-Wirkung“ ermöglichen.

Substitol in flüssiger Form anzubieten geht schon deshalb nicht, weil damit die 24-Stunden Wirksamkeit verloren geht. Abgesehen davon, erachten wir es als ethisch bedenklich, ein Medikament, das ausschließlich für die orale Einnahme zugelassen und entwickelt wurde, so zu verändern, dass es zu weniger Gesundheitsschäden beim Missbrauch führt. Hier gilt es Maßnahmen zur Reduktion des Missbrauchs zu setzen.

Aus bestimmten medizinischen Gründen, die unmittelbar mit Sucht als Krankheit zusammenhängen, kann die medizinische Notwendigkeit entstehen, Substanzen intravenös zu geben. in Ländern wie Deutschland, Schweiz, Holland und England gibt es Heroin-gestützte Programme. Wir appellieren an die Verantwortlichen in Österreich, andere Therapiemöglichkeiten, wie eben z. B. Heroin-gestützte Programme, auch für Österreich zu evaluieren.

Was ist mit den 200 Todesfällen auf Grund von Substitol-Missbrauch, von denen im „Drogenreport Österreich“ gesprochen wird?

Ganzinger: Jedes Drogenopfer ist eines zu viel. Österreich hat im Jahr 2005 laut dem „ÖBIG Bericht zur Drogensituation 2006“ insgesamt 191 Drogenopfer zu beklagen. Die im Buch angesprochene Zahl von Todesfällen, noch dazu im Zusammenhang mit unserer Substanz, deckt sich nicht mit den veröffentlichten Statistiken.

Veränderungen in der Zahl der Drogenopfer in den letzten Jahren müssen unbedingt im Zusammenhang mit der immer häufigeren Mehrfachabhängigkeit gesehen werden, wo neben Heroin und Kokain auch große Mengen von Beruhigungsmitteln und Alkohol gleichzeitig konsumiert werden. Die Statistik zeigt dies in einer zunehmenden Zahl von sogenannten Mischintoxikationen. Wie auch im Bericht des Österreichischen Bundesinstitut für Gesundheitsforschung (ÖBIG) nachzulesen ist, ist es bei Opiatintoxikationen nicht möglich, zwischen Morphin und Heroin zu unterscheiden, da Heroin im Körper innerhalb kürzester Zeit zu Morphin umgewandelt wird. Mit herkömmlichen Methoden kann nicht unterschieden werden, woher das Morphin stammt.

Leitner: Im Zuge der gesetzlich verpflichtenden Arzneimittelüberwachung gehen wir von Mundipharma jeder einzelnen Meldung über eine unerwünschte Arzneimittelwirkung (UAW) mit und ohne Todesfolge auf Grund von Substitol nach. Wir erstellen alle sechs Monate einen Bericht zu allen berichteten und gemeldeten Nebenwirkungen und legen diese der Agentur für Gesundheit und Ernährungssicherheit vor. Diese dem Ministerium nachgeordnete Agentur bestätigte, dass basierend auf diesen Daten und Fakten das Nutzen-Risiko Verhältnis zu Gunsten der Arzneispezialität vorliegt.

Könnte man Talkum in der Obduktion nachweisen?

Ganzinger: Im Prinzip ist es möglich. Aber das wäre so, als würde man eine Stecknadel im Heuhaufen suchen. Erst die Folgen eines langjährigen Missbrauchs von großen Mengen ließen sich feststellen – nämlich in Form der in der Wissenschaftsliteratur beschriebenen Krankheitsbilder. Wie uns u. a. das gerichtsmedizinische Institut der Universität Wien bestätigt hat, konnten derartige Fälle im Rahmen von Obduktionen bisher nicht für Substitol nachgewiesen werden.

Im „Drogenreport Österreich“ wird die oft schlampige Vorgehensweise bei Obduktionen von Todesfällen in Folge von Drogenmissbrauch kritisiert. Sind diese Vorwürfe berechtigt?

Ganzinger: Uns steht es nicht zu, dies zu kommentieren. Wie schon erwähnt, ist es sehr schwierig, die Todesursache bei einem Opiatabhängigen an einer spezifischen Ursache aufzuhängen. Meist sind es mehrere Gründe und Umstände, die zum Tod führen. Wir fordern aber schon seit langem, dass Obduktionen und deren Befunde nach einheitlichen Kriterien durchgeführt werden. Dies gilt auch für die Nachweismethoden von illegalen Substanzen in Blut- und Harnproben.

Zusätzlich könnten über eine genauere Erhebung sozialmedizinische Informationen zum Umfeld des Toten gewonnen werden, womit die Maßnahmen zur Prävention wesentlich verbessert werden könnten.

Seit seiner Zulassung im Jahr 1999 hat sich Substitol gut in der heimischen Substitutionstherapie etabliert. Was sind die Gründe?

Ganzinger: Die Wirksamkeit von Morphin in der Substitutionstherapie ist seit Jahrzehnten bekannt und durch mehrere Studien belegt. Patienten unter Morphinsubstitution fühlen sich wesentlich besser als vergleichsweise unter Methadon, sie sind deutlich weniger depressiv. Darüber hinaus ist Morphin sehr gut verträglich. Das wissen wir auch von Patienten, die Morphin zur Behandlung ihrer Schmerzen bekommen. Es ist sehr wesentlich, dass sich Patienten in ihrer Behandlung auch subjektiv gut fühlen, denn ihre Befindlichkeit entscheidet, ob sie in der Therapie bleiben oder diese vorzeitig abbrechen.

Es gibt also klinische Studien?

Leitner: Natürlich gibt es mehrere klinische Studien, die auch in Fachjournalen publiziert sind und nachgelesen werden können. Die vorher erwähnten positiven Eigenschaften im Vergleich zu Methadon sind u. a. in einer der international sehr angesehenen Fachzeitschrift auf diesem Gebiet veröffentlicht worden (Eder H. et al.: Comparative study of the effectiveness of slow release morphine and methadone for opioid maintenance therapy. Addiction 100: 1101-1109 (2005)).

Zum Abstract der Studie: http://www.ncbi.nlm.nih.gov

Warum ist Substitol nur in drei Ländern zugelassen?

Leitner: Substitol ist derzeit in . In anderen Ländern wurde bisher um keine Zulassung angesucht.

Im Endeffekt ist also nicht das Medikament Substitol das Problem, sondern dessen Kriminalisierung und missbräuchliche intravenöse Anwendung. Wie kann man dem entgegensteuern?

Leitner: Es geht letztlich darum, die Gruppe jener Opiatabhängigen, die ein intravenöses Konsumverhalten zeigen und mehrere Substanzen gleichzeitig einnehmen, von diesem gefährlichen Konsumverhalten abzubringen und in ein Substitutionsprogramm zu integrieren. Bislang ist von den geschätzten 30.000 Opiatabhängigen in Österreich nur etwa ein Drittel in einer Substitutionstherapie. Nur unter ärztlicher Fürsorge können Missbrauch langfristig unterbunden und Patienten auf die Gesundheitsrisiken aufmerksam gemacht werden. Dafür engagieren wir uns und arbeiten intensiv mit Behörden und Drogeninstitutionen zusammen.

Greift die heimische Drogenpolitik diesbezüglich?

Leitner: Österreich hat mit seiner Drogenpolitik sicherlich europaweit eine Vorreiterrolle – speziell in Wien. Das breit gefächerte Angebot in der Substitutionstherapie ermöglicht ein individuell auf den Patienten abgestimmtes Programm, was wiederum die Erfolgsquote, also die Therapietreue und Wiedereingliederung in den Alltag, erhöht.

Ganzinger: Vorrangiges Problem ist, und da stimmen wir mit dem Buch überein: Es gibt nach wie vor zu wenig Therapieplätze. Für einen sichereren Rahmen in der Substitutionstherapie sollte zusätzlich die seit 1. März in Kraft befindliche Verordnung sorgen.

  1. „We have shown that treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone. Furthermore, this difference was evident within the first 6 weeks of treatment.

    „This randomised controlled trial of treatment with supervised injectable opiates builds on the findings of five randomised trials of supervised injectable heroin versus oral methadone.“

    Source:

    Strang, John; Metrebian, Nicola; Lintzeris, Nicholas; Potts, Laura; Carnwath, Tom; Mayet, Soraya; Williams, Hugh; Zador, Deborah; Evers, Richard; Groshkova, Teodor; Charles, Vikki; Martin, Anthea; and Forzisi, Luciana, „Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial,“ The Lancet (London, United Kingdom: May 29, 2010) Vol. 375, Issue 9729, p.
    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960…

  2. „Heroin prescription is a form of medical care that involves strictly regulated and controlled prescription of heroin. Offered on its own or as a complement to treatment programs, it is often targeted for use by people for whom opioid substitution treatment and other programs have not succeeded.“

    „Findings show such programs are feasible and are associated with a number of positive outcomes,12 including:

    Health benefits:
    • helping people to stop or reduce their illegal drug use;13
    • avoiding illness and death as a result of overdose by ensuring access to a drug of known quality and strength;14
    • retention in medical care;15
    • facilitating a gradual change from heroin to opioid substitution therapy;16
    • reducing the risk of HIV and hepatitis resulting from unsafe injection practices;17 and
    • promoting general health and well-being.18

    Social benefits:
    • reducing crime related to the acquisition of drugs;19
    • reducing the number or visibility of drug markets and public drug use;
    • lowering costs associated with health care, social welfare, criminal justice and prisons;20 and
    • promoting social integration, including with respect to employment, accommodation and family life.21“

    Source:

    Canadian HIV/AIDS Legal Network, „Legislating on Health and Human Rights: Model Law on Drug Use and HIV/AIDS Module 8: Heroin prescription programs,“ (Tornoto, Ontario: 2006), p. 8.
    http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=875

  3. „Heroin prescription is consistent with a number of state responsibilities under international human rights instruments. The Universal Declaration of Human Rights states that ‚everyone has the right to a standard of living adequate for the health and wellbeing of himself … including … medical care and necessary social services.’24 Similarly, the International Convention on Economic, Social and Cultural Rights (ICESCR) recognizes the ‚right of everyone to the highest attainable standard of physical and mental health.’25 The UNAIDS/OHCHR International Guidelines on HIV/AIDS and Human Rights recommend that states ensure the ‚widespread availability of qualitative prevention measures and services, adequate HIV prevention and care information‘ in order to protect the human rights of people living with HIV/AIDS and stem the spread of the virus.“

    Source:

    Canadian HIV/AIDS Legal Network, „Legislating on Health and Human Rights: Model Law on Drug Use and HIV/AIDS Module 8: Heroin prescription programs,“ (Tornoto, Ontario: 2006), p. 9.
    http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=875

  4. „Overall, results indicate that heroin prescription is a very promising approach in reducing any type of drug related crime across all relevant groups analyzed. It affects property crime as well as drug dealing and even use/possession of drugs other than heroin. These results suggest that heroin maintenance does not only have an impact by reducing the acquisitive pressure of treated patients, but also seems to have a broader effect on their entire life-style by stabilizing their daily routine through the commitment to attend the prescription center twice or three times a day, by giving them the opportunity for psychosocial support, and by keeping them away from open drug scenes.“

    Source:

    Ribeaud, Denis, „Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of Treated Heroin Users,“ Journal of Drug Issues (Talahassee, FL: University of Florida, Winter 2004), p. 188.
    http://www.esrnexus.com/displayArticle.aspx?codedarticleid=394110

  5. „The existing interference and non-evidence-based opposition from politicians and care providers, who refuse to acknowledge the limitations of methadone maintenance and the superiority of prescribed heroin in selected populations, is arguably unethical. Denying effective second-line therapy to those in need ultimately serves to condemn many users of illicit heroin to the all too common outcomes of untreated heroin addiction, including HIV infection or death from overdose.“

    Source:

    Kerr, Thomas; Montaner, Julio SG; and Wood, Evan, „Science and politics of heroin prescription,“ The Lancet (London, United Kingdom:May 29, 2010) Vol. 375, Issue 9729, p. 1850.
    http://www.thelancet.com/journals/lancet/article/PIIS0140673610605442/fu…

  6. „Many countries believe (erroneously) that the international drug conventions prohibit the use of heroin in medical treatment. Furthermore, the International Narcotics Control Board (INCB) has exerted great pressure on countries to cease prescribing heroin for any medical purpose. Nevertheless, a few countries, including the UK, Belgium, the Netherlands, Iceland, Malta, Canada and Switzerland, continue to use heroin (diamorphine) for general medical purposes, mostly in hospital settings (usually for severe pain relief). Until recently, however, Britain was the only country that allowed doctors to prescribe heroin for the treatment of drug dependence.“

    Source:

    Stimson, Gerry V., and Nicky Metrebian, Centre for Research on Drugs and Health Behavior, „Prescribing Heroin: What is the Evidence?“ (London, England: Rowntree Foundation, 2003), p. 4.
    http://www.jrf.org.uk/sites/files/jrf/1859350836.pdf

  7. „The harm reduction policy of Switzerland and its emphasis on the medicalisation of the heroin problem seems to have contributed to the image of heroin as unattractive for young people.“

    Source:

    Nordt, Carlos, and Rudolf Stohler, „Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis,“ The Lancet, Vol. 367, June 3, 2006, p. 1830.
    http://www.cesda.net/downloads/lancet1.pdf

  8. „Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains. Musto’s generational theory regards the decline in incidence more as a social learning effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant early experiences to devastating circumstances for addicts, families, and communities later on.“

    Source:

    Nordt, Carlos, and Rudolf Stohler, „Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis,“ The Lancet, Vol. 367, June 3, 2006, p. 1833.
    http://www.cesda.net/downloads/lancet1.pdf

  9. „Prescribing injectable opiates is one of many options in a range of treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health and social status, our findings endorse the view that it is a feasible option.“

    Source:

    Metrebian, Nicky, Shanahan, William, Wells, Brian, and Stimson, Gerry, „Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users; associated health gains and harm reductions,“ The Medical Journal of Australia (MJA 1998; 168: 596-600).
    http://mja.com.au/public/issues/jun15/mtrebn/mtrebn.html

  10. (2002) „The incidence of regular heroin use in the canton of Zurich started with about 80 new users in 1975, increased to 850 in 1990, and declined to 150 in 2002, and was thus reduced by 82%. Incidence peaked in 1990 at a similar high level to that ever reported in New South Wales, Australia, or in Italy. But only in Zurich has a decline by a factor of four in the number of new users of heroin been observed within a decade. This decline in incidence probably pertains to the whole of Switzerland because the number of patients in substitution treatment is stable, the age of the substituted population is rising, the mortality caused by drugs is declining, and confiscation of heroin is falling. Furthermore, incidence trends did not differ between urban and rural regions of Zurich. This finding is suggestive of a more similar spatial dynamic of heroin use for Switzerland than for other countries.“

    Source:

    Nordt, Carlos, and Rudolf Stohler, „Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis,“ The Lancet, Vol. 367, June 3, 2006, p. 1833.
    http://www.cesda.net/downloads/lancet1.pdf

  11. (heroin maintenance vs. methadone „The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs.

    „The NAOMI study will enrol 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal sites are expected to begin recruitment this spring. „Each site will enroll about 157 participants. About half of these volunteers will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic. Those in the heroin group will be treated for 12 months then transitioned, over three months, into either methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that the total time to complete the study will be 21 to 24 months.“

    Source:

    Health Canada News Release, „North America’s First Clinical Trial Of Prescribed Heroin Begins Today,“ (Vancouver: February. 9, 2005).
    http://www.cihr-irsc.gc.ca/e/26516.html

  12. (heroin maintenance) „The central result of the German model project shows a significant superiority of heroin over methadone treatment for both primary outcome measures. Heroin treatment has significantly higher response rates both in the field of health and the reduction of illicit drug use. According to the study protocol, evidence of the greater efficacy of heroin treatment compared to methadone maintenance treatment has thus been produced. Heroin treatment is also clearly superior to methadone treatment when focusing on patients, who fulfill the two primary outcome measures.“

    Source:

    Naber, Dieter, and Haasen, Christian, Centre for Interdisciplinary Addiction Research of Hamburg University, „The German Model Project for Heroin Assisted Treatment of Opioid Dependent Patients — A Multi-Centre, Randomised, Controlled Treatment Study: Clinical Study Report of the First Study Phase,“ January 2006, p. 117.
    http://www.heroinstudie.de/H-Report_P1_engl.pdf

  13. (heroin maintenance) „To conclude, it must be stated that heroin treatment involves a somewhat higher safety risk than methadone treatment. This is mainly due to the intravenous form of application. The rather frequently occurring respiratory depressions and cerebral convulsions are not unexpected and can easily be clinically controlled. Overall, the mortality rate was low during the first study phase, and no death occurred with a causal relationship with the study medication. Compared to much higher health risks related to the i.v. application of street heroin, the safety risk of medically controlled heroin prescription has to be considered as low.“

    Source:

    Naber, Dieter, and Haasen, Christian, Centre for Interdisciplinary Addiction Research of Hamburg University, „The German Model Project for Heroin Assisted Treatment of Opioid Dependent Patients — A Multi-Centre, Randomised, Controlled Treatment Study: Clinical Study Report of the First Study Phase,“ January 2006, p. 150.
    http://www.heroinstudie.de/H-Report_P1_engl.pdf

  14. (heroin maintenance) „The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts.“

    Source:

    Naber, Dieter, and Haasen, Christian, Centre for Interdisciplinary Addiction Research of Hamburg University, „The German Model Project for Heroin Assisted Treatment of Opioid Dependent Patients — A Multi-Centre, Randomised, Controlled Treatment Study: Clinical Study Report of the First Study Phase,“ January 2006, p. 122.
    http://www.heroinstudie.de/H-Report_P1_engl.pdf

  15. (heroin maintenance) „The UK is exceptional internationally because heroin is included in the range of legally sanctioned treatments for opiate dependence. In practice, this treatment option is rarely utilised: only about 448 heroin users receive heroin on prescription.“`

    Source:

    Stimson, Gerry V., and Nicky Metrebian, Centre for Research on Drugs and Health Behavior, „Prescribing Heroin: What is the Evidence?“ (London, England: Rowntree Foundation, 2003), p. 1.
    http://www.jrf.org.uk/sites/files/jrf/1859350836.pdf

  16. „These pilot study findings showed that opiate-dependent injecting drug users with long injecting careers (most started between 1970 and 1982) and for whom opiate treatment had failed multiple times previously were attracted into and retained by therapy with injectable opiates.“

    Source:

    Metrebian, Nicky, Shanahan, William, Wells, Brian, and Stimson, Gerry, „Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users; associated health gains and harm reductions,“ The Medical Journal of Australia (MJA 1998; 168: 596-600).
    http://mja.com.au/public/issues/jun15/mtrebn/mtrebn.html

  17. A study of the Swiss heroin prescription program found:
    „With respect to the group of those treated uninterruptedly during four years, a strong decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers towards program participants.

    „On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences were found with regard to in-treatment rates. Taken as a whole, this suggests that the treatment had a somewhat more beneficial effect on men than women. This result is corroborated by self-report data (Killias et al., 2002). With respect to age and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated addicts, this retention rate is, at least, promising.“

    Source:

    Ribeaud, Denis, „Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of Treated Heroin Users,“ Journal of Drug Issues (Talahassee, FL: University of Florida, Winter 2004), p. 187.
    http://www.esrnexus.com/displayArticle.aspx?codedarticleid=394110

  18. A study of the Swiss heroin prescription program found:
    „Finally, the analysis of the reasons for interrupting treatment revealed that, even in the group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment – and a fortiori abstinence treatment – is able to substantially reduce acquisitive crime, the redirection of heroin maintenance patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back ‚on the street‘.“

    Source:

    Ribeaud, Denis, „Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of Treated Heroin Users,“ Journal of Drug Issues (Talahassee, FL: University of Florida, Winter 2004), p. 188.
    http://www.esrnexus.com/displayArticle.aspx?codedarticleid=394110

Scientists have finally confirmed what the rest of us have suspected for years: Bacon, cheesecake, and other delicious yet fattening foods may be addictive.

A new study in rats suggests that high-fat, high-calorie foods affect the brain in much the same way as cocaine and heroin. When rats consume these foods in great enough quantities, it leads to compulsive eating habits that resemble drug addiction, the study found.

Doing drugs such as cocaine and eating too much junk food both gradually overload the so-called pleasure centers in the brain, according to Paul J. Kenny, Ph.D., an associate professor of molecular therapeutics at the Scripps Research Institute, in Jupiter, Florida. Eventually the pleasure centers „crash,“ and achieving the same pleasure–or even just feeling normal–requires increasing amounts of the drug or food, says Kenny, the lead author of the study.

„People know intuitively that there’s more to [overeating] than just willpower,“ he says. „There’s a system in the brain that’s been turned on or over-activated, and that’s driving [overeating] at some subconscious level.“

In the study, published in the journal Nature Neuroscience, Kenny and his co-author studied three groups of lab rats for 40 days. One of the groups was fed regular rat food. A second was fed bacon, sausage, cheesecake, frosting, and other fattening, high-calorie foods–but only for one hour each day. The third group was allowed to pig out on the unhealthy foods for up to 23 hours a day.

Not surprisingly, the rats that gorged themselves on the human food quickly became obese. But their brains also changed. By monitoring implanted brain electrodes, the researchers found that the rats in the third group gradually developed a tolerance to the pleasure the food gave them and had to eat more to experience a high.

They began to eat compulsively, to the point where they continued to do so in the face of pain. When the researchers applied an electric shock to the rats‘ feet in the presence of the food, the rats in the first two groups were frightened away from eating. But the obese rats were not. „Their attention was solely focused on consuming food,“ says Kenny.

In previous studies, rats have exhibited similar brain changes when given unlimited access to cocaine or heroin. And rats have similarly ignored punishment to continue consuming cocaine, the researchers note.

The fact that junk food could provoke this response isn’t entirely surprising, says Dr.Gene-Jack Wang, M.D., the chair of the medical department at the U.S. Department of Energy’s Brookhaven National Laboratory, in Upton, New York.

„We make our food very similar to cocaine now,“ he says.

Coca leaves have been used since ancient times, he points out, but people learned to purify or alter cocaine to deliver it more efficiently to their brains (by injecting or smoking it, for instance). This made the drug more addictive!

According to Wang, food has evolved in a similar way. „We purify our food,“ he says. „Our ancestors ate whole grains, but we’re eating white bread. American Indians ate corn; we eat corn syrup.“

The ingredients in purified modern food cause people to „eat unconsciously and unnecessarily,“ and will also prompt an animal to „eat like a drug abuser [uses drugs],“ says Wang.

The neurotransmitter dopamine appears to be responsible for the behavior of the overeating rats, according to the study. Dopamine is involved in the brain’s pleasure (or reward) centers, and it also plays a role in reinforcing behavior. „It tells the brain something has happened and you should learn from what just happened,“ says Kenny.

Overeating caused the levels of a certain dopamine receptor in the brains of the obese rats to drop, the study found. In humans, low levels of the same receptors have been associated with drug addiction and obesity, and may be genetic, Kenny says.

However, that doesn’t mean that everyone born with lower dopamine receptor levels is destined to become an addict or to overeat. As Wang points out, environmental factors, and not just genes, are involved in both behaviors.

Wang also cautions that applying the results of animal studies to humans can be tricky. For instance, he says, in studies of weight-loss drugs, rats have lost as much as 30 percent of their weight, but humans on the same drug have lost less than 5 percent of their weight. „You can’t mimic completely human behavior, but [animal studies] can give you a clue about what can happen in humans,“ Wang says.

Although he acknowledges that his research may not directly translate to humans, Kenny says the findings shed light on the brain mechanisms that drive overeating and could even lead to new treatments for obesity.

„If we could develop therapeutics for drug addiction, those same drugs may be good for obesity as well,“ he says.

Prescribing heroin to addicts who can’t kick their habit helps them stay off street drugs, British researchers said Friday.

So far, doctors have had little hope of treating the 10 percent or more of heroin users who don’t respond to methadone, the standard anti-addiction medication. Fueled by drug cravings, those users often spiral downward into crime and diseases spread by dirty needles and unhealthy living.

Short of actually getting addicts off the drug, „heroin clinics“ can at least get them off the streets.

„What we are dealing with here is a very severe group of heroin addicts, where all of the treatments have been tried and have failed,“ said Dr. John Strang, an addiction expert at King’s College London, who led the new study.

„They are like oil tankers heading for disaster,“ he added. „The question we were asking was, ‚Can we change the trajectory of these tankers?‘ And the answer was, ‚Yes we can.'“

To test how prescription heroin would work for this group, Strang and his colleagues invited 127 addicts into supervised injecting clinics. The researchers then randomly chose who would get heroin, injected methadone or typical swallowed methadone.

After six months, 101 addicts had stuck with their treatment. More than two-thirds of those on heroin had no sign of street heroin in their urine at least half the time they were tested; before the study, they had been using the street drug almost every day.

In comparison, less than a third of the addicts on either type of methadone had a similar number of „clean“ tests.

At this point, said Strang, several users have continued in the program for more than two years. He did not have exact numbers, but told Reuters Health that some had been able to get jobs and reconnect with their families.

„These sorts of changes are typical of what we are seeing,“ he said. „People are not only physically getting better, but they’re getting back into society.“

The researchers had to treat about two addicts for each one who get off of street drugs at least half of the time.

An estimated 3.7 million people in the US have used heroin at some point in their lives, according to the National Institute on Drug Abuse. Of current users, studies suggest that some 200,000 spend time in jails each year.

The most common drug treatment for heroin users is methadone, a synthetic drug related to heroin. Although methadone decreases the cravings for its chemical cousin, it doesn’t produce the same high, according to experts. This could help explain why a substantial proportion of addicts in treatment backslide.

Before the new study, a handful of other reports had indicated that prescription heroin could help these people. But the scientific community wasn’t completely convinced, in part because earlier urine tests weren’t very sophisticated.

„What this study did is that it used a very novel urine test that can differentiate between street heroin and prescription heroin,“ said Thomas Kerr, director of the Urban Health Research Initiative at the University of British Columbia in Vancouver, Canada. Street heroin contains papaverine, a remnant of the opium poppy that can be detected in the urine.

Now, he said, „the evidence is quite clear that there is a place for prescription heroin for the treatment of individuals who do not respond to methadone.“

Only a few European countries prescribe heroin to addicts, and in the US this practice has been illegal since before World War I.

Many argue that giving addicts more of the substance they abuse makes little sense, and would be like treating an alcoholic with whiskey. But Kerr said that analogy wasn’t apt. „I would argue it’s completely immoral and unethical to fail to treat those individuals and to allow them to suffer and allow the community around them to suffer,“ Kerr said. Strang said he supported the UK Government’s 2008 Drug Strategy, which proposes rolling out prescription heroin. „Now that we know that it works, we have to debate whether or not we should use it,“ he said. SOURCE: The Lancet, May 28, 2010. http://www.thelancet.com/