Archive for Oktober, 2010

Multi-National Operation Nets $55.9 Million Heroin Seizure in Afghanistan
First-ever joint mission for DEA, Afghan, and Russian drug agents nets nearly one metric ton of drugs

OCT 29 — A multinational DEA operation led to the seizure of $55.9 million in heroin at four clandestine laboratories located in Nangarhar Province, Afghanistan. The nearly one metric ton of narcotics was seized as a result of a large-scale joint narcotics enforcement operation by DEA, Afghan, and Russian anti-drug agents in Afghanistan.

Members of the U.S. military’s 101st Airborne Division, along with ISAF, took part in “Operation Tar Pit.”

Acting on DEA intelligence, the multinational task force was able to identify a major clandestine heroin laboratory in the Zerasari Village of the Achin District. Upon arrival at the site, agents discovered three additional labs hidden by vegetation. Evidence collected confirmed that all of the labs were actively producing heroin and morphine.

“Thanks to the close cooperation among DEA, Afghan, and Russian anti-drug personnel as well as U.S. Military and ISAF in Afghanistan, one metric ton of heroin was seized from four clandestine laboratories along with various precursor chemicals. Operation Tar Pit was a significant enforcement success due to the fearsome force multiplier arrayed against the narco-traffickers and insurgents,” said DEA Acting Administrator Michele M. Leonhart. “This nearly $60 million worth of heroin seized in Afghanistan will never find its way to vulnerable communities around the world.”

In addition to 932 kilograms of heroin and 156 kilograms of opium seized, the following precursor chemicals and materials were also confiscated: 10 liters of acetic anhydride, 15 kilograms of ammonium chloride, 10 kilograms of soda ash, 40 kilograms of charcoal, two mechanical heroin presses, three metal industrial cooking vats, and 500 feet of plastic irrigation equipment.‪

An investigation into the drug trafficking organization responsible for operating the clandestine heroin labs is ongoing.

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Heroin, cocaine, ecstasy, cannabis, prescription and over-the-counter medicines, alcohol, tobacco, coffee, tea – we are all people who use drugs. Our refusal to acknowledge this comes from a deep-seated fear that ‘we’ might become, or be seen as, one of ‘them’. What we really need to focus on is the difference between drug use and drug addiction or dependency. Global prohibitionist drug policy continues to focus efforts primarily on the substances alone. This is wrong.


Of course, the harms associated with some drugs are worse than others. Sometimes these are due to the degree of addictiveness of a particular drug. But most of the harms are due to the way that a particular drug is acquired (for example, in a dark alley versus from a pharmacy), the way in which it is used (as a pill, for example, versus smoking, snorting or injecting), and, even more importantly, the way in which society treats people who use drugs. The vast majority of the horrific harms associated with drug use—crime, HIV and other blood-borne infections, violence, incarceration, death—are clearly fuelled by the prohibitionist drug policies our governments pursue.


The use of non-medical drugs, and more importantly the ‘War on Drugs’ itself, have had a profound influence on the global HIV epidemic over the past 25 years. Today, injecting drug use accounts for 30% of HIV infections worldwide outside of sub-Saharan Africa. In the Eastern Europe/Central Asia region as a whole over 60% of HIV infections are due to injecting drug use.
Global normative guidance on HIV prevention, treatment, care and support for people who inject drugs emphasises the use of a comprehensive set of evidence-based interventions aimed at reducing the harms associated with drug use. This normative guidance, as endorsed by the World Health Organization, the United Nations Joint Programme on HIV/AIDS, the International AIDS Society and other organisations, is in direct contrast to global drug control policy, as set out in the three major UN drug conventions of 1961, 1971 and 1988. These call for a strict prohibitionist stance on the production, distribution and use of non-medical drugs.


It doesn’t take a rocket scientist to show that criminalising drugs and drug use has directly and indirectly led to a dramatic increase in drug-related harms, and that controlling and regulating the production and distribution of all drugs would go a long way towards reducing those harms. So long as we continue to define the drug user as ‘other’ and define the drug itself as the problem, we will be trapped in our misguided and harm-inducing programmes and policies.


‘After the War on Drugs: Blueprint for Regulation’ lays out, for the first time, a set of practical and pragmatic options for a global regulatory system for non-medical drugs. It comes at a critical time. A number of Latin American governments, including Argentina, Brazil, Ecuador, Bolivia and Mexico have moved, or are moving, towards decriminalisation of drug possession and are shifting to a public health model to prevent and treat misuse of drugs. They are no longer able to tolerate the damage done to their societies by the War on Drugs. Portugal decriminalised possession of all drugs in 2001.


There are signs that the US government, under the new US ‘Drug Czar’ Gil Kerlikowske, is ready to review its position on the War on Drugs. Given that prohibitionist policy has been dominated by the US, and to some extent Russia, Japan and Sweden, any shifts in US policy could have dramatic effects at the global level.


This is not a radical book, nor does it posit radical approaches to global drug policy. In fact, as it points out, the prohibitionist model is the radical approach, in that it is based exclusively on a moral judgment against drug use and drug users and not on an evidence based approach to reducing drug-related harms. Underscoring a century of prohibitionist policy is a deep-seated fear that moving from prohibition to a regulatory approach will lead to a ‘free-for-all’ situation vis-à-vis drug availability and use. ‘Blueprint’ outlines clearly that this fear is irrational and that reform of any kind will be vastly superior to the status quo.


Reform will not happen overnight. In fact, as ‘Blueprint’ makes clear, it will be important that changes are phased in gradually and closely monitored through intensive policy research that comprehensively documents health and other outcomes. The book proposes a number of regulatory options for each class of drug. Various approaches currently in use for the regulation and management of alcohol, tobacco, cannabis, and pharmaceutical medicines can be adapted for regulating non-medical drugs and drug use.


There often appears to be a vast gulf of irreconcilable differences between those of us advocating for harm reduction approaches to drug use, and those in the anti-drugs movement. To bridge the gap between these movements, harm reduction advocates must not be coy about the horrific problems that can be associated with drug use. Individuals in the anti-drugs movement are motivated too by their experience of these

harms. Discussing these experiences openly and without prejudice could lead to a common language we can all share. If we are not able to reach out to the anti-drugs movement and find common ground, then our evidence will never overcome their fear. We must aim towards a unified voice where public health and human rights are two sides of the same coin.
‘Blueprint’ envisages a world in which non-medical drug supply and use is addressed through the right blend of compassion, pragmatism, and evidence-based interventions focussed on improving public health. These have been missing from the debate for too long. The time for change in global drug policy is long overdue. Nothing less than the future health of individuals, families, communities and societies is at stake.


Acknowledgements ix
Foreword xi
Craig McClure, Former Executive Director, International AIDS Society
1 Introduction
1.1 An ethics of effectiveness 3
1.2 No-one wants anarchy 5
1.3 Being radical? 6
1.4 Our proposals 7
1.5 Knowing the limits 10
1.6 A starting point, not a conclusion 11
2 Five models for regulating drug supply
2.1 Regulation, prohibition and free markets 15
2.2 Defining the five basic regulation models 20
2.3 Prescription 20
2.4 Pharmacy sales 23
2.5 Licensed sales 24
2.6 Licensed premises 25
2.7 Unlicensed sales 26
3 The practical detail of regulation
3.1 Production controls 31
3.2 Availability controls 37
3.3 Product controls 40
3.4 Supplier and outlet controls 48
3.5 Purchaser and end user controls 52
4 Making a regulated system happen
4.1 A cautious, phased introduction 67
4.2 Assessing and ranking drug harms 70
4.3 Legislating globally, nationally and locally 81
4.4 Effective research for effective policy 82
4.5 Broader social, political and economic impacts 84
5 Regulated drug markets in practice 99

5.1 Alcohol 100
5.2 Tobacco 105
5.3 Cannabis 110
5.4 Stimulants 117
5.5 Psychedelics 146
5.6 Depressants 156
6 Appendices
Appendix 1: Reforming the UN drug control system 165
Appendix 2: Current legal production frameworks
for opium, coca, cannabis and pharmaceuticals 193

Read it: Transform_Drugs_Blueprint

(It is a little bit above 200 pages)

Most patients hospitalized for opioid detoxification don’t fit the „hooked on street drugs“ stereotype, according to a recent small study from the University of Buffalo. About 40 percent of the 75 study patients became addicted to opioids legitimately prescribed for pain. Another 32 percent initially obtained prescription opioids from the family medicine cabinet, driven by pain or curiosity, or from a friend — often at „pill parties.“ Only about 27 percent—20 patients—said they first became hooked on street drugs.

Almost all—92 percent—eventually bought street drugs, primarily heroin, finding them more effective and less expensive than prescription drugs. They continued using in order to „feel normal“ or „feel like a better person,“ or because the drugs „helped to take away my emotional pain and stress.“

Users said prescription drugs are available in high schools, „at the prom,“ and are used by athletes „to make it through the game,“ and to get high during weekends and off-seasons.

Patients in the study had an average age of 32 years. About 65 percent were men, 75 percent were white, and 75 percent had a high school diploma or equivalent. Those who became addicted from taking drugs legally prescribed for pain were more likely to be older and female, have a college degree, and take the drugs orally.

When asked if any doctor had ever questioned them about a substance use problem before writing a prescription, 74 percent of the 53 participants who answered the question said no.

Recently published in the Journal of Addiction Medicine, the study will be used to educate physicians about screening, treating, and referring patients before addiction becomes life-threatening.


University of Buffalo, August 20, 2010.

Walter Ginter, CMA, has been one of the country’s leading advocates of medication-assisted treatment (MAT) for opioid addiction over the past decade. He has been in recovery for more than 30 years. In September we talked with him about the success of his pilot project on peer recovery support in the Bronx, New York.

If Walter were to post a credo on his office wall, it might read something like this:

  • Opioid addiction is a brain disorder
  • Opioid addiction is a chronic disease
  • Some people will be prescribed methadone maintenance for an indefinite time

The medical community wasn’t convinced of these facts 30 years ago, when Walter began methadone treatment. At several intervals over the next 20 years, his counselors and family told him it was time to quit MAT—despite his successful therapy. Each time he tried to quit, he relapsed to illicit opioids.

It wasn’t until the late 1990s, when Walter met advocates from the National Alliance for Medication-Assisted Recovery (NAMA), that he was introduced to the science of addiction and methadone.

His initial response was anger. „Why did I have to go through 20 years of feeling miserable about myself because I couldn’t get off of methadone?

„After I got over my anger, I didn’t want others to go through what I did. That’s when I became a patient advocate supporting recovery.“

The MARS Project

In short, what happened to Walter many years ago led to his becoming the founder and director of the Medication Assisted Recovery Services (MARS) Project, a peer-initiated and peer-based recovery support project sponsored by NAMA. Funded in the fall of 2006 through the Recovery Community Support Program (RCSP) under the Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Substance Abuse Treatment (CSAT), MARS is the first project funded for MAT patients, and the first recovery support project created and carried out by MAT patients themselves. According to Walter, „the learning curve of grant writing is steep, and the project didn’t succeed until its third submission round.“

MARS is a collaboration between NAMA and Albert Einstein College of Medicine (AECOM), Division of Substance Abuse (DoSA), in the Bronx, New York. „AECOM provided our space. It’s not actually inside the OTP, but it’s right next door and gives us convenient access. We provide peer recovery support services; Einstein provides treatment, from primary care to medication-free services, links to vocational rehab, and mental health services. MARS offers a place for all patients who want to take part to meet and share experiences, strengths, and resources, and to support each other.

MAT patients are welcome to participate in MARS as regular attendees or on a drop-in drop-out basis. The depth of participation is their choice; there are no „stages“ or „phases“ to pass through.

Core Training on Addiction and Methadone


„The most important thing we do is our core training,“ Walter explains. „We realized patients were missing exactly what I missed during those early years: an understanding of what opioid addiction is, how it affects your brain, its chronic nature, and how methadone works. The MARS project differs from other programs in that we teach about medications, including stabilization during induction, the half-life of methadone, and the importance of coming to the clinic every day to receive medication. And why some patients may need methadone for the rest of their lives, like me; how each patient is an individual.

„For a long time, the medical community had two views about methadone. The ‚magic bullet‘ view, ‚Just take the methadone, that’s all you need.‘ On the other side was, ‚You don’t need methadone, just go to groups and control your behavior.‘

„Now we know that opioid addiction has two components. Many patients need medication, and methadone works. But opioid addiction has behavioral components as well; managing them may require peer recovery support services that traditionally have been available only in the medication-free or drug-free recovery community.“

Group Sessions and Advocacy

„We’ve registered about 450 peers in MARS. About 50 are at our recovery project on a given day. MARS has 12 peer leaders who come from the community of patients at Einstein.

„We established a MARS council, where peers decide weekly what the project is going to do, what groups they want, what events they want to hold, and what their plans are for the future. We plan for recovery month events each September. The peers make decisions regarding recovery and project issues.

„Each week there is one peer-leader training session and 18 group sessions. We also provide two types of advocacy for patients: one with treatment providers, such as Albert Einstein; the other with social services. Some peers are intimidated when they try to enroll in Medicaid, so they walk out without getting a card. We go back with them and help them obtain Medicaid and other entitlements.

„Except for core training, our groups are peer initiated and peer led. Many groups are about health and wellness. Peers choose the topics; they know what they need—such as information about hepatitis C. We also have groups on HIV, trauma, and other health and mental health issues.

„Every Friday, MARS conducts a relapse-prevention course that addresses the upcoming weekend, and is designed to help peers maintain their recovery focus through to Monday morning. That was something the peers wanted. MARS also holds off-campus events funded from the grant. We visit museums, often go bowling, and have picnics. We don’t go to movies. Instead, we focus on places where our peers are able to communicate with one another. Many peers don’t know how to socialize without a glass of wine or some cocaine or marijuana. Just learning to socialize, to talk with people, is so important.

„When patients come into an OTP, they view being on medication as the low point of their life. ‚I’m now in the methadone program.‘ Many will say, ‚I’m just going to be here for three months, until I get my act together, then I’m going to detox, and then I’ll be off.‘ If they want to try to taper, we support their choice. I tell them, ‚I’m not selling medication, I’m selling an informed decision.‘ I want them to have all of the answers I didn’t have.“

Are They Patients . . . or Peers?

„When we first became part of the RCSP community, we were encouraged to use the term ‚peers‘ instead of ‚patients.‘ It took a long time for our people to refer to themselves as ‚patients‘ instead of ‚clients,‘ and it wasn’t something I was prepared to abandon. But those in MARS made the decision for me. They decided that when they’re at the OTP, they’re patients, but when they’re in the MARS recovery project, they’re peers—and peers in the purest form: equals. That was one of my happiest days, because I knew that they had taken ownership of the MARS project, as well as their own recoveries.“

Recovery Is . . . and Isn’t . . .

Recovery is a key component of the MARS project, and something few people understand. „Some patients come in believing that recovery is something that happens after you leave treatment,“ Walter says. „At some 12-step meetings, methadone patients are often forbidden to speak. They’re viewed as using a mind-altering drug [methadone] and as still getting high.‘ That’s not true, of course.

„So, many come away with the attitude, ‚I’m less worthy than somebody who’s medication-free‘ — the same way I felt years ago. ‚What’s the matter with me?‘ Well, it’s just the nature of the disease of opioid addiction.

„Our core training helps patients understand that if they stop using alcohol and illicit drugs, they’re in recovery. If they start using less, they’re on the road to recovery.

„Recovery has nothing to do with giving up or not giving up medication. Those who stop using are in recovery, whether they’re taking medication as part of treatment or not.“

The Future of MARS

The MARS project is now up for renewal. Walter notes: „During our four-year pilot project we’ve proved our premise: There are certain things patients—peers—can do better than treatment providers can.“

Peer recovery support provides someone to share experiences with, someone to learn from, „and,“ Walter notes, „more important, someone to teach the lessons I didn’t learn during those first 20 years.

„The MARS pilot project is a huge responsibility for our peers. They realize this project is unique. People go out of their way to help one another, because we all want MARS to be successful and to continue beyond the initial funding.“

As Walter notes, the current success of MARS is especially remarkable because the clinic is located in the south Bronx, a poverty epicenter in our nation, with the highest rates of addiction and HIV infection in New York City. „We’re located next door to the OTP. Patients leaving the OTP have a conscious decision to make—a right turn into the elevator, then out to the street, where heroin and crack cocaine are easily available, or a left turn into our MARS project, and an investment in recovery.“

The fact that so many patients choose that left turn into MARS describes much better than words the success of the MARS project.

In addition to his work at MARS, where he is a project director and director of training and recovery services, Walter Ginter represents NAMA as a planning partner for National Alcohol and Drug Addiction Recovery Months. Walter served as a board member of Faces and Voices of Recovery, and remains an active member of that group. He is often called upon by SAMHSA/CSAT to represent medication-assisted recovery on panels and workgroups, and delivers presentations at major conferences throughout the nation on this topic.

Walter received the Richard Lane Advocacy Award at the April 2009 conference of the American Association for the Treatment of Opioid Dependence (AATOD).

As AT Forum went to press, Walter received word that the MARS project will be funded for four more years.

At a press conference in New York on Tuesday 26 October, at the 65th session of the United Nations General Assembly, one of the UN’s key human rights experts will call for a fundamental rethink of international drug policy.
Anand Grover, from India, is the UN Special Rapporteur on the Right of Everyone to the Highest Attainable Standard of Physical and Mental Health, whose mandate is derived from the UN Human Rights Council. Mr Grover’s annual thematic report, to be presented on October 25/26, sets out the range of human rights abuses that have resulted from international drug control efforts, and calls on Governments to:
  • Ensure that all harm-reduction measures (as itemized by UNAIDS) and drug-dependence treatment services, particularly opioid substitution therapy, are available to people who use drugs, in particular those among incarcerated populations.
  • Decriminalize or de-penalize possession and use of drugs.
  • Repeal or substantially reform laws and policies inhibiting the delivery of essential health services to drug users, and review law enforcement initiatives around drug control to ensure compliance with human rights obligations.
  • Amend laws, regulations and policies to increase access to controlled essential medicines
  • To the UN drug control agencies, Mr Grover recommends the creation of an alternative drug regulatory framework based on a model such as the Framework Convention on Tobacco Control.
The report is the clearest statement to date from within the UN system about the harms that drug policies have caused and the need for a fundamental shift in drug policy.
The report has been welcomed by the European Union in the EU statement on crime and drugs to the UN General Assembly.

Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health

UN Doc No A/65/255
The current international system of drug control has focused on creating a drug free world, almost exclusively through use of law enforcement policies and criminal sanctions. Mounting evidence, however, suggests this approach has failed, primarily because it does not acknowledge the realities of drug use and dependence. While drugs may have a pernicious effect on individual lives and society, this excessively punitive regime has not achieved its stated public health goals, and has resulted in countless human rights violations.
People who use drugs may be deterred from accessing services owing to the threat of criminal punishment, or may be denied access to health care altogether. Criminalization and excessive law enforcement practices also undermine health promotion initiatives, perpetuate stigma and increase health risks to which entire populations – not only those who use drugs – may be exposed. Certain countries incarcerate people who use drugs, impose compulsory treatment upon them, or both. The current international drug control regime also unnecessarily limits access to essential medications, which violates the enjoyment of the right to health.
The primary goal of the international drug control regime, as set forth in the preamble of the Single Convention on Narcotic Drugs (1961), is the “health and  welfare of mankind”, but the current approach to controlling drug use and possession works against that aim. Widespread implementation of interventions that reduce harms associated with drug use — harm-reduction initiatives — and of decriminalization of certain laws governing drug control would improve the health and welfare of people who use drugs and the general population demonstrably.
Moreover, the United Nations entities and Member States should adopt a right to health approach to drug control, encourage system-wide coherence and communication, incorporate the use of indicators and guidelines, and consider developing a new legal framework concerning certain illicit drugs, in order to ensure that the rights of people who use drugs are respected, protected and fulfilled.
Member States should:
  • Ensure that all harm-reduction measures (as itemized by UNAIDS) and drug-dependence treatment services, particularly opioid substitution therapy, are available to people who use drugs, in particular those among incarcerated populations.
  • Decriminalize or de-penalize possession and use of drugs.
  • Repeal or substantially reform laws and policies inhibiting the delivery of essential health services to drug users, and review law enforcement initiatives around drug control to ensure compliance with human rights obligations.
  • Amend laws, regulations and policies to increase access to controlled essential medicines.
The United Nations drug control bodies should:
  • Integrate human rights into the response to drug control in laws, policies and programmes.
  • Encourage greater communication and dialogue between United Nations entities with an interest in the impact of drug use and markets, and drug control policies and programmes.
  • Consider creation of a permanent mechanism, such as an independent commission, through which international human rights actors can contribute to the creation of international drug policy, and monitor national implementation, with the need to protect the health and human rights of drug users and the communities they live in as its primary objective.
  • Formulate guidelines that provide direction to relevant actors on taking a human rights-based approach to drug control, and devise and promulgate rights-based indicators concerning drug control and the right to health.
  • Consider creation of an alternative drug regulatory framework in the long term, based on a model such as the Framework Convention on Tobacco Control.


1,6 Millionen alkoholkranke Menschen leben in Deutschland – Professoren, Obdachlose, Mütter, Mediziner. Das Therapiekonzept ALITA könnte vielen helfen – doch niemand will dafür bezahlen

Weinflaschen ©

Kerstin Saller* ist 56 Jahre, 18 davon hat sie im Alkohol ertränkt. Um von der Flasche loszukommen, lässt sie sich in Suchtkliniken behandeln. Immer wieder. Und immer wieder wird sie rückfällig. „Irgendwann wurde mir klar, dass ich es auf diesem Weg nicht packe“, erzählt sie im Gespräch mit NetDoktor. Doch dann hat Kerstin Glück: Sie ist eine von 180 Alkoholkranken, die an einer zweijährigen Studie des Max-Plank-Instituts in Göttingen teilnehmen. Die letzte Chance. Erprobt wird ein neues Konzept zur Alkoholtherapie. ALITA heißt es und steht für Ambulante Langzeit-Intensivtherapie für Alkoholkranke. „Alles was hilft, ist erlaubt – das war unser Motor“, erklärt Prof. Hannelore Ehrenreich, die Entwicklerin des Modells, gegenüber NetDoktor. Die Medizinerin besitzt jahrelange Erfahrung mit Alkoholkranken, und von diesen gibt es in Deutschland viele. Rund 1,6 Millionen Menschen hängen an der Flasche, bei 3,2 Millionen ist der Konsum im roten Bereich, so die Zahlen der Bundeszentrale für gesundheitliche Aufklärung (BZgA).

Täglich auf Trab

In den kritischen ersten Wochen ist die Betreuung sehr intensiv. „Denn viele Alkoholiker greifen gleich am ersten Tag nach dem Entzug wieder zur Flasche“, weiß die Suchtexpertin. Täglich müssen die Patienten zu einem Gespräch in die Ambulanz. Erscheint ein Patient nicht, telefonieren die ALITA-Betreuer hinterher oder suchen ihn sogar zu Hause auf. „Aggressive Nachsorge“ nennen Ehrenreich und ihr Team das. Auch wenn ein Rückfall droht, sind die Betreuer da – 24 Stunden täglich, 365 Tage im Jahr. „Diese intensive Betreuung war für mich die letzte Rettung“, bestätigt Kerstin. Klassische ambulante Modelle sehen Therapiesitzungen nur ein- bis zweimal wöchentlich vor. Für viele Alkoholkranke reicht das nicht aus.

Unter der Käseglocke

Auch stationäre Therapieansätze für Alkoholkranke haben Schwachstellen, aber andere. Die Patienten werden abgeschirmt vom problematischen Alltagsleben. „Die Klinik“, sagt Kerstin, „wirkt wie eine Käseglocke“. Auf das Ende der Therapie folgt dann der Realitätsschock. Einsamkeit, Familienstress, Arbeitslosigkeit, Geldsorgen, Frust und … der erneute Griff zur Flasche. Kerstin erzählt: „Eine ambulante Therapie ist zwar erstmal härter, aber man lernt von Anfang an im Alltag ohne Alkohol zurechtzukommen.“

Künstliche Alkoholvergiftung

Bei ALITA ist neben der intensiven Betreuung auch die Kontrolle wichtig. Ein täglicher Urintest zeigt, ob der Patient Alkohol getrunken hat oder nicht. Vor den Augen der Betreuer schluckt er täglich ein Mittel mit dem Wirkstoff Disulfiram (Antabus). Es verhindert, dass Alkohol im Körper abgebaut wird. Wer sich jetzt einen genehmigt, bekommt die Symptome einer Alkoholvergiftung: knallroter Kopf, Herzrasen, Schwindel und Übelkeit.

„Wir bleuen den Entzugspatienten die Wirkung des Mittels immer wieder ein“, sagt Ehrenreich. In ihrem Konzept ist das Medikament ein wichtiger Verbündeter im Kampf gegen die Sucht. Entscheidend ist die psychische Wirkung. Kerstin sagt: „Ich hatte die drohenden Folgen dauernd im Hinterkopf, das hat geholfen, dem nächsten Schluck zu widerstehen.“

Jedenfalls ist sie seitdem trocken – so wie rund 50 Prozent ihrer Mitstreiter. „Eine solche Erfolgsquote gibt es sonst weltweit nicht“, betont Ehrenreich. Bei anderen Therapieangeboten seien nach zwei Jahre nur noch 5 bis 30 Prozent trocken, so ihre Erfahrung.

Bürokratisches Tauziehen

Trotzdem gibt es ALITA für Alkoholkranke in Deutschland nicht. Ein wesentlicher Grund ist offenbar das bürokratische Tauziehen zwischen Krankenkasse und Rentenversicherung, bei dem es ums Geld geht. Normalerweise zahlen die Kassen den medizinischen Part (Entzug und manchmal Entwöhnung). Alle therapeutischen Maßnahmen für die Wiedereingliederung ins Berufsleben (also die Nachsorge) übernehmen die Rentenversicherer.

Eine solche Aufteilung gibt es aber beim ALITA-Konzept nicht, weshalb sich keine der Parteien so recht zuständig fühlt. „Unser Gesundheitswesen ist an vielen Stellen wurmstichig und veraltet“, kritisiert die Ärztin Ehrenreich. „Jeder hält an seinen Pfründen fest.“

Kein Interesse an ALITA

Auf Nachfragen von NetDoktor gab der Bund der Rentenversicherer an: Man sehe keine Veranlassung, ein weiteres Therapiekonzept aufzunehmen, sie hätten schon Angebote, die genauso wirksam seien. Konkret benennen konnten die Verantwortlichen allerdings auf Rückfrage keines.

Der Verband der Krankenkassen entdeckte ein anderes Haar in der Suppe. So wurde während der ALITA-Studie in einigen Fällen ein Medikament eingesetzt, das heute in Deutschland nicht mehr verordnet wird. Ein ausreichender Grund, um das gesamte Projekt abzuschmettern.

Schmuddelkinder der Gesellschaft

Erschwerend kommt hinzu, dass Alkoholiker keine Lobby, aber dafür ein denkbar schlechtes Image haben: Sie sind die Schmuddelkinder des Gesundheitssystems. Zu dieser Krankheit mag sich kaum einer bekennen.

So gibt es die Anonymen Alkoholiker seit Jahrzehnten, von anonymen Diabetikern hat noch niemand etwas gehört. Viele Privaten Krankenkassen haben Alkoholentzugstherapien sogar ganz aus dem Leistungskatalog gestrichen. „Das geht soweit, dass Ärzte, die sich mit Alkoholikern befassen, von Kollegen scheel angesehen werden“, berichtet Ehrenreich.

Therapie aus eigener Tasche

Einige Suchtmediziner setzen die Therapie zumindest in Grundzügen ein. Die Drogenhilfe Provivere in Hamburg bietet das Konzept Plan A an, das auf ALITA basiert – allerdings nur für Selbstbezahler. 18.000 Euro müssen die Patienten für die zweijährige Therapie berappen. Das Westfälische Zentrum für Psychiatrie in Bochum setzt das Konzept in Grundzügen im Rahmen ihrer Alkoholambulanz um – einen 24-Stunden-Service wie ALITA ihn eigentlich vorsieht, kann das Team jedoch nicht leisten. „Darunter leidet vermutlich auch die Erfolgsquote“, bestätigt der Leiter der Ambulanz, Dr. Alfred Wähner, gegenüber NetDoktor.

Dass ALITA dauerhaft wirkt, dafür ist Kerstin der beste Beweis. Sie versucht sich unverdrossen als freiberufliche Ernährungsberaterin zu etablieren. Zwar ist die Situation der Hartz-IV-Empfängerin alles andere als rosig – trotzdem hat die Droge die Macht über sie verloren. Sie sagt: „Ich verschwende heute keinen Gedanken mehr an Alkohol.“


Christiane Fux


The present review aims to clear up the issue of the neurological processes  underlying the personality changes induced by chronic opioid use. The effects  of methadone treatment on brain functions have been analyzed, too. Brain disintegration becomes evident very soon after an onset of chronic heroin abuse and continues throughout the period of drug consumption. A considerable  proportion of opioid addicts are characterized by conspicuous neuropsychological  deficits, which preclude the maintenance of complete opioid abstinence  in this patient subgroup. At present, there are no data to testify that the effects of methadone maintenance on brain functions exceed the adverse neurological effects of chronic heroin use.

Progressive personality changes in opioid addicts are a considerable burden for  their families and for the community. Opioid addiction is associated with a high risk  of death. Only about 50% of these patients live longer than 20 years after an onset of
opioid use [6], and about 10% of them try to commit suicide over a 12-month period  [11].

It is also appropriate to stress the contribution of heroin addiction to the prevalence of HIV infection and other morbid conditions. Hence, the progressive personality  changes seen in opioid addicts represent the core and most serious complication of
chronic opioid use. Unfortunately, all existing treatment approaches, including complete  opioid abstinence, do no more than partly alleviate these personality changes in
a proportion of addicts.

The present review aims to clear up the issue of neurological processes underlying  the personality changes induced by chronic opioid use. The effects of methadone treatment  on brain functions in this patient population have been analyzed, too.

Progressive brain disintegration in heroin abusers

Abnormal electric activity in central brain regions in heroin addicts.

There is growing evidence that electric activity in central brain regions is radically  altered in heroin addicts, and that these alterations emerge very soon after an onset of chronic opioid use.

In the late ’90s heroin addiction spread all over Russia on the scale  of an epidemic. In that period, street heroin was relatively pure and in most cases it  did not contain contaminants. The duration of daily heroin use ranged from several  months to 3.5 years in the addict population of Moscow.

Besides this, a considerable  proportion of Russian heroin abusers were very young (mean age about 23 years) and otherwise psychiatrically healthy people coming from well-educated and socially integrated families.

This gave us the opportunity to evaluate the early effects of daily  heroin use on the electric activity of the brain in young patients with a relatively normal  psychiatric premorbid history.

We found that the mean frequency of alpha2 band electric activity in heroin addicts  was significantly above normal throuhout the brain, as assessed by comparison with controls, and that this electroencephalographic (EEG) phenomenon was significantly correlated with the duration of chronic heroin use in our patient cohort [34].

The most  important finding in this study referred to relationships between changes in brain electric  activity and selective cognitive dysfunctions in the early stages of heroin addiction.

Planning deficits (the Tower of London test) was strongly associated with alpha2 mean  frequency increases in central derivations (C3, Cz and C4) in our patients [13].

This association was mediated by the length of chronic heroin use in the right hemisphere  (C4), whereas it was not related to chronic heroin use at the left central lead (C3). These  data gave grounds for hypothesizing that the functioning of central brain structures is
affected very soon after an onset of chronic heroin use, and that these alterations first  arise in the left hemisphere and a little later spread to the central region of the right hemisphere in heroin addicts.

At least four other research groups similarly recordedelectric activity abnormalities in central brain regions in patients with a mean duration  of chronic heroin use ranging from 3.5 to 15 years; all of these findings refer to slow  wave activity in central structures.

Shufman and colleagues [39] reported an excessive intensity of delta activity at Cz in abstinent patients with a mean length of chronic heroin use of 3.5 years, but in no  case did these authors find any similar electric abnormality in current heroin users
with a mean duration of opioid use of 4.5 years. Papageorgiou and colleagues [31] also  found an abnormal spread of slow wave electric signals from C3 to right hemisphere  central and frontal regions during the performance of a cognitive test by heroin addicts  who had been abstinent for at least 6 months. The most important findings on electric  activity in central brain structures in heroin addicts were reported by Franken and colleagues
[16, 17].

This research group found that heroin cues elicited slow wave-evoked potentials with the largest amplitude at central leads (C3, Cz and C4) in heroin addicts  who were compared with normal controls, and that the amplitude of these potentials  was significantly correlated with the severity of craving for heroin.

These authors also reported a significant correlation between craving severity and the coherence of delta activity at central temporal derivations in the same patient cohort.

It should be noted that in our patient cohort we recorded significant correlation  between the intensity of delta activity at Cz and C4 and the amounts of heroin which  patients used per day before their admission to the in-hospital unit. Following a different
line of inquiry, Greenwald & Roehrs [20] found increased delta activity in central  derivations in addicts who self-administered fentanil, in comparison with patients who  received the drug passively. Both findings may be interpreted as an indirect confirmation  of causal association between delta activity in central brain structures and craving processes.

These contemporary EEG studies go to show that central brain structures are radically  altered in heroin addicts at an early stage. This functional brain system is involved  in incentive sensitization and craving processes, and is unable to adequately support
cognitive operations which do not relate to heroin use in this patient population. The severity of the dysfunction of central brain structures seems to be directly related to the severity of addiction behavior.

All the characteristics of the central brain electric system mentioned above closely  resemble the abnormalities of the mesocorticolimbic dopamine system in opioid-abusing
subjects. Animal and human studies have shown that the structures of mesocorticolimbic  system (dopamine neurons of the ventral tegmental area, the nucleus accumbens and  anterior cingulate gyrus) are highly sensitized to opioids and neuroplastically altered  in addicts [35, 36].

The baseline activity in these structures is abnormal in abstinent heroin abusers [18]. These structures are involved in incentive sensitization and craving processes  [8, 9, 38], and are unable to adequately support cognitive operations which are not related
to drug addiction behavior in opioid addicts [14, 15, 26]. Hence, EEG studies confirm the findings of human neuroimaging and animal experimental studies on the quickly initiated, inevitable long-term reorganization of the dopamine mesocorticolimbic system in heroin abusers.

Frontal dysfunction in heroin addicts.

In our study of heroin abusers, a subgroup of patients with a duration of chronic  heroin use of under 18 months did not differ from healthy controls in their performance on two cognitive tests evaluating prefrontal functions (Delayed Alternation Test and
Wisconsin Card Sorting Test) [4].

Even so, individual variations in cognitive performance
were significantly associated with the amount of heroin which patients self-administered  each day before their admission to the in-patient unit [5]. Patients who performed poorly  on both prefrontal tests self-administered about 0.7 gram of heroin per day, whereas patients who performed ‘ideally’ on prefrontal tests used only 0.18 gram per day. The subgroup of patients with a selective deficit on Delayed Alteration Test self-administered
0.4 gram per day. Three subgroups did not differ in the duration of chronic heroin use.
We concluded that premorbid prefrontal dysfunctions significantly affect patterns of  daily heroin use in subjects with a relatively short drug use history.

Four other research groups reported significant clinical effects of prefrontal dysfunctions  in opioid addicts. Gerra and colleagues [19] observed right prefrontal hypoactivation in heroin addicts with antisocial and/or depressive personality characteristics, i.e. a
subgroup of patients with especially severe addictive behavior. Similar findings were  reported by Bauer [3], who found significant correlation between childhood conduct disorder and amplitude of the P300 component of EEG evoked potential which was
recorded during a continuous performance test in adult drug-abusing patients.

Besides this, Pezawas and colleagues [32] observed a significant effect of the frontal lobe volume on the longest periods of abstinence in methadone-maintained patients, and Lyvers &
Yakimoff [29] found a correlation between the severity of opioid dependence and the number of perseverative errors made in performing the Wisconsin Card Sorting Test in
their similar patient cohort.

Hence, prefrontal dysfunction is an individual characteristic of heroin abusers, and it underlies the prominent severity of drug abuse patterns in a proportion of opioid addicts.

Although patients with a short duration of chronic heroin did not differ from normal controls on their performance on the Delayed Alternation Test in our study, patients with a longer heroin abuse history (18 months to 3.5 years) gave a significantly poorer
performance on this orbito-frontal neuropsychological task compared with normal subjects (p=.04). Moreover, we found a significant association between performance on Tower of London test (medial prefrontal cortex) and the duration of chronic heroin
use [4]. These data gave grounds for concluding that dysfunctions in the orbito-frontal and medial frontal cortex progress in subjects sowing a chronic use of heroin.

Two other research groups reported a similar association between frontal cortex  deficits and chronic opioid use history. Liu and colleagues [27] found significant and  negative correlation between bilateral white matter volume and length of chronic heroin
usage in addicts with a drug abuse history of 2 – 15 years. Franken and colleagues [17] reported significant negative correlation between frontal interhemispheric coherence and chronic heroin history duration. It should be noted that, along with neuropsychological deficits, brain electric activity in frontal regions was also significantly correlated with heroin abuse history in our patient cohort [34]. Overall, these findings provide
evidence that prefrontal dysfunction progresses in opioid users during their period of drug consumption.

Concomitant brain damage in opioid addicts.

Concomitant brain damage is common in opioid addicts. About 70% of opioid users report non-fatal overdoses and mild to moderate head injuries, which significantly affect cognitive performance in this patient population [10].


Concomitant alcohol and cocaine abuse also significantly contribute to brain damage in chronic opioid users [10, 28].

Ischaemic-hypoxic brain lesions are commonly found in long-term heroin addicts, and these brain alterations develop at significantly earlier age than in non-drug abusing controls [1, 28].

Concomitant adverse factors probably underlie the posterior brain disintegration which was reported in addicts with a long-term heroin history (about 15 – 20 years), but not in patients with a shorter duration of chronic heroin use [2].

The course of brain disintegration in chronic heroin users.

The findings of neuroimaging, EEG and neuropsychological studies cited above  may be summarized as follows. Brain disintegration becomes apparent very soon after an onset of chronic heroin abuse. First, opioids inevitably reorganize the dopamine
mesocorticolimbic system, which begins to implement addictive behaviour and is ineffective in other domains in chronic heroin users. Second, prefrontal dysfunction progresses in opioid addicts, and its severity is associated with especially prominent
patterns of addictive behaviour. Third, concomitant brain damage is another common feature in heroin addicts, and may contribute to cognitive dysfunctions in this patient population!

Physiological correlates of complete opioid abstinence.

Gritz and colleagues [21] registered significant elevation of heart rate with the same trend for arterial blood pressure in opioid addicts who had been completely abstinent for two months. At the same time methadone-maintained patients demonstrated normal
haemodynamics, along with a somewhat depressed respiration rate. This study therefore confirmed clinical observations concerning persistent sympathetic hyperactivation
in abstinent opioid addicts [33], whereas methadone treatment normalized autonomic dysfunctions in this patient cohort.

Shufman and colleagues [39] demonstrated that both abstinent and methadone-maintained patients were characterized by abnormalities in brain electric activity not found in healthy controls. The two groups demonstrated similar significant deficits of alpha2 band power, but differed in delta and alpha1 power displayed. Delta activity was significantly higher in abstinent subjects, whereas the intensity of alpha1 activity
was higher in methadone-maintained patients. Similar data were reported by Gritz and
colleagues [21], who recorded significant slower alpha rhythms in methadone-maintained patients than in normal controls, with intermediate alpha peak frequencies in abstinent subjects.

Cognitive dysfunctiona are also commonly reported in both methadone-maintained and abstinent patient populations.

Two neuropsychological studies found cognitive deficits
to be more frequent and more conspicuous in methadone-maintained patients than in abstinent addicts [12, 21].

However, methadone-maintained subjects were characterized
by considerably longer histories of street opioid use compared with abstinent controls in both reports. Bauer [2] too observed significantly more radical changes in visually evoked potentials in methadone-maintained subgroups compared with abstinent ones.
Even so, statistical procedures showed that these differences were mediated by the
length of chronic heroin use, but not by the effects of methadone treatment.

Methadone-maintained patients and abstinent former addicts with an equal length of chronic heroin use were compared in the study of Mintzer and colleagues [30].
Psychomotor speed was slower in both patient groups than in normal controls, while this deficit was even more marked in former addicts than in the methadone group. However, methadone-maintained patients demonstrated additional cognitive impairment while performing the Gambling Task, which measures orbito-frontal cortex functions.

In our opinion, these data provided evidence that the orbito-frontal dysfunction underlies the inability of methadone patients to maintain complete opioid abstinence, whereas addicts
showing a normal orbito-frontal performance entered the abstinent subgroup.

Overall, the studies just cited can be summarized as follows. Both methadone- maintained and abstinent addicts display cognitive impairment when compared with
healthy controls. At the same time, patients entering methadone maintenance treatment are characterized by more comspicuous cognitive deficits than patients who are able to maintain complete opioid abstinence.

Correlates of cognitive dysfunction in methadone-maintained patients.

At least 4 neuropsychological studies failed to find any significant association between methadone dosage regimen and cognitive performance [10, 21, 37, 40].

Moreover, Gruber and colleagues [22] demonstrated an improvement in cognitive functions as little as two months after the beginning of methadone treatment in opioid addicts. At the same time, cognitive deficits in methadone-maintained patients was significantly correlated with the number of non-fatal overdoses, mild to moderate head injuries, severity of
alcohol dependency and global health in the study of Darke and colleagues [10].

These data all provide evidence that methadone maintenance per se does not seem to radically affect cognitive functions in chronic opioid abusers. However, mildly sedative effects
attributable to methadone may not be completely excluded by the data just quoted.


From the neurological point of view, populations of opioid addicts are not homogeneous.
A considerable proportion of opioid addicts are characterized by conspicuous neuropsychological deficits, which preclude the continuation of complete opioid abstinence by this patient subgroup. So far, no data have been found to testify that the
effects of methadone maintenance on brain functions exceed the adverse neurological effects of chronic heroin use.


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The southern Kyrgyz city of Osh saw violent ethnic clashes in June. But the city has other problems – it is also a major hub for Afghan heroin on its way to Europe. Rayhan Demytrie has been investigating the impact of drug trafficking on the region.

A poster advertising the NGO the runs the needle exchange in Osh
An NGO runs a needle exchange programme in Osh for heroin addicts

A group of volunteers are smoking cigarettes outside a needle distribution centre in Osh.

Most of them are former drug addicts.

„When we started taking drugs, we watched films, saw people snorting drugs through dollar bills and we thought it looked so cool,“ says Oleg.

„We did not know what it might lead to. But now those who are starting up can see what it leads to and yet they still do it.“

Yulia, standing nearby, blames a lack of jobs.

„There is nothing to do, there is no work. Young people don’t have anything to do,“ she says. „They will try it once, twice and then the third time they are already hooked.“

Osh – the centre of ethnic fighting in June between the Kyrgyz and Uzbek communities – is one of the drug capitals of Central Asia.

A quarter of the world’s heroin is believed to travel through Central Asia on its way to Russia and Europe. Osh is a key hub along the route.


Mamasabir Burhanov, who set up the needle distribution project, says the growth in heroin users is linked to the collapse of the Soviet Union.

„In Soviet times the borders were strong and drugs didn’t get through. With the collapse of the Union, the borders got much weaker. Drugs offered such good profits, and lots of people got involved in trafficking,“ he said.

„The resources we have to fight against the drug traffickers here are like a sling against a tank. We don’t have enough resources to stop the drugs that come through our country.“

Most who know the region well believe that serious money is generated in the south through criminal activity, especially the drug trade.

„There is no other business here,“ says Radmir, a local journalist.

Red town

Driving through town on the way to distribute clean syringes, Oleg points to the home of a drug dealer.

„Everybody in Osh knows who he is. He’s been selling hashish, opium and heroin since the early days. And what’s most important is that he will keep selling it,“ he says.

File image of a heroin addict injecting a fellow addict in Kabul, Afghanistan
Heroin addicts in Osh say police target them rather than their dealers

At the syringe collection point, heroin addicts were quick to condemn local police.

„They detain us for carrying small amounts of drugs even though we have ID showing that we are heroin addicts. Why don’t they detain drug dealers?“ said one.

„They bring drugs to drug dealers and profit from sales, it’s a red town. It means it is controlled by the police,“ said another.

At the city’s Ministry of Internal Affairs, the deputy head of the anti-narcotics department played down the corruption allegations.

Melis Mamasaliyev said there had not been any such cases this year. But he was willing to talk about successes.

„Our biggest seizure was in May – over 100kg, more than half of it was heroin,“ he said

„Immediately after that we had the inter-ethnic conflict in June. Since then we haven’t been able to concentrate on drugs – because we’ve been involved in dealing with the conflict.“

‚Tears of Allah‘

It is true that it has been a year of political and social unrest in Kyrgyzstan.

President Kurmanbek Bakiyev was ousted in popular protests in April, leaving an interim government in charge of a fragile nation.

Ethnic Uzbeks eat outside their destroyed house on 7 October 2010
The violence in April between Kyrgyz and Uzbek residents left thousands of people displaced

A struggle developed in the south – Mr Bakiyev’s home region – between the former president’s supporters and new political leaders in Bishkek.

Old ethnic tensions between Kyrgyz residents and ethnic Uzbeks were exploited. Organised crime, corrupt politicians and those who benefited from drug money are suspected of having played a hand in the violence.

Criminal gangs who thrive on the heroin trade are believed to have influence and protection among government officials.

In 2009 after noted successes, Mr Bakiyev’s decision to shut down Kyrgyzstan’s Drug Control Agency (DCA) strengthened the widespread suspicion that gangs enjoyed the patronage of powerful government figures.

Vitaliy Orzaliyev, who was the deputy head of the DCA, says his agency was becoming too successful and independent.

„Just a few months before the closure there were a few successful seizures, including liquid heroin called the Tears of Allah which fetches 45,000 euros ($63,000) per kg,“ he said.

„Another 200kg of heroin that we tracked was seized in Russia with a street value of around 6 million euros, huge money.“

The Drug Control Service has since been reinstated by current Kyrgyz leader Roza Otunbayeva. Mr Orzaliyev is now heading the unit.

„Ms Otunbayeva said at the UN General Assembly in September that one of the reasons for the disorders in June was the fight against the drug channels, the transit, and fighting between drug clans,“ he said.

„When the Bakiyevs were overthrown and the authorities were weakened, no-one was monitoring organised crime. They were left to their own devices, and different interests were in play. They had money to support one side or the other.“

New patrons

Regional observers say the trend in which drug gangs seek protection from figures in the government may continue.

According to Paul Quinn-Judge, the Central Asia director for International Crisis Group, organised crime and narcotic groups may already be looking for a new set of patrons.

The road to Batken on the Tajik border that traffickers use to bring in drugs
Officials say drugs are flowing into Osh from Afghanistan and then on to Europe

„They have to make sure that drugs continue to flow through here in the way they had in the past. Having very high-level protection as they had here in Kyrgyzstan, they were probably feeling rather spoiled. So we assume that the narcotics dealers are looking for a similar deal in the future,“ he said.

In Kyrgyzstan’s recent parliamentary elections many of Mr Bakiyev’s allies from the south were re-elected. They are now seeking office in a possible coalition government.

It is not clear yet how high the fight against organised crime or drug trafficking will be on the new government’s list of priorities.

Listen to Rayhan Demytrie’s Assignment documentary:  ‚Drugs and Power in Kyrgyzstan‘


A medical calculator to help generate equivalent doses of various oral and intravenous opioids to treat chronic pain.

What’s New in Version 1.3

Added a second slider for lower doses of opioids.

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There’s at least one in most British households, even if it’s rarely used. The humble teapot has a fascinating story to tell about our country’s complex past.

Did you know that the early tea trade was bankrolled by drug trafficking and sparked wars?

Or that afternoon tea and high tea began as two distinct traditions that polarised the class divide in Britain?

The story of 19th century empire: Behind the modern British cup of tea lies the high politics of Victorian Britain
The story of 19th century empire: Behind the modern British cup of tea lies the high politics of Victorian Britain


This week, the fascinating Radio 4 series, A History Of The World In 100 Objects, tells the story behind an earthenware tea set  –  produced in the 1840s at Wedgwood’s Etruria factory in Stoke-on-Trent  –  and, in so doing, lifts the lid on a tale of high politics, greed, social engineering and an empire built on tea leaves.

Tea first arrived here in the early 1600s, and it was so expensive it was served in tiny cups. Then, along came a tea-loving royal, Charles II’s queen-consort Catherine of Braganza, who made it the fashionable drink of the wealthy classes.

It remained a luxury until the end of the 18th century  –  hardly surprising given that a pound of tea would have cost a British labourer the equivalent of nine months‘ wages.

The ritual of afternoon tea was a Victorian invention and is credited to the Duchess of Bedford. Finding she was in need of an afternoon pick-me-up between luncheon and dinner, the Duchess took to enjoying a cake or crustless sandwich with her afternoon cup of Darjeeling.

Soon, it was de rigueur for society hostesses to serve tea at 4pm, and before long every fashionable household boasted a china tea set as cheaper versions spread through society.

Funding the tea trade: A cartoon depicting the Opium Wars
Funding the tea trade: A cartoon depicting the Opium Wars


While the upper echelons enjoyed their tea in genteel surroundings, the drink started to be promoted among the urban population as an alternative to alcohol.

By the 19th century, beer, port and gin had become central to the diet of men, women and even children, since alcohol  –  with its mild antiseptic properties  –  was much safer to drink than unpurified city water, and alcohol consumption had become a real social problem.

So religious leaders and temperance movements joined together to proclaim the merits of tea as an alternative, promoting it as ‚cheap, refreshing and tasting good‘.

At the same time, tea became a symbol of the re-branded British character  –  polite and respectable, with none of the old rowdy conviviality. And along with this came a distinctly working-class, tea-drinking ritual  –  the high tea  –  served at the dinner or ‚high‘ table.

This was a hearty meal dished up at 6pm after a hard day’s work. There on the table would be a feast of bread and butter, cheese, meat, fish or eggs and cake. All washed down with a mug of tea.

Not surprisingly, as tea established itself right at the heart of British life, it became big business. But, to buy the tea in China at a more reasonable price, the British East India Company encouraged an illicit opium trade, smuggling opium grown in India into China and using the ill-gotten gains to fund the tea trade.

Potted history: The 1840 Wedgwood teapot
Potted history: The 1840 Wedgwood teapot


The first Opium War with China broke out more or less as this Wedgwood teapot was leaving the factory.

It was partly because of these difficulties with China that the British set up plantations in the area around Calcutta in the 1830s, and that’s why it was the strong, dark Assam tea that was to become the patriotic British cuppa. It soon became the drink that sustained an empire.

As the century went on, tea plantations were established in Sri Lanka  –  and large numbers of Tamils were moved there from South India to work on them. Meanwhile, fortunes were made in shipping as this rapidly expanding trade required huge numbers of clippers to ferry the tea to Britain.

Getting sugar on to a British tea table also came at a human cost. The first African slaves to arrive in the Americas worked on sugar plantations, the start of the long and terrible network that carried European goods to Africa, African slaves to the Americas and slave-produced sugar to Europe.

After a long campaign involving many of the people who also supported temperance movements, slavery in the British West Indies was abolished in 1830. But there was still a great deal of slave sugar around  –  Cuba was a massive producer  –  and it was, of course, cheaper than anything grown on free plantations. So the ethics of sugar continued to be hot politics.

By 1900, the average tea consumption per person in Britain was a staggering 6lb a year. But it’s one of the extraordinary ironies of British national identity  –  or perhaps it says everything about our national identity  –  that the drink that epitomises Britishness is not actually British at all and is the result of a complex imperial history.

Behind the modern British cup of tea lies the high politics of Victorian Britain, the story of 19th-century empire, of mass production and mass consumption, the taming of an industrial working class and the displacement of millions of people. It’s a lot to think about as you tuck into a slice of Victoria sponge!

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BANGKOK, Sep 29, 2010 (IPS) – Dustbins in a university toilet rarely elicit a second look, but those at one of the oldest universities in Burma’s Kachin State do offer reason to pause. The bins, after all, collect a special form of garbage disposed of by students – hypodermic needles and syringes they have used to inject themselves with heroin.

The special bins were introduced to Myitkyina University as part of a humanitarian gesture by two non-government organisations – the French-based Medecins Du Monde (MDM) and Holland-based Artsen Zonder Grenzen (AZG) – with the aim of reducing injuries that students often get from stepping on used needles and syringes strewn around the campus.

It is normal to find „discarded bloody syringes, needles, and syringe packets (that) are littered in latrines, under stairwells and bushes, and even scattered on the football field“, according to the Kachin News Group.

It is these details, which expose the alarming level of heroin addiction in the university of some 3,000 students, that Nawdin Lahpai of the Kachin News Group cites when painting a grim picture of „the future leaders of the Kachins being destroyed by drugs“.

„The drug addiction was not as high as it is now in the university, which is located in the capital of the Kachin State,“ the editor of the news organisation, based in Thailand’s northern city of Chiang Mai, told IPS. „It has changed since 2004. Now heroin is easily accessible everywhere.“

Some estimate that over 50 percent of the male and female students seek a narcotic fix. „Students can be seen openly purchasing drugs in shops, cafes, billiard centres and houses near the university,“ with sales beginning as early as 8 a.m. in some places, states a brief study released Wednesday by Nawdin’s media group.

The leaders of the Kachin, an ethnic minority that has, like other ethnic groups, been persecuted by the Burmese military, place the blame for this situation of drug abuse squarely on the country’s junta.

They accuse the regime of promoting the narcotics trade to further torment the country’s beleaguered minorities – and weaken their social fabric.

„The military government must bear responsibility for this spread of drugs into the communities,“ Col James Lum Dau, deputy chief of foreign affairs of the Kachin Independence Organisation, said in an interview. „But the students being addicted to drugs also need to discipline themselves.“

Such concern about heroin use in Burma, also known as Myanmar, is shared in both the Kachin and the neighbouring Shan State, home to the ethnic Shan, near the Chinese border. Both provinces are where most of the opium – a thick paste extracted from poppy to make heroin – is grown in the country.

The Kachin and the Shan are among the 130 ethnic communities in Burma, majority of whose more than 55 million people are with the Burman ethnic group.

Currently, 46 of the Shan State’s 55 townships are growing poppy, Khuensai Jaiyen of the Shan Drug Watch told a press conference here on Sep. 29 to launch the Chiang Mai- based organisation’s 2010 report. „This is attributed to the Burma Army’s reliance on taxation of opium, and its policy to allow numerous proxy militia to deal in drugs.“

„Most of the poppy-growing areas are under control of the Burmese army and the Burmese army’s local militia,“ he added. „The Burmese army needs the drug trade to feed its own troops.“

The continuing presence of poppy fields in the rugged, mountainous corner of Burma over a decade after the regime announced it was determined to eradicate the drug trade by 2014 troubles the United Nations Office on Drugs and Crime (UNODC).

In a December 2009 report, the U.N. agency revealed that the area under poppy cultivation had increased 50 percent since 2006 to 31,700 hectares. „More than one million people are now involved in opium cultivation in Myanmar, most of them in Shan State, where 95 percent of Myanmar’s poppy is grown.“

In fact, „2009 saw the third successive annual increase in cultivation,“ said Gary Lewis, head of the UNODC’s East Asia and Pacific office, in an interview. „Our assessment convinces us that we need to remain very concerned about the extent of opium cultivation in Myanmar.“

This trend marks a reversal of the dramatic drop in Burma’s opium production in the mid-1990s, when it enjoyed the notoriety of being the world’s leading opium producer. The 1995-96 harvest season saw poppy cultivation peak at an estimated 163,000 hectares, producing 1,760 metric tonnes of opium, says the UNODC.

„At that time these figures were the highest in the world,“ said Lewis. „By 2001-2002 however, domestic cultivation had declined to 81,400 hectares and estimated opium production had decreased to 828 metric tonnes.“

The Burmese regime’s 1999 announcement that it would eradicate the drug trade in 15 years saw the country give way, in 2000, to Afghanistan as the world’s largest heroin supplier.

But the junta’s continued support of opium production convinces the likes of Khuensai that the regime’s ‘war on drugs’ is a „charade“. „This is evident from the junta’s local militias emerging as the new drug lords in Burma.“

The easy access to drugs in Kachin State exposes the junta’s plans „to profit at the expense of the ethnic groups,“ adds Nawdin. „It is almost like a Cold War to destroy the young.“

source is:


By Gordon Duff STAFF WRITER/Senior Editor

Republicans and “Tea Party” candidates are expecting to take over congress in a very few days, a “big win” totally underwritten with drug money.  There is no secret about it.

By June, $200 million in “foreign” contributions had already come into the GOP and Tea Party and not one cent of it is accounted for.  It is “corporate” money, money that doesn’t have to be American, doesn’t have to be legal, money that would put any normal American in prison for years if they had one cent in their pockets.

The $200 million is laundered drug money, much from Afghanistan but much also from Mexico, those drug money cartels that are buying America’s Southwest, the same cartels that did so well during the Bush years when the border with Mexico was open and totally unwatched.

You didn’t know that?

Those photographs showing backpacks and trash, abandoned by drug money “mules” and other illegals, the massive flow across the border, you didn’t know those photos were taken between 2001 and 2008?  You didn’t know that, in 8 very long years, the 8 years of the “W” Bush presidency, the number of illegal aliens in the United States doubled?

Now you wonder why the Mexican drug cartels are sending millions into America, all legal and proper “corporate” contributions, nice and clean, laundered just the way the Supreme Court wants it, drug money to keep their business growing, reopen the border, money to guarantee them favorable courts, friendly “law enforcement” and a return to “business as usual.”

The majority of the cash, however, originates from Afghanistan.  Not from the country itself, but from the $65 billion dollar a year heroin industry created from nothing after the US invasion of Iraq.  America joined with the drug money cartels of the Northern Alliance to remove the Taliban.  You remember the Taliban, the group that wanted too much of a percentage from the American oil companies who were planning a pipeline through Afghanistan, the same Taliban that eliminated opium production entirely?

Drug Money Made from American Fertilizer

Now the opium is being processed right there in Afghanistan, heroin made from opium grown with American fertilizer in fields protected by American soldiers, fields controlled by war lords working closely with the CIA and America’s military commanders in the region who make sure Russia, Europe and America have that needle in the arm and stay hooked for another generation.

Vietnam was a drug war as were the Reagan era phony wars in Central America.  You can’t turn on the TV without seeing it in a movie.  Movies aren’t always right but whenever you see Stephen Seagal or Chuck Norris stomp a drug money baron, we only wish they were doing it for real.

What is this election going to create?  Never in American history has foreign money been allowed this freely into the United States.  Japan, Saudi Arabia, Germany and Israel have typically spent the most and bought the most power.  Then came China.  They began buying politicians too, a million here, a hundred thousand there.

There is a lot of reasons to invest in a new congress.  If the war in Afghanistan ends, drugs won’t move freely.  If torture and rendition end, those planes that fly prisoners around won’t be able to carry the tons of heroin around the world too.  Isn’t part of the plan to make heroin so cheap that millions of Russians will be addicted?  Isn’t this part of the secret CIA plan also?

Drug Money War Being Taken Over By Terrorists

Isn’t all that drug money keeping Afghanistan from being taken over by terrorists?  This is what Ambassador Richard Holbrooke keeps telling us, keep the drugs flowing and America will be safe, safe except for that addict who just kicked down your door.

Over $1.2 billion will be spent on the upcoming election, over a billion to fund the jobs of 200 legislators whose income wouldn’t cover two days interest on that money.  Can you smell that smell, that rotten “government” smell?  Money used to come from big oil, crooked banks, pharma and nutty billionaires with names like Buffett and Scaife or perhaps DeVos.

Now the money is from drug cartels, mercenary armies and huge drug money laundering banks, brought in by the carload, open and free, no laws can control it.  All that is needed is a corporation, and that can be done in some states for 15 bucks.  Corporations can take foreign assets, send them to the United States, assets from any source, legal or illegal, and transfer those assets to a political party.

This year 90% of the drug money is going to the Republicans.  I wonder what is is buying?  I suspect Americans will eventually find out.


BACKGROUND: In Finland, buprenorphine (Subutex) is the most abused opioid. In order to curb this problem, many treatment centres transferred („forced transfer“) their buprenorphine patients to the buprenorphine plus naloxone (Suboxone) combination product in late 2003.

METHODS: Data from a retrospective study involving five different treatment centers, examining the effects of switching patients to Suboxone, were gathered from 64 opioid-dependent patients who had undergone the medication transfer.

RESULTS: Most patients (90.6%) switched to Suboxone at the same dose of buprenorphine that they had been receiving as Subutex (average 22 mg). The majority of these patients (71.9%) were maintained at the same dose of Suboxone throughout the 4-week study period. During the first 4 weeks, 50% of the patients reported adverse events and at the four month time point, 26.6% reported adverse events. However, due to adverse events one patient only discontinued treatment with Suboxone during the 4-week study period, and five during the four month follow-up period. Of the 26 patients in the follow-up period, Suboxone was misused intravenously once each by 4 patients and twice by 1 patient. These 5 patients all reported that injecting Suboxone was like injecting „nothing“ with any euphoria, or that it was a bad experience.

CONCLUSION: We conclude that when patients are transferred from high doses (> 22 mg) of buprenorphine to the combination product, dose adjustments may be necessary especially in the later phase of the treatment. We recommend that a transfer from Subutex to Suboxone should be carefully discussed and planned in advance with the patients and after the transfer adverse events should be regularly monitored. With regard of buprenorphine IV abuse, the combination product seems to have a less abuse potential than buprenorphine alone.




Abuse and misuse of pharmacological therapies represent major challenges in the healthcare system, particularly in patients receiving long-acting opioid drugs for the treatment of heroin or opioid addiction. The partial mu-opioid receptor agonist buprenorphine is used to treat opioid dependence, but diversion and misuse may occur.

The sublingual combination formulation of buprenorphine and the opioid receptor antagonist naloxone (buprenorphine/naxolone) is associated with a reduced abuse potential, and has been shown to have promising efficacy for the treatment of opioid dependence. This observational study assessed the safety and efficacy of sublingual buprenorphine/naloxone combination therapy in patients with opioid dependence after therapeutic switch from buprenorphine monotherapy. A total of 94 patients being treated with buprenorphine monotherapy (average dose 8 mg/day; mean duration of therapy 840 days) were switched to buprenorphine/naloxone combination therapy. Patients were asked to rate their level of satisfaction with buprenorphine/naloxone combination treatment with respect to the management of withdrawal symptoms, and urinary toxicology tests were carried out before and 14 days after switching to combination therapy. Within 3 months, 75/94 patients (80%) previously treated with buprenorphine monotherapy had switched to sublingual buprenorphine/naloxone combination treatment (average dose buprenorphine 8 mg).

Among patients receiving combination treatment for >3 months, 83% were receiving medication either weekly or fortnightly, based on the results of toxicological testing. A reduction in positive urinary toxicology tests was observed in patients within two weeks after being switched to combination treatment (before switch: 28, 9 and 2 positive tests for heroin, cocaine and heroin + cocaine, respectively vs 11, 3 and 1 after switch) and a total of 64 patients of the 75 who switched to combination therapy (85%) were satisfied with the management of withdrawal symptoms during buprenorphine/naloxone treatment.

Few adverse events were reported and no patients dropped out of treatment. This study shows that switching from buprenorphine monotherapy to sublingual buprenorphine/naloxone combination therapy is effective and well tolerated, and associated with good control of withdrawal symptoms in the majority of patients. In addition, combination therapy reduced illicit drug use (based on negative urinary toxicology texts) and allowed the time between clinic visits to be increased.


AMA. 2010;304(14):1612-1614. doi:10.1001/jama.2010.1496

Illicit drug use is a major cause of morbidity and mortality worldwide. In the United States, the 2009 National Survey on Drug Use and Health documented that 8.7% of individuals older than 12 years reported past month illicit drug use.1 Illicit opioid use is an important contributor to health problems, including human immunodeficiency virus and hepatitis C infection and overdose-related deaths. While historically heroin has been most commonly abused, nonmedical use of prescription opioid pain relievers is now the dominant form of opioid abuse in the United States. In 2009, more than 5.3 million Americans reported past month prescription opioid abuse1 and the 2009 Monitoring the Future Study demonstrated that among 12th-graders, 9.7% reported abuse of hydrocodone and 4.9% reported abuse of oxycodone in the past year.2 Thus, illicit opioid use is a critical national health issue that requires creative approaches to prevention and treatment.

Opioid dependence is characterized by physical dependence, medical and psychological problems, and social dysfunction. Treatment strategies include counseling and pharmacotherapy. Medications have been particularly effective for treating opioid dependence given the unique effects of opioids on the brain and the availability of medications that can modulate these effects. Opioid agonist treatment has been demonstrated to most effectively decrease craving and drug use and improve health and social outcomes; furthermore, sustained medication maintenance is much more effective than short-term detoxification.3 Methadone maintenance has been the gold standard treatment since it was described by Dole and Nyswander in JAMA in 1965.4 Since then, dozens of studies have reaffirmed the effectiveness of methadone although it has not been without controversy, including potential toxicities and the strict regulatory restrictions on its use.5 Other agonist medications such as levo-alpha-acetylmethadol (LAAM) and diacetylmorphine (heroin)6 have been examined, but none has gained significant acceptance.

The newest medication treatment for opioid dependence is the partial opioid agonist buprenorphine. When used alone, or in combination with naloxone (buprenorphine-naloxone) in a sublingual tablet formulation, buprenorphine improves drug use–related outcomes in a manner similar to methadone7 with an improved safety profile. The naloxone component is not significantly absorbed sublingually but is included to block opioid effects if intravenous use is attempted. Buprenorphine was approved by the US Food and Drug Administration (FDA) in 2002 and its use has increased considerably. Along with enhanced safety, buprenorphine has the advantage of being available through prescription by trained generalist and specialty physicians in their offices, thus expanding the availability of maintenance treatment outside the confines of licensed programs.8 Subsequent research has expanded knowledge on how9 and in whom10 buprenorphine can be used most effectively.

Despite these advantages, buprenorphine use has been limited by the small (but increasing) number of trained physicians, concerns about diversion, and its high cost relative to methadone. In addition, buprenorphine typically requires daily supervised or self-administration. Thus, particularly in office-based treatment where medication administration is generally unsupervised, effectiveness relies on patient adherence. Efforts to improve adherence have been investigated, including less than daily dosing and electronic compliance monitoring; however, these approaches are seldom used.

Thus, the study of subdermal buprenorphine implants reported by Ling and colleagues11 in this issue of JAMA is an important addition to the literature because this method of medication administration may address limitations of sublingual buprenorphine, in particular adherence and diversion. Patients from 18 addiction treatment centers were randomly assigned to receive buprenorphine or placebo implants and were followed up for 24 weeks. Efforts to blind treatments and assessments were used and meaningful outcomes were selected. Along with the primary outcome of percentage of illicit opioid–negative urine samples, treatment retention, study completion, craving, and withdrawal and dependence severity were assessed. Safety and pharmacokinetic assessments are particularly important when new medication technologies are examined and these were also performed.

The manner in which treatment was provided has important implications regarding study limitations and clinical utility. Both groups received buprenorphine induction with sublingual buprenorphine-naloxone tablets, implant insertion, and up to twice-weekly counseling. In addition, supplemental sublingual buprenorphine-naloxone was provided based on patient-reported withdrawal and craving, and otherwise when requested. Thus, this treatment is not without complexity (eg, the implantation/removal procedures) or resource intensity (eg, specialized counseling). The need to use supplemental medication indicates that risk of diversion is not completely eliminated, especially if its use is unsupervised as is common in practice. Moreover, because this study was performed in treatment centers with specialized counseling and close medication supervision, it provides relatively little information about how implants might be used in office practice.

With these caveats in mind, Ling et al demonstrated that implant buprenorphine was more effective than placebo implants for the primary and major secondary outcomes.11 It is certainly not surprising that buprenorphine implants performed better than placebo implants and one could argue a control group other than placebo should have been used given the established efficacy of buprenorphine. However, attention to patient safety along with the need to carefully assess this new delivery method in a definitive manner, the availability of „rescue“ buprenorphine for all patients, and the 2:1 randomization ratio moderate this concern. Despite the superior urine toxicology results noted with buprenorphine implants, more than 50% of urine samples were positive, suggesting that even the active treatment had significant limitations. This, along with the relatively low buprenorphine plasma levels noted in these patients and the degree to which they required supplemental buprenorphine, suggests that further improvement in the implant delivery system may be warranted. However, the meaning of low drug plasma levels is not entirely clear clinically because effective buprenorphine plasma concentrations are likely to vary considerably between individuals.12 Ultimately, a direct comparison of implant to sublingual administration that examines pharmacokinetics and drug use is required to better understand the pharmacology and effectiveness of implant buprenorphine and to ensure that effectiveness is not sacrificed for convenience.

The study by Ling et al11 should be viewed in the context of what has been learned about opioid dependence treatment over the past 50 years. While counseling is critical for all substance abuse treatment, opioid dependence is uniquely susceptible to pharmacologic therapy. Patients and their physicians are often tempted to use „quick fix“ detoxification in which short-term medication treatment is provided rather than longer-term maintenance. However, for most opioid-dependent patients there is no quick fix. Detoxification has been conclusively demonstrated to have exceedingly high long-term failure rates13 and is not nearly as effective as opioid maintenance.3, 10 Extensive research on the effectiveness of methadone maintenance is irrefutable and research on buprenorphine maintenance has followed suit.

The question of where to provide buprenorphine has been the subject of extensive research that has allowed treatment to expand from the maintenance clinic to the physician’s office. Ling et al are addressing the question of how to provide buprenorphine. Intramuscular buprenorphine has been available for many years for pain management and a sublingual liquid formulation was initially used in investigational studies prior to FDA approval for treating opioid dependence. Buprenorphine was subsequently formulated in sublingual tablet forms in combination with naloxone (buprenorphine-naloxone) to discourage diversion. In addition, sublingual film buprenorphine has been developed,14 a version of which was approved by the FDA in 2010. The use of much longer-acting depot and implant medications has a long history and has demonstrated utility in enhancing adherence in the treatment of conditions such as schizophrenia and as an approach to providing hormonal contraception. A small study of depot injection buprenorphine demonstrated low plasma levels and pharmacologic activity over 6 weeks after one injection.15 The use of implant buprenorphine in this study suggests that a promising new approach to long-acting buprenorphine administration may be close at hand.

The study by Ling et al11 represents a potentially important step forward in the effort to improve and expand the treatment options for opioid dependence. Further research is needed to assess how this treatment compares with current opioid maintenance treatment prior to the widespread use of implant buprenorphine in clinical practice. If further research suggests that this buprenorphine implant is as good as or better than current treatment approaches, then the study by Ling et al would represent a major advance in the substantial and continued progress that has occurred in the treatment of opioid dependence since methadone maintenance began in the 1960s.

Despite these advances, significant challenges remain. As new and potentially better medications are developed, promoting access to treatment for opioid-dependent patients continues to be a major concern. In addition, physicians must be more knowledgeable about addiction and embrace their responsibility to care for individuals with, or at risk for, substance use disorders so that more patients can be identified and offered treatment. Treatments also need to be carefully designed so that medication effectiveness is maximized and counseling therapies are tailored to meet the needs of individual patients in a cost-effective manner.

Context Limitations of existing pharmacological treatments for opioid dependence include low adherence, medication diversion, and emergence of withdrawal symptoms.

Objective To determine the efficacy of buprenorphine implants that provide a low, steady level of buprenorphine over 6 months for the treatment of opioid dependence.

Design, Setting, and Participants A randomized, placebo-controlled, 6-month trial conducted at 18 sites in the United States between April 2007 and June 2008. One hundred sixty-three adults, aged 18 to 65 years, diagnosed with opioid dependence. One hundred eight were randomized to receive buprenorphine implants and 55 to receive placebo implants.

Intervention After induction with sublingual buprenorphine-naloxone tablets, patients received either 4 buprenorphine implants (80 mg per implant) or 4 placebo implants. A fifth implant was available if a threshold for rescue use of sublingual buprenorphine-naloxone treatment was exceeded. Standardized individual drug counseling was provided to all patients.

Main Outcome Measure The percentage of urine samples negative for illicit opioids for weeks 1 through 16 and for weeks 17 through 24.

Results The buprenorphine implant group had significantly more urine samples negative for illicit opioids during weeks 1 through 16 (P = .04). Patients with buprenorphine implants had a mean percentage of urine samples that tested negative for illicit opioids across weeks 1 through 16 of 40.4% (95% confidence interval [CI], 34.2%-46.7%) and a median of 40.7%; whereas those in the placebo group had a mean of 28.3% (95% CI, 20.3%-36.3%) and a median of 20.8%. A total of 71 of 108 patients (65.7%) who received buprenorphine implants completed the study vs 17 of 55 (30.9%) who received placebo implants (P < .001). Those who received buprenorphine implants also had fewer clinician-rated (P <.001) and patient-rated (P = .004) withdrawal symptoms, had lower patient ratings of craving (P <.001), and experienced a greater change on clinician global ratings of severity of opioid dependence (P<.001) and on the clinician global ratings of improvement (P < .001) than those who received placebo implants. Minor implant site reactions were the most common adverse events: 61 patients (56.5%) in the buprenorphine group and 29 (52.7%) in the placebo group.

Conclusion Among persons with opioid dependence, the use of buprenorphine implants compared with placebo resulted in less opioid use over 16 weeks as assessed by urine samples.

Dependence on opioids, in the form of heroin or prescription pain medications, is a significant health concern.13 Methadone maintenance treatment for opioid dependence reduces morbidity, mortality, and the spread of infectious diseases4 but is restricted to licensed specialty clinics in the United States, requires frequent clinic visits, and has a risk of mortality with overdose.5 These issues have led to increased use of buprenorphine, and numerous studies support the efficacy of sublingually administered buprenorphine.6 In the United States, buprenorphine can be prescribed in office-based physician practice.7 Because it is a partial agonist, buprenorphine has less risk of overdose than methadone.8 However, there are concerns about diversion and nonmedical use of sublingual buprenorphine, even when a buprenorphine-naloxone combination (designed to reduce misuse) is used.911 Poor treatment adherence, resulting in craving and withdrawal symptoms that increase the likelihood of relapse, is also a concern with sublingual buprenorphine.12

To address these problems with adherence, diversion, and nonmedical use, an implantable formulation of buprenorphine has been developed. This implant is a polymeric matrix composed of ethylene vinyl acetate and buprenorphine that delivers buprenorphine over 6 months. Following an initial pulse release, a constant and low level of buprenorphine is released, avoiding plasma peaks and troughs observed with sublingual administration. A preliminary open-label phase 2 study reported favorable results with this implant in opioid-dependent patients.13

The present study reports results of a phase 3 multicenter, randomized, placebo-controlled investigation of buprenorphine implants for treatment of opioid dependence.


Patients were recruited for the study from 6 academic, 3 Veterans Affairs, and 9 nonprofit community addiction treatment centers in the United States between April 2007 and June 2008. The study was approved by institutional review boards at each site, and written informed consent was obtained from all participants.

To be eligible for the study, men or nonpregnant women, aged 18 to 65 years, were required to meet Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) diagnosis of current opioid dependence at a screening visit as determined by the Mini International Neuropsychiatric Interview.14 Exclusion criteria were AIDS, met DSM-IV criteria for current dependence on psychoactive substances other than opioids or nicotine, currently using nonprescribed benzodiazepines, had received medication treatment for opioid dependence within the previous 90 days, or had a current diagnosis of chronic pain that required opioid treatment. Patients were also excluded if they had any of the following: aspartate aminotransferase (AST) levels at least 3 times higher than the upper limit of normal, alanine aminotransferase (ALT) levels at least 3 times the upper limit of normal, total bilirubin levels of at least 1.5 times the upper limit of normal, or creatinine levels at least 1.5 times the upper limit of normal.

Demographics and history were collected by patient self-report based on a list of choices.

Study Intervention and Randomization

Eligible patients entered into an open-label induction phase designed to ensure that buprenorphine could be safely administered. Patients were required to complete induction within 10 days of screening and receive a fixed dose of 12 to 16 mg/d sublingual buprenorphine-naloxone tablets for at least 3 consecutive days immediately before randomization. Patients were excluded from participation if during the induction phase they had reported significant withdrawal symptoms, defined as more than 12 on the Clinical Opiate Withdrawal Scale,15 or significant cravings for opioids, defined as more than 20 mm on a 100-mm opioid craving visual analog scale (VAS).

At the end of the induction phase, patients were randomized (stratified by sex and site) at a 2:1 ratio to double-blind treatment with either 4 buprenorphine implants (80 mg each) or 4 placebo implants. The 2:1 ratio was used to reduce patient exposure to placebo implants. The implants (26 mm in length x 2.5 mm in diameter) were placed in the subdermal space (2-3 mm below the skin) all at the same time in the inner side of the nondominant arm by a physician who had participated in a 1-day training in implant insertion and removal or who had prior similar experience. No sutures are required for implantation (sutures were used at removal). The physicians who placed and removed the implants were from various medical specialties (eg, family practice, psychiatry, dermatology, obstetrics and gynecology) and had surgical training but did not serve as the site investigator. The implants were removed after 6 months.

After implant placement, patients could receive supplemental sublingual buprenorphine-naloxone tablets, beginning with 4 mg and increasing in 2-mg increments as clinically necessary and tolerated up to 12 to 13 mg, if they experienced significant withdrawal symptoms or significant craving or if they had requested a dose increase that the treating physician judged to be appropriate. The supplemental sublingual buprenorphine-naloxone tablets were administered at the clinic under observation, except for weekends and holidays, for which participants received a maximum of 3 days of dosing to take at home. Patients could receive an additional implant if they required 3 or more days per week of any supplemental sublingual buprenorphine-naloxone tablets for 2 consecutive weeks, or 8 or more days of any supplemental buprenorphine-naloxone tablets over 4 consecutive weeks.

Because the placebo implants had a slightly different appearance than buprenorphine implants, steps were taken to maintain the blind: (1) the physician and staff involved in the implant insertion and removal procedures did not participate in efficacy evaluations or discuss with other study staff any information regarding a patient’s implants, (2) surgical draping prevented patients from viewing the implants during insertion or removal procedures, (3) staff not involved in implant insertion and removal procedures were forbidden from asking those involved in these procedures about the rod’s appearances, (4) each implant was sealed in an opaque, foil-lined pouch that hid the contents from view and was only opened by those involved with the implanting procedures.

All patients received manual-guided individual drug counseling.16 Sessions were held twice a week during the first 12 weeks and then weekly for the subsequent 12 weeks. If a patient missed 6 consecutive counseling sessions, this was judged to be clinically meaningful nonadherence, causing the patient to be withdrawn from the study. Because experienced drug counselors at each site who were familiar with the drug-counseling treatment model provided services, they received no formal training.

Urine samples were obtained 3 times per week throughout the entire 6-month treatment period. Drug screens were performed by a central laboratory and study staff, and patients remained blind to results. If a patient did not provide 9 consecutive urine samples, they were considered nonadherent and withdrawn (ie, 3 weeks was considered a clinically important interval). Participants could continue in the study regardless of test results. Urine toxicology samples were verified at collection by measurement of urine temperature. Patients provided another sample if a urine sample was outside of a valid temperature range. If the second sample was outside of the temperature range, the sample was designated as missing.

Efficacy Assessments

The primary outcome measure was the percentage of the 48 urine samples that were negative for illicit opioids during the first through 16th week of the trial. This 16-week period was selected because of the interest in examining early-treatment response in the context of this longer-term treatment.

The secondary outcome measure was assessed as the percentages of the 24 urine samples that were negative for illicit opioids during weeks 17 through 24. Additional outcomes measured included the proportion of treatment failures, the proportion of study completers, the patient-report and clinician-report withdrawal scales, a craving scale, and clinician severity and improvement ratings.

Treatment failure was defined as receiving a fifth implant and subsequently requiring 3 or more days per week of supplemental sublingual buprenorphine-naloxone treatment for 2 consecutive weeks or 8 or more days of supplemental sublingual buprenorphine-naloxone treatment over 4 consecutive weeks at any time after the implant dosage increase. Patients who met this definition of treatment failure were withdrawn from the study.

Patient report of withdrawal symptoms was assessed by the Subjective Opiate Withdrawal Scale.17 Clinician report of withdrawal symptoms was measured with the Clinical Opiate Withdrawal Scale, administered by the investigator or other qualified clinical staff. Craving for opioids was measured using a 100-mm VAS: 0 indicates no cravings; and 100, the maximum craving experienced. All 3 measures were obtained at baseline and at weeks 1, 4, 8, 12, 16, 20, and 24. The clinician-rated Clinical Global Impressions-Severity (CGI-S)18 (of opioid dependence) and Improvement scales (CGI-I)18 were obtained at baseline and at weeks 16 and 24 (or end point).

Safety and Pharmacokinetic Assessments

Vital signs, blood and urine laboratory tests (hematology, liver function tests, coagulation, pregnancy test), and electrocardiograms were obtained at regular study visits. The assessment protocol required that study investigators visually inspect the surgical implant location of each participant during each study visit. Levels of plasma buprenorphine were obtained and analyzed from blood samples taken at baseline and monthly thereafter.

Statistical Analyses

Baseline variables were compared across treatment groups using {chi}2 for categorical variables and t tests for continuous variables.

The primary analysis was conducted using an intention-to-treat approach that included all randomized patients. The primary statistical analysis specified in the study protocol was a van Elteren Wilcoxon rank sum test,19 stratified by sex and treatment site, comparing study groups on the distributions of the percentages of urine samples that tested negative for illicit opioids over 16 weeks. Sample size determination was conducted using a 2-sided {alpha} of .05 and 80% power to detect a shift of 20% (a difference deemed to be clinically relevant) between the placebo and buprenorphine groups on the distributions of the percentage of urine samples negative for illicit opioids over 16 weeks. Approximately 150 patients were required, taking into account the 2:1 randomization scheme, normal distributions without stratification with a common standard deviation of 30% as a conservative powering model, and an attrition rate of approximately 40%.

The denominator for the primary end point was all possible urine samples that could have been collected from implantation through week 16. Missed samples were considered positive for opioids. After a patient was withdrawn from the study, urine samples from the point of withdrawal onward were also considered positive.

A secondary analysis examined the percentage of urine samples over weeks 17 through 24 (using a van Elteren Wilcoxon test stratified for sex and site). Hypothesis testing for the primary analysis and the first secondary analysis was conducted using a fixed-sequence testing procedure. First, the primary hypothesis was tested using a 5% {alpha} level. Only if the null hypothesis was rejected for the primary analysis did testing proceed to the first secondary analysis. In accordance with this procedure, no {alpha} adjustment for multiple tests is required and the accepted alternative hypotheses may be claimed significant at the 5% level. An additional van Elteren Wilcoxon rank sum test examined the percentage of urine samples negative for the full 24-week period (72 samples per patient).

The proportions of participants who completed the study (defined as completing 24 weeks) were compared between treatment groups with a Cochran Mantel-Haenszel test, stratified by sex and site. The clinical and subjective withdrawal scales and the craving VAS were analyzed using a mixed-effects repeated-measure analysis of covariance using all available assessments and adjusting for sex, site, and baseline value. A spatial power law correlation structure was specified for these analyses. This covariance structure was used because it is appropriate for modeling data when the measurement time points are continuous (unequally spaced) rather than discrete categories, and the correlations decline as a function of the time difference. The CGI-I and CGI-S were analyzed as categorical variables using a Cochran Mantel-Haenszel test stratified by sex and site.

The incidence of specific adverse events was compared across treatment groups using {chi}2 tests. All statistical analyses were performed using SAS software version 8.2 (SAS Institute Inc, Cary, North Carolina).

Figure 1


Treatment Exposure

The median number of weeks of exposure to the implants (before they were removed) was 24 (range, 0-43 weeks) for buprenorphine and 16.6 (range, 3-34 weeks) for placebo. Additional implants were received by 20.3% (22 of 108) of those in the buprenorphine group and 58.2% (32 of 55) of those in the placebo group. During weeks 1 through 16, 64 of 108 participants (59%) in the buprenorphine implant group received supplemental sublingual buprenorphine-naloxone tablets for a median of 7.5 days for emergent withdrawal or craving, whereas 50 of the 55 patients in the placebo group (91%) received the buprenorphine-naloxone tablets for a median of 19.5 days. The buprenorphine implant group received a mean dose of 94.1 mg (95% confidence interval [CI], 71.3-117.0 mg) for the weeks 1 through 16 and received an average daily dose of 9.8 mg (95% CI, 8.8-10.8 mg), whereas the placebo group received a mean of 208.3 mg (95% CI, 163.1-253.5 mg) for an average daily dose of 10.4 mg (95% CI, 9.3-11.4 mg). For weeks 17 through 24, 12% (13 of 108) in the buprenorphine implant group received a mean dose of 56.9 mg (95% CI, 29.2-84.6 mg) and an average daily dose of 12.7 mg (95% CI, 10.1-15.2 mg) for a median of 3 days, whereas 20% (11 of 55) in the placebo group received a mean of 175.8 mg (95% CI, 21.0-330.6 mg) and an average daily dose of 12.8 mg (95% CI, 9.8-15.8 mg) for a median of 7 days.

The most frequent reasons for early discontinuation in the buprenorphine implant group were nonadherence with the protocol and being lost to follow-up. In the placebo group, patients most frequently withdrew early because of treatment failure or nonadherence (Figure 1).

Of those who discontinued because of protocol nonadherence, 2 participants in the buprenorphine implant group and 1 in the placebo group missed 6 consecutive counseling sessions and were therefore withdrawn. There was no evidence of unscheduled implant removal or attempted removal.


A mean of 40.4% (95% CI, 34.2%-46.7%; median, 40.7%) of the 48 urine samples taken for each patient in the buprenorphine group during the first 16 weeks of the study tested negative for opiate use vs a mean 28.3% (95% CI, 20.3%-36.3%; median, 20.8%) in the placebo group (P = .04). The distributions of the percentage of 24 urine samples taken from week 17 through 24 that tested negative for opioid use also showed a statistically significant difference (P < .001). For the full 24-week treatment period for a total of 72 urine samples from each patient, the buprenorphine group had a mean 36.6% (95% CI, 30.5%-42.6%; median, 29.9%) of urine samples that tested negative for opioids vs 22.4% (95% CI, 15.3%-29.5%; median, 13.9%) for the placebo group (P = .01).

A mean of 42.9 (44.0%) urine samples were actually provided by patients for weeks 1 through 16 and 17.5 (31.1%) for weeks 17 through 24 for the buprenorphine group vs 31.9 (43.2%) for weeks 1 through 16 and 8.5 (14.1%) for weeks 17 through 24 for the placebo group. Retention in the study is shown in Figure 2.

Figure 2


reatment group differences were also evident on additional efficacy measures (Table 2). During weeks 1 through 16, 88 of 108 (81.5%) in the buprenorphine implant group remained in the study vs 28 of 55 (50.9%) in the placebo group (P < .001). A significant difference (P < .001) was also evident in completion rates for the full 24-week study period: 71 of 108 (65.7%), buprenorphine implant group; 17 of 55 (30.9%), placebo group. The buprenorphine implant group had lower scores for clinical (P < .001) and subjective (P = .004) opiate withdrawal and for opioid craving (P < .001) than those in the placebo group across 24 weeks of treatment. At week 24, there were significant differences between the treatment groups on the CGI-S (P <.001) and CGI-I (P < .001) rating scales favoring buprenorphine (Table 2).


No patients in the buprenorphine implant group met the definition of treatment failure; 30.9% (17of 55) of placebo patients were classified as treatment failures.


Ninety-three (86.1%) of those in the buprenorphine implant group had at least 1 adverse event vs 45 (81.8%) of those in the placebo group (Table 3). Implant site adverse events were the most common; these events were normal and expectable consequences of the surgical procedure (not due to difficulties with insertion or removal).


mong adverse events not related to implant site, headache and insomnia were the most common in the buprenorphine group. No significant treatment group differences were apparent for adverse events that occurred with 10% or greater frequency (Table 3). No adverse events resulted in discontinuation of treatment in the placebo group. In the buprenorphine group, 3.7% of the patients experienced adverse events for which they were discontinued. These adverse events were implant site pain and infection (2 cases), implant site pain, and elevated liver enzymes. Two patients (1.9%) in the buprenorphine implant group experienced serious adverse events compared with 4 (7.3%) in the placebo group. One patient with a history of pulmonary embolism and chronic obstructive pulmonary disease in the buprenorphine group had a pulmonary embolism and an exacerbation of chronic obstructive pulmonary disease, and these events were judged as possibly related to treatment (because of the effect of opioids on respiratory function). The other patient experienced a burn injury. In the placebo group, 1 patient experienced suicidal ideation, another had pneumonia and cellulitis (related to implant site), another had a relapse of opioid dependence resulting in hospitalization, and another had respiratory failure. The patient with pneumonia and cellulitis was hospitalized for 1 day, during which time an incision and drainage were performed on the infected site, and the patient was treated with intravenous and oral antibiotics.

There were no clinically meaningful changes from baseline in vital signs, physical examinations, or electrocardiograms. No clinically significant changes from baseline were observed in hematology or coagulation values in either group. There was a minor increase in mean ALT and mean AST levels in the buprenorphine group, which was attributable to 1 patient who had significant increases in ALT and AST levels that were likely related to a hepatitis C infection and history of alcohol and drug use.


Mean (SD) steady state plasma buprenorphine concentrations over weeks 4 through 24 were 941 (832) pg/mL vs 495 (720) pg/mL in the placebo group, and the respective medians were 775 pg/mL (range, 378-8070 pg/mL) vs 237 pg/mL (range, 0-3070 pg/mL). The plasma buprenorphine in the placebo group can be attributed to use of rescue sublingual buprenorphine-naloxone tablets and possibly buprenorphine obtained from outside the study.

his study demonstrated that buprenorphine implants are effective in the treatment of opioid dependence over a 24-week period following implantation. Of particular clinical importance are the favorable urinalysis toxicology results and the good patient retention—with 65.7% of patients who received the active implants completing 24 weeks of treatment without experiencing craving or withdrawal symptoms that necessitated withdrawal from the study. In contrast, a recent study reported a median duration of 40 days for individuals who received sublingual buprenorphine in clinical settings.12 Available 6-month trials of sublingual buprenorphine have reported retention rates of 35%,20 38%,21 and 35%.22

The improved retention rate was found in the current study despite the buprenorphine implants resulting in relatively low plasma concentrations of buprenorphine. Given the known pharmacokinetics of buprenorphine,23 the steady state plasma concentration levels are consistent with a constant buprenorphine release of 1 to 1.3 mg/d from 4 to 5 buprenorphine implants. Results from the prior phase 2 study showed that average plasma concentrations of buprenorphine implants were lower than trough plasma concentrations of sublingual buprenorphine measured in the same patients (prior to implants) and that the initial pulse of buprenorphine in the 24 hours following implant insertion was less than half of peak plasma concentration observed with sublingual buprenorphine prior to implant insertion.13 Extrapolating from the low buprenorphine plasma concentrations, it is possible that a higher number of implants would result in greater efficacy. However, no patients in the buprenorphine implant group exceeded the criterion for treatment failure based on the need for sublingual buprenorphine-naloxone tablets. Thus, it appears that 4 or 5 implants are sufficient to control most cravings and withdrawal symptoms.

Minor implant site reactions were common. However, only 1 patient in the placebo group experienced a major implant site reaction (cellulitis). There was no evidence of unscheduled implant removal or attempted removal. Thus, diversion of the buprenorphine implants appears unlikely.

Several limitations of this study are important to consider: (1) All patients received psychosocial counseling in addition to implants. The extent to which the efficacy of the implants is dependent on this ancillary counseling is not known, although this is the standard of care in addiction treatment. (2) Placebo patients had an average buprenorphine plasma concentration that was almost half that of the active implant group due to the need for rescue buprenorphine-naloxone treatment. The use of rescue buprenorphine-naloxone treatment complicates the interpretation of study results, particularly the plasma buprenorphine levels. (3) The current trial was not statistically powered to examine efficacy within subgroups of patients. The number of implants and extent of supplemental sublingual buprenorphine-naloxone treatment may need to vary depending on initial severity of opioid dependence, duration of opioid dependence, or type of opioid. (4) Attrition was high because of the regulatory requirement to include a placebo control.

In summary, this study found that the use of buprenorphine implants compared with placebo resulted in less opioid use over 16 weeks and also across the full 24 weeks.

os Angeles – Subkutane Implantate könnten die Compliance der Opiatabhängigen bei der Buprenorphin-Substitution verbessern und einen Schwarzmarkt verhindern. Eine Phase-III-Studie im US-amerikanischen Ärzteblatt JAMA 2010; 304: 1576-1583) attestiert dem Präparat eines US-Herstellers jetzt eine passable Wirksamkeit. In der Substitutionstherapie von Heroinabhängigen ist Buprenorphin eine attraktive Alternative zu Methadon. Denn der partielle Opiat-Agonist ist weniger anfällig gegenüber Überdosierungen und auch außerhalb der großen Substitutionszentren verfügbar. In vielen Ländern ist die sublinguale Buprenorphin-Substitution deshalb sehr beliebt.

Es lässt sich allerdings kaum verhindern, dass das starke Opiat auf den Schwarzmarkt gelangt – selbst wenn es in vielen Ländern mit dem Antagonisten Naloxon versetzt ist. Bei einer unzuverlässigen Einnahme kommt es außerdem schnell zu Entzugssymptomen und die Rückfallquote der Patienten ist deshalb hoch.

Beide Probleme könnten durch subkutane Implantate gelöst werden, die den Wirkstoff über mehrere Monate kontrolliert freisetzen. Das Präparat eines US-Herstellers wurde jetzt an 18 Behandlungszentren des Landes in einer Phase-III-Studie untersucht.


08 Patienten – zu zwei Drittel Heroin-, zu einem Drittel Medikamentenabhängige – wurden jeweils vier 26 mm lange und 2,5 mm dicke Implantate in 2 bis 3 mm Tiefe ins Unterhautfettgewebe am Arm eingebracht.

Wenn notwendig konnten die Probanden ein fünftes Implantat erhalten. Nach 6 Monaten wurden alle Implantate entfernt, was einen kleinen chirurgischen Eingriff erfordert, der eine kurze Narbe hinterlässt. In einer Vergleichsgruppe von 55 Patienten wurden Implantate mit Placebo implantiert, was ethisch gerechtfertigt war, weil die Patienten in beiden Gruppen bei Bedarf zusätzlich Sublingualtabletten mit Buprenorphin erhalten konnten.

Wie Walter Ling von der Universität Los Angeles und Mitarbeiter berichten, erhöhten die Buprenorphin-Implantate den Anteil der negativen Urinkontrollen – als Hinweis auf einen fortgesetzten Drogenkonsum – von durchschnittlich 28,3 auf 40,4 Prozent.

Auch in den sekundären Endpunkten wurde eine Wirksamkeit nachgewiesen: Insgesamt 65,7 gegenüber 30,9 Prozent nahmen bis zum Schluss an der Studie teil. Auch die Häufigkeit von Entzugssymptomen wurde ebenfalls signifikant gesenkt.

Im Buprenorphin-Arm gab es keine Therapieversager: Alle kamen mit vier oder fünf Implantaten aus. Im Placebo-Arm wurden 30,9 Prozent der Patienten als Therapieversager eingestuft, weil sie häufiger als dreimal in der Woche Sublingualtabletten nachfragten.

Die Implantate lösten nur geringe Lokalreaktionen aus, wobei es zwischen Buprenorphin und Placebo keine Unterschiede gab. Der Hersteller führt derzeit eine zweite Phase-3-Studie durch und will sich nach deren Abschluss um eine Zulassung in den USA und in Europa bemühen. © rme/

Die Krankenkassen haben die Behandlung von schwer Opiatabhängigen zur Regelleistung erklärt. Diamorphin darf nur in speziellen Einrichtungen verabreicht werden.

Hamburg. Die Behandlung schwerstkranker opiatabhängiger Patienten mit Diamorphin ist als Regelleistung der gesetzlichen Krankenkassen in den Leistungskatalog aufgenommen worden. Für Hamburg haben Verbände der gesetzlichen Krankenkassen mit der Kassenärztlichen Vereinigung Hamburg (KVH) eine entsprechende Honorarvereinbarung geschlossen, wie die Krankenkassen am Donnerstag in einer gemeinsamen Erklärung mitteilten. Zuvor hatte der Gemeinsame Bundesausschuss (G-BA) diese Behandlung geprüft und insbesondere die Erfahrungen in den Modellversuchen unter anderem in Hamburg ausgewertet.

Bei Diamorphin handelt es sich den Angaben zufolge um synthetisches Heroin. Schwerstkranke opiatabhängige Patienten erhalten das Medikament, wenn sie mit herkömmlichen Methoden nicht therapierbar sind. Für diese Behandlung kommen laut G-BA-Beschluss ausschließlich schwerstabhängige Patienten infrage. Diese müssen seit mindestens fünf Jahren abhängig sein, zwei erfolglos beendete beziehungsweise abgebrochene Suchtbehandlungen hinter sich und das 23. Lebensjahr vollendet haben.

Die Regelung sieht zudem vor, dass eine begleitende psychosoziale Betreuung mit einer Dauer von mehr als sechs Monaten stattfindet. Die Behandlung mit Diamorphin darf nur in speziell dafür geeigneten Einrichtungen vorgenommen werden. In Hamburg ist dies die Ambulanz Altona der Abteilung für Abhängigkeitserkrankungen der Asklepios Klinik Nord. (dapd/

Fensterlose Räume mit Sicherungen wie in einer Bank, verdeckt installierte Überfallmelder – so sollen die Zentren aussehen, in denen in Baden-Württemberg künftig Diamorphin abgegeben wird.

STUTTGART (fst). Das Landeskabinett in Stuttgart hat nach langem internen Widerstand Mitte Juni den Rechtsrahmen für die Umsetzung der diamorphingestützten Substitution in Baden-Württemberg vorgelegt. Das entsprechende Bundesgesetz ist bereits seit Juli 2009 in Kraft.

Mappus galt als rigoroser Kritiker des Projekts

Doch als Stefan Mappus (CDU) im Februar zum Ministerpräsidenten gewählt wurde, hielt man im Sozialministerium die Luft an: Mappus war – wie viele CDU-Kollegen im Südwesten –  als rigoroser Kritiker der Diamorphinabgabe in Erscheinung getreten. „Wir sind nicht bereit, finanziell in die Bresche zu springen“, sagt der damalige CDU-Fraktionschef noch im Oktober 2008, als es um eine Anschlussfinanzierung für die Karlsruher Heroinambulanz ging.

Mit dem Kabinettsbeschluss hat Mappus zähneknirschend zugestimmt. Doch die administrativen Hürden sind hoch – Experten meinen: zu hoch. Das Sicherheitskonzept für die vermutlich zehn Standorte, an denen Diamorphin abgegeben werden soll, ist aufwändig. „Die baulichen Anforderungen sind – gelinde gesagt – übertrieben“, sagt Dr. Gisela Dahl, Vorstandsmitglied bei der KV Baden-Württemberg. Das Beste sei, man kaufe für die Einrichtungen „eine alte Bank“, meint Dahl. Denn das sechsseitige Sicherheitskonzept verlangt quasi den Bau eines Hochsicherheitstrakts für Lagerung und Abgabe des Diamorphins – Überfall- und Einbruchmeldeanlage mit Direktschaltung zur Polizei inklusive. Weil diese Infrastruktur kein Arzt alleine stemmen kann, zahlt das Land für jeden Standort einen Investitionszuschuss von 100 000 Euro.

Die politischen Debatten im Vorfeld hat KV-Vorstand Dahl nie verstanden: „Es geht um eine medizinische Behandlung, nicht um ein Politikum.“ Die Suchtmedizinerin Dr. Inge Hönekopp, die in Mannheim eine Methadon-Schwerpunktpraxis leitet, erinnert an den Modellversuch, der dem Beschluss des Bundestags im Juli 2009 vorausgegangen ist: „Die Begleitforschung zum Modellprojekt über die heroingestützte Behandlung Opiatabhängiger hat klar ergeben, dass diese Behandlungsform medizinisch und ökonomisch für Patienten, die GKV und die Gesellschaft insgesamt vorteilhaft ist.“ Der Kreis der in Frage kommenden Suchtkranken werde sehr klein sein. „In Mannheim werden es 15 bis 30 Personen sein. Ich denke, dass sich diese Zahl aber noch erhöhen wird“, sagt Hönekopp. Insgesamt wird landesweit mit bis zu 300 Teilnehmern gerechnet.

Wahrscheinlich werden im laufenden Jahr nur die Standorte Karlsruhe und Stuttgart an den Start gehen. Dahl hofft, dass bis Ende 2011 auch Einrichtungen in Mannheim, Freiburg, Heilbronn, Tübingen/Reutlingen, Singen, Ulm und Ravensburg den Betrieb aufnehmen können.

Honorierung der Ärzte ist noch ungewiss

Aus Sicht des KV-Vorstands ist nicht ausgemacht, ob sich genügend Ärzte für die Arbeit in den Spezial-Einrichtungen finden. Denn unklar ist auch noch die Honorierung der Ärzte. Anfang Juli wird dazu im Bewertungsausschuss eine Entscheidung erwartet. Dass in der Politik das Misstrauen gegenüber substituierenden Ärzten noch längst nicht passé ist, zeigte im Dezember 2009 ein Papier der baden-württembergischen Landesregierung zur Honorierung der Diamorphin-Abgabe. Werde die Substitution „zu schlecht bezahlt, finden sich keine qualifizierten Ärzte, wird sie zu gut bezahlt, wird der Wechsel auf andere Substitutionsmittel erschwert“, heißt es. Für KV-Vorstand Dahl eine befremdliche Sichtweise: „Ich gebe doch nicht Heroin ab, weil ich damit mehr Geld verdiene.“

Diamorphingestützte Substitution

Mit dem Gesetz zur diamorphingestützten Substitution hat der Bundestag im Juli 2009 einen Rechtsanspruch für Schwerstabhängige auf entsprechende Behandlung geschaffen.
Allerdings gelten für potenzielle Teilnehmer strenge Voraussetzungen: Die Betroffenen müssen unter anderem mindestens 23 Jahre alt und seit fünf Jahren opiatabhängig sein sowie mindestens zwei erfolglose Therapieversuche mit Methadon oder Subutex hinter sich haben. Anders als bei der Methadon-Substitution ist eine Take-home-Regelung verboten. Außerdem gilt ein Sondervertriebsweg, bei dem das Diamorphin vom Hersteller direkt zu den substituierenden Einrichtungen transportiert wird.
Der Gemeinsame Bundesausschuss hat zudem Mitte Juni festgelegt, dass Patienten, die Diamorphin erhalten, in den ersten sechs Monaten psychosozial betreut werden. Hoch sind auch die Anforderungen an die Einrichtungen. Sie müssen mindestens drei Ärzte in Vollzeit beschäftigen und die Behandlung täglich über zwölf Stunden sicherstellen. Alle beteiligten Ärzte müssen über suchttherapeutische Qualifikationen verfügen oder sie müssen mindestens sechs Monate beim Modellprojekt zur heroingestützten Behandlung tätig gewesen sein.

Diamorphinabgabe im Südwesten nach strengen Regeln

STUTTGART (fst). Das baden-württembergische Landeskabinett hat nach langem internen Streit eine Grundlage für die diamorphingestützte Substitution geschaffen. Sozialministerin Monika Stolz (CDU) betonte, man setze den Rechtsanspruch für Schwerstabhängige „mit der gebotenen Sorgfalt um“. Dabei solle der Missbrauch von Diamorphin „sicher ausgeschlossen“ werden.

Für Baden-Württemberg wird mit 200 bis 300 Teilnehmern gerechnet. Um eine Zulassung zu erhalten, müssen die Träger in das örtliche System der Suchtkrankenhilfe eingebunden sein. Im Gespräch sind Standorte in Mannheim, Karlsruhe, Freiburg, Heilbronn, Stuttgart, Tübingen/Reutlingen, Singen, Ulm und Ravensburg. Die Einrichtungen sollen Investitionszuschüsse von 100 000 Euro erhalten, um die strengen Sicherheitsvorschriften erfüllen zu können.

Erwartet wird, dass Karlsruhe als erster Standort einen Genehmigungsantrag stellen wird. Auch in Stuttgart seien die Planungen „recht weit fortgeschritten“. Für alle anderen genannten Städte erwartet Stolz einen Start erst im kommenden Jahr.
Das vom Bundestag verabschiedete Gesetz zur diamorphingestützten Substitution ist am 21. Juli 2009 in Kraft getreten.

Methods and definitions

1. EMCDDA definition

‘Drug-related death’ is the term used by the EMCDDA to refer to deaths happening shortly after consumption of one or more psychoactive drugs, and directly related to this consumption. Often these deaths are referred as ‘overdoses’, although equivalent concepts are also ‘deaths directly related to drug use’, ‘poisonings’ or ‘drug-induced deaths’.

Most national statistics refer to these deaths, which are usually recorded through general mortality registries or special registries (forensic or police).

The EMCDDA has developed a common definition, in agreement with national experts (see below summary definition and also the DRD-Standard protocol) focusing on those deaths directly related to consumption of illegal substances (although alcohol or psychoactive medicines are also found frequently in the toxicological analysis).

At present, national statistics are improving in most countries and their definitions are becoming the same, or relatively similar, to the common EMCDDA definition. Some countries still include cases due to psychoactive medicines or non-overdose deaths, generally as a limited proportion (Drug-related deaths: ‚National definitions‘ specifies in detail the definition of drug-related death used in each Member State).

In addition, there are still differences between countries in procedures of recording cases, and in the frequency of post-mortem investigation (including autopsy rates). In some countries information exchange between general mortality registries and special registries (forensic or police) is insufficient or lacking, which compromise the quality of information.

Direct comparisons between countries in the numbers or rates of drug-related deaths should be made with caution; but if methods are maintained consistently within a country, the trends observed can give valuable insight when interpreted together with other drug indicators.

In addition to deaths directly related to the use of drugs, also deaths indirectly related to drug use (e.g. AIDS, accidents, suicides, violence) should also be taken into account from a public health perspective, although their estimation requires different methodologies and data sources. The EMCDDA Report CT.00.RTX.22 presents an example of methodology to estimate the ‘total burden of mortality’ related to drug use that includes both deaths directly and indirectly related to drugs (Annex 1, pages 47 to 53).

The EMCDDA definition of drug-related deaths

The EMCDDA definition of drug-related death in the Key Indicator ‘Drug-related deaths and mortality among drug users’ refers to those deaths that are caused directly by the consumption of drugs of abuse. These deaths occur generally shortly after the consumption of the substance(s).

The cases are selected as follows:

  1. The preferred method to estimate the number of deaths is to extract cases from existing general mortality registries according to the following criteria:

based on the WHO International Classification of Diseases, 9th edition -ICD-9-

Cases will be counted when their underlying cause of death was drugs psychoses, drug dependence, nondependent drug abuse, accidental poisoning, suicide and self-inflicted poisoning, and poisoning with undetermined intent.

Cases will be included when the death was due to a standard list of specific drugs: opiates, cocaine, amphetamines and derivates, cannabis, and hallucinogens.

The precise ICD-9 codes to be selected are the following:

Category of drug-related death

Selected ICD-9 code(s)

Drug psychoses


Drug dependence

304.0, 304.2-9

Nondependent drug abuse

305.2-3, 305.5-7, 305.9

Accidental drug poisoning

E850.0, E850.8 (1), E854.1-2, E855.2, and E858.8 (1)

Suicide and self-inflicted drug poisoning

E950.0 (1) , E950.4 (1)

Drug poisoning undetermined intent

E980.0 (1), E980.4 (1)

(1) In combination with N-codes (N965.0, and/or N968.5, and/or N969.6, and/or N969.7

This selection was agreed by the EMCDDA expert group on drug-related deaths. It was called ‘Selection B’ for general mortality registries based on ICD-9.

based on the WHO International Classification of Diseases, 10th edition -ICD-10-

Case will be counted when their underlying cause of death was mental and behavioural disorders due to psychoactive substance use (see list of substances below) or poisoning accidental, intentional or undetermined intent (see list of substances below)

  • Harmful use, dependence, and other mental and behavioural disorders due to:

    • opioids (F11)

    • cannabinoids (F12)

    • cocaine (F14)

    • other stimulants (F15)

    • hallucinogens (F16)

    • multiple drug use (F19)

  • Accidental poisoning (X41, X42), intentional poisoning (X61, X62), or poisoning by undetermined intent (Y11, Y12) by:

    • opium (T40.0)

    • heroin (T40.1)

    • other opioids (T40.2)

    • methadone (T40.3)

    • other synthetic narcotics (T40.4)

    • cocaine (T40.5)

    • other and unspecified narcotics (T40.6)

    • cannabis (T40.7)

    • lysergide (T40.8)

    • other and unspecified psychodysleptics (T40.9)

    • psychostimulants (T43.6)

The T-codes are to be selected in combination with the respective X-codes and Y-codes.

Underlying cause of death

Selected ICD-10 code(s)


F11-F12, F14-F16, and F19

Accidental poisoning

X42 (1), X41 (2)

Intentional poisoning

X62 (1), X61 (2)

Poisoning undetermined intent

Y12 (1), Y11 (2)

(1) in combination with the T-codes: T40.0-9

(2) in combination with T code: T43.6.

This selection was agreed by the EMCDDA expert group on drug-related deaths. It was called ‘Selection B’ for general mortality registries based on ICD-10.

  1. An alternative method is to estimate the number of deaths by extracting cases from existing special registers (forensic or police registries). The method based on the special registries will be applied in countries where the preferred method cannot be implemented, but also will be used whenever possible as a backup estimate for the general mortality registries.

Cases will be counted when the death was due to poisoning by accident, suicide, homicide, or undetermined intent.

Cases will be included when the death was due to opiates, amphetamines, cocaine (or crack), cannabis, hallucinogens, solvents, or synthetic designer drugs like amphetamine derivates.

The precise groups of deaths are the following:

Category of drug-related death

Selected groups

Poisoning by accident, suicide, homicide, or undetermined intent

Opiates only (excluding methadone only)

Methadone only

Poly-substances including opiates

Poly-substances excluding opiates


– ‘poly-substances’ should include at least one of the above mentioned substances

– ‘unspecified/unknown’ will be included when it is assumed to include one of the above mentioned substances

This selection was agreed by the EMCDDA group of experts. It was called ‘Selection D’ for special registries

For more information on EMCDDA work on drug-related deaths see:

For the EMCDDA protocol ‘DRD-Standard Protocol’ see:

2. Drug-related deaths: ‘National definitions’

Definitions of ‘acute drug-related death’ in EU Member States, as used to report cases for the EMCDDA annual report

(It is recommended that for reporting to the EMCDDA, the national definitions are in line with the EMCDDA definition)


Case definition

EMCDDA standard definition for special registries (‘Selection D’)

Technical information

‘Selection D’ is described in the protocol EMCDDA-DRD Standard, version 3.0 (for special registries)

Data collection procedure

Cases are reported by the police and hospitals to the Federal Ministry of Health and Women, which orders and checks the results of forensic examinations.


Suchtgiftbezogene Todesfälle-Statistik; Federal Ministry of Health and Women



Case Definition

EMCDDA definition for general mortality registries(‘Selection B’ for ICD-9)

Technical information

‘Selection B’ is described in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure

Cases are reported by health authorities of the French and Flemish Communities that collect death certificates filled by physicians. The National Institute of Statistics centralises the morbidity statistics of the two communities


National Institute of Statistics. General mortality registry: personal communication (ad-hoc data extraction for REITOX national focal point for the 2002 National Report).


Since 1998, cases will be selected by ICD-10 codes


Case definition

A death is included in the statistics, if the death is caused by poisoning and also non-overdose deaths, such as for example accidents and suicides. The definition includes deaths due to all forms of narcotic substances.


A death is included in the statistics, if

(1) the dead is causes by poisoning (or)

(2) there is a strong causal relation between use of drugs and death

Technical information

If no report from autopsy is available, the case is decided on available information of the deceased and circumstances of death.

Data collection procedure

Cases are reported from forensic institutes to the National Commission of Police.




Case definition

From 1988 through 1995 (ICD-9, Finnish adaptation), deaths due to identified drugs by:

  • Diseases (dependence, harmful use, substance induced brain syndrome);

  • accidental poisoning;

  • events of undetermined intent.

From 1996 onwards, EMCDDA definition for general mortality registries(‘Selection B’ for ICD-10)

Technical information

From 1988 through 1995 cases selected by ICD-9 (Finnish adaptation. See Finnish National Report 2003, Appendix 7)

From 1996 onwards, ‘Selection B’ for ICD10, which is described in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure

Collection and processing of causes of death statistics at Statistics Finland.


STAKES. General mortality registry. Personal communication (Ad-hoc data extraction for REITOX national focal point for the 2004 National Report)


The Finnish adaptation of ICD-9 did not allow the implementation of ‘Selection B’ of DRD standard protocol. For these reason, Selection B is only available from 1996 onwards, where ICD-10 was implemented.

The breach of trends observed between 1995 and 1996 could be in part due to change from ICD-9 to ICD-10 and to change from national definition to Selection B


Case definition

  • Deaths due to overdose in the strictest sense of the term.

  • Deaths occurring directly and immediately after consumption of drugs.

Technical information

Data collection procedure

After investigations following suspicious death, which generally include an autopsy and a toxicological analysis, cases are reported by the police and the Gendarmerie to the Office Central pour la Répression du Traffic Illicite de Stupéfiants (OCRTIS) at the Ministry of the Interior.


Office central pour la répression du trafic illicite des stupéfiants (2004) Usage et trafic des produits stupéfiants en France en 2003, OCRTIS, Nanterre


Deaths due to poisoning by psychoactive medicines are included but, in practice, case definition is an approximation to ‘Selection D’ (only 10 cases of difference in 2003)


Case definition

  • Deaths following intentional or unintentional overdose.

  • Deaths as a result of long-term abuse.

  • Deaths due to suicide resulting from despair about the circumstances of life or the effects of withdrawal symptoms.

  • Deaths due to fatal accidents suffered by people under the influence of drugs

Technical information

Data collection procedure

Cases are reported by local police units that are working jointly with the forensic physicians, to the National Police Department, the Federal Criminal Police Office (BKA) that records the information.


Bundeskriminalamt OA21 (2004). Bundeslagebild Rauschgift 2003. Wiesbaden: Bundekriminalamt


  • From 1985 through 1990, the figures only refer to the former West Germany (the old Länder).

Since 1991, the figures refer to the reunited Germany, which includes the old and the new Länder.


Case definition

EMCDDA standard definition for special registries (‘Selection D’)

In national terms:

  • Deaths caused by overdose.

  • Deaths caused by the synergic activity of different drugs.

Technical information

‘Selection D’ is described in the protocol EMCDDA-DRD Standard, version 3.0 (for special registries)

Data collection procedure

Cases of sudden death are notified to the police who refer the cases to the forensic department for autopsy and toxicology, which notifies the police of the results. Cases are then reported by local police units to Section C of the Directory of Public Security at the Ministry of Public Order (Hellenic Police). Statistics are reported by the National Anti-Drug Co-ordinative Unit, National Anti-Drug Intelligence Unit, Joint Secretariat.


Hellenic Police, 2004. Reference for 2003 data:



Case definition

  • Deaths due to drug dependence.

  • Deaths due to poisoning by opiates and related narcotics.

Technical information

Cases selected by ICD-9 codes

– 304 (drug dependence)

– 965.0 (poisoning by opiates and related narcotics)

Data collection procedure

Cases are reported by regional registrars of births and deaths, who collect information from doctors, the police, and coroners, to the general mortality register at the Central Statistics Office (CSO).


Central Statistics Office, Vital Statistics Section


The increase between 1995 and 1997 is (partly) due to an increased awareness of the need for more accurate information and reporting.


Case definition

EMCDDA standard definition for special registries (‘Selection D’)

In national terms:

Deaths directly attributed to drug misuse (acute intoxication, overdose) and reported by local and special police units to the Central Drugs Directorate.

Technical Information

‘Selection D’ is described in the protocol EMCDDA-DRD Standard, version 3.0 (for special registries

Data collection procedure

Cases are reported by local and special police units to the Central Drugs Directorate at the Ministry of the Interior.


Relazione Annuale 2003. Direzione Centrale per i Servizi Antidroga (DCSA), Ministero dell’Interno



Case definition

Deaths caused by acute/direct reaction to the use of illegally acquired high risk consume (HRC) drugs.

Technical information

Fatal (accidental, intentional or of undetermined intention) intoxication caused by

the use of at least one illicitly acquired drug or

other drug(s) in case the victim has been known as a persistent user of illicitly acquired drugs.

Death is due to the acute pharmacological and or toxicological effects(s) of the consumed substances(s)

Data collection procedure

All suspected deaths require a judicial enquiry, and after forensic evidence from autopsy, cases are reported by the local police to the special drug section (SDU) of the judicial police.


Origer, A.(in press). National report on the state of the drugs problem -RELIS 2003. NFP – CRP-Santé. Luxembourg



Case definition

EMCDDA definition for general mortality registries(‘Selection B’)

From 1985 through 1995, based on ICD-9

Since 1996, based on ICD-10

Technical information

‘Selection B’ is described in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure

Cases are reported by municipal registrars, who collect information from physicians and coroners, to the causes of death statistics at Statistics Netherlands.


Causes of death statistics, Statistics Netherlands


Only persons retrievable in the Dutch population register are included


Case definition

Death due to misuse of illegal drugs (Drug dependence or poisoning).

mental and behavioural disorders due to drug use

accidental or undetermined poisoning by drugs of abuse

Technical information

  • Up to 1996, cases were selected by ICD-8 and ICD-9 codes (304).

  • Since 1996, the ICD-10 codes used (underlying causes) are:

F11-F12, F14-16, F19,

X42 and Y12 in combination with T40.0-9

X41 and Y11 in combination with T43.6.

Data collection procedure

Registry of causes of death, from Statistics Norway. Data from Statistics Norway are manly based on autopsy reports from the National Institute of Forensic medicine.


Statistics Norway


National definition is an approximation to ‘Selection B’ for ICD-10 but excluding ‘intentional poisoning’ (X61 and X62)


Case definition

A person whose post-mortem toxicological analysis is positive for any illicit drug of abuse (whatever was the cause of death.

Technical information

  • The proportion of cases with positive toxicology and information on presumed cause of death suspected to be acute drug-related deaths were: 44 % (2003), 58 % (2002) and 73 % (2001)

  • The cases refer to Lisbon, Oporto and Coimbra regions

Data collection procedure

Cases are reported to the delegations at the three forensic institutes of the Ministry of Justice.

Reference 2003

Relatório Anual do IDT- 2003. Lisboa


Due to under-reporting in previous annual reports, more cases are reported in the annual report since 1995.


Case definition

Deaths due to acute reaction following non-medical use of psychoactive substances

Technical information

  • From 1985 through 1995: Deaths due to acute reactions following opiate or cocaine consumption.

  • Since 1996: Deaths due to acute reactions following consumption of any psychoactive drug.

  • The cases refer to five large cities Barcelona, Bilbao, Madrid, Valencia, and Zaragoza.

Data collection procedure

Cases are reported by medical pathologists for the Mortality Indicator at the Delegación del Gobierno para el Plan Nacional Sobre Drogas (DGPNSD).

Reference 2003

1990 to 1995 State Information System on Drug Abuse (SEIT) Reports.

1996 to 2002 Unpublished reports


Deaths due to poisoning by psychoactive medicines are included, but in practice, case definition is an approximation to ‘Selection D’ (only 1 case of difference in 2002)

A small breach of trend took place in 1996 due to a change from reporting only on opiate and cocaine cases to all psychoactive substances.


Case definition

EMCDDA definition for general mortality registries(‘Selection B’ for ICD-10)

Cases codified with T40.4 are excluded (in Sweden are mainly due to dextropropoxifen poisonings)

Technical information

‘Selection B’ is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure

Cases are reported by physicians to the cause of death register at Statistics Sweden and are reported and published by the Epidemiological Centre of the National Board of Health and Welfare (NBHW).


National Death Cause Registry (Run by the Epidemiological Centre, at the NBHW)


In 2003 ‘national case definition’ was adapted to the EMCDDA definition (Selection B) with the exception described

United Kingdom

Case definition

  • Deaths due to drug dependence.

  • Deaths due to nondependent abuse.

  • Deaths due to accidental, suicidal, or undetermined poisonings.

Technical information

  • England and Wales, Northern Ireland and Scotland (‘ONS standard definition’)

Based on ICD-9 Classification:

292 (Drug psychoses),

304 (Drug dependence),

305.2 – 9 (Non-dependent abuse of drugs),

E850 – E858 (Accidental poisoning by solid or liquid substances – drugs, medicaments, and biologicals),

E950.0 – 5 (Suicide and self-inflicted poisoning by solid or liquid substances – drugs and medicaments),

E980.0 – 5 (Poisoning by solid or liquid substances, undetermined whether accidentally or purposely inflicted – drugs and medicaments),

E962.0 (Assault by poisoning – drugs and medicaments).

Scotland (From 2000) and England & Wales and N Ireland (From 2001) (‘ONS standard definition’

Based on ICD-10 Classification:

F11-F16, F18, F19,

X40-X44 (accidental poisoning),

X60-X64 (intentional self poisoning),

Y85 (assault by drugs, medicaments and biological substances),

Y10-Y14 (poisoning undetermined intent).

Data collection procedure

Cases from England and Wales are reported to the Office for National Statistics (ONS), cases for Northern Ireland are reported to the General Register Office (Northern Ireland) and cases for Scotland are reported to the General Register Office (Scotland).

Reference 2003

See Health Statistics Quarterly, Nos 5, 7, 9, 11, 13, 17 & 21, ONS 2000, 2001, 2002, 2003 & 2004


Drug Strategy Definition

Recently it has been developed an additional national definition that in this reports is referred as ‘UK Drug Strategy Definition’.

The UK Drug Strategy Definition is a more restrictive extract from the ONS description that focuses on drugs controlled under the Misuse of Drugs Act of 1971. Drugs controlled by the Misuse of Drugs Act include class A, B and C drugs.

A description of this definition is given in the Annexed Box 1) ‘UK Drug Strategy Definition’.

This definition produces estimates approximated to the EMCDDA Standard ‘Selection B’.

Figures reported on the basis of this definition are presented separately in Table DRD-2 part (ii).

National Programme on Substance Abuse Deaths (np-SAD)

In addition, in the UK there is a special registry on drug-related deaths within the National Programme on Substance Abuse Deaths (np-SAD). This registry is based on data submitted voluntarily by coroners.

This registry can produce estimates for the EMCDDA Standard ‘Selection D’.

A description of this special registry is given in the Annexed Box (2) ‘UK np-SAD’.


1) ICD-9, ICD-10 = International Classification of Diseases, edition 9, edition 10, established by the World Health Organisation (WHO).

2) In some countries, traditional definitions of ‘drug-related deaths’ used at national level are different from those presented here and may also include cases related to medicines, or some other deaths indirectly related to drug use (e.g. diseases, accidents).

(1) Annexed Box ‘UK Drug Strategy Definition’

UK Drug Strategy definition

Extract from ONS description (based on ICD-9)

A) Deaths where the underlying cause of death has been coded to the following categories:

Drug psychoses (292);

Drug dependence (304.0 -.5 and 304.7-.9);

Nondependent abuse (305.2 -.9)

B) Deaths coded to the following categories and where a drug controlled under the Misuse of Drugs Act 1971 was mentioned on the death record:

– Accidental poisoning by drugs, medicaments and biologicals (E850-E858);

– Undetermined whether accidentally or purposely inflicted (E980.0-E980.5);

– Assault by poisoning – drugs and medicaments (E962.0)

– Dependence on other drugs (304.6).


1. Deaths coded to opiate abuse which resulted from the injection of contaminated heroin have been included in the indicator. This is opposite to the approach taken in Scotland, where these deaths have been excluded for 2000.

2. Specific rules were adopted for dealing with compound analgesics which contain relatively small quantities of drugs listed under the Misuse of Drugs Act, the major ones being dextropropoxyphene, dihydrocodeine and codeine. Where these drugs are present on a death record, they have been ignored if they are part of a compound analgesic (such as co-proxamol, co-dydramol or co-codamol) or cold remedy. Dextropropoxyphene has been ignored on all occasions. However, codeine or dihydrocodeine mentioned alone were included in the indicator.

3. Drugs controlled under the Misuse of Drugs Act 1971 include class A, B and C drugs.

Extract from ONS description (based on ICD-10)

a) deaths where the underlying cause of death was

F11; F12; F13; F14; F15; F16; and F19.

b) deaths coded to the following categories and where a drug listed under the Misuse of Drugs Act (1971) was known to be present in the body at the time of death:

accidental poisoning (X40 – X44);

intentional self-poisoning by drugs, medicaments and biological substances (X60 – X64);

assault by drugs, medicaments and biological substances (X85); and

event of undetermined intent, poisoning (Y10 – Y14)


Deaths excluded:

deaths coded to F10 (alcohol), F17 (tobacco) and F18 (volatile substances);

deaths coded to drug abuse which were caused by secondary infections and related complications

deaths from AIDS where the risk factor was believed to be the sharing of needles;

deaths from road traffic and other accidents which occurred under the influence of drugs; and

deaths where a drug listed under the Misuse of Drugs Act was present because it was part of a compound analgesic or cold remedy: examples are: Co-proxamol Co-dydramol and co-codamol. Dextropropoxyphene has been ignored on all occasions. However, deaths involving codeine or dihydrocodeine alone have been included.

(2) Annexed Box ‘National Programme Substance Abuse Deaths’

Special registry np-SAD

The National Programme on Substance Abuse Deaths (np-SAD), based in the Department of Addictive Behaviour and Psychological Medicine at St George’s Hospital Medical School in London, collects data from inquests held on drug-related deaths submitted voluntarily by coroners.

The electronic database’s current coverage is about four-fifths of all coroners’ jurisdictions in England and Wales. Recently coverage was extended to Scotland and Northern Ireland.

A ‚case‘ is defined as a drug-related death where any of the following criteria are met at an inquest or fatal accident inquiry:

one or more psychoactive substances directly implicated in death;

history of dependence or abuse of psychoactive drugs; or

presence of controlled drugs at post-mortem.

New Member States and candidate countries


Reported separately in this edition of the statistical bulletin to highlight the developments of these countries.

Czech Republic

Case definition

Deaths due to poisoning caused by psychoactive substances (drugs of abuse and psychoactive medicines).

Technical information

Selection D of EMCDDA standard definition (drugs of abuse) PLUS deaths due to poisonings by psychoactive medicines

Data collection procedure.

Special semiautomated electronic registry run by national focal point and Society of Forensic Medicine and Toxicology.


Special mortality register – drug-related deaths in 2003. Prague: National Monitoring Centre for Drugs and Drug Addiction. Unpublished


In 2003, according to the national definition, 167 cases out of a total of 222 were due to psychoactive medicines

Since the practice in Czech Republic does not allow to include into the GMR any examination newer than 3 days after the death, this registry is not observed for the purposes of drug epidemiology as appropriate.


Case Definition

Cases according to the EMCDDA definition for general mortality registries(‘Selection B’ for ICD-9 classification):

Technical information

‘Selection B’ is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure


Ad hoc data extraction by national focal point from general mortality registry for the 2004 Reitox National Report



Case definition

The EMCDDA standard definition for special registries (‘Selection D’) will be used.

Technical information

Data collection procedure

Reference 2003


Not information provided yet.


Case definition

Cases according to the EMCDDA definition for general mortality registries(‘Selection B’ for ICD-9 classification)

Technical information

‘Selection B’ is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure


Ad hoc data extraction from Forensic Medical Institute 2003



Case definition

Cases according to the EMCDDA definition for general mortality registries(‘Selection B’ for ICD-9 classification):

Technical information

‘Selection B’ is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure


Ad hoc data extraction by national focal point from general mortality registry for the 2004 Reitox National Report



Case definition

Cases according to the EMCDDA definition for general mortality registries(‘Selection B’ for ICD-9 classification

Technical information

‘Selection B’ is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for General Mortality Registries)

Data collection procedure


Ad hoc data extraction by national focal point from general mortality registry for the 2004 Reitox National Report



Case definition

Cases according to the EMCDDA definition for general mortality registries(‘Selection B’ for ICD-10 classification)

Technical information

‘Selection B’ is described in detail in the protocol EMCDDA-DRD Standard, version 3.0 (for general mortality registries)

Data collection procedure


Dept of Health Information. Malta National Mortality Registry



Case definition

Technical information

Data collection procedure




Case definition

Deaths due to drug abuse; that means deaths happening during the time drugs is affecting the organism (accidental poisonings, intentional poisonings, poisonings of undetermined intent)

Technical Information

National definition takes into account the ICD-10 codes of the EMCDDA definition, but without exact implementation of Selection B or selection D

Data collection procedure

From 2002 onwards cases were obtained by linkage of four different databases: i) general mortality registry, ii) police database, iii) first treatment demand database and iv) toxicology department at the Institute of forensic medicine


Ad hoc data extraction by national focal point from general mortality registry for the 2004 Reitox National Report


Information of the GMR is completed with forensic and toxicology data, with police data and with first treatment demand data


Case definition

Technical information

Data collection procedure

Reference 2003



Case definition

Cases of death which underlying cause of death is drug psychosis, drug addiction, drug abuse, accidental poisoning

Technical information

The cases are selected according to the ICD-9 codes

292, drug psychosis

304, drug dependence

305, drug abuse

E854, accidental poisoning with other psychrotropic substances

E939, psychotropic substances

Data collection procedure

Death certificates filled in by family doctors do not specify the substance even if they have reasonable doubts. Deaths occurring in hospitals are followed by toxicological examination.


Ad hoc data extraction by national focal point from general mortality registry for the 2004 Reitox National Report


– ICD-10 will be implemented in 2003

– There are difference in number of cases obtained from the general mortality registry (15) and from police reports (56) in 2003


Case definition

Drug-related deaths refers to those deaths that are caused directly by the consumption of drugs of abuse

Technical information

Cases extracted according to codes X62 in combination to T40.1

Data collection procedure


Ad hoc data extraction by national focal point from general mortality registry for the 2004 Reitox National Report


Konzeptionelle Fragen betreffend „drogenbedingte Todesfälle”
Der Begriff „drogenbedingter Todesfall” ist nicht leicht einzugrenzen. Es ist wichtig, sowohl direkte („Überdosis”) als auch indirekte (Aids, Unfälle usw.) drogenbedingte Todesfälle zu berücksichtigen. Es sind sehr unterschiedliche Methoden und Datenquellen erforderlich, um die verschiedenen mit dem Drogenkonsum verbundenen Todesursachen zu bewerten.
Die EBDD-Definition für drogenbedingte Todesfälle
Die EBDD-Definition für drogenbedingte Todesfälle im Schlüsselindikator „Drogenbedingte Todesfälle und Mortalität von Drogenkonsumenten” bezieht sich auf jene Todesfälle, die direkt durch den Konsum von Missbrauchsdrogen verursacht werden. Diese Todesfälle ereignen sich im Allgemeinen kurz nach dem Konsum der Substanz/en.

Praktisch werden die Fälle wie folgt ausgewählt:

(1) Die bevorzugte Methode zur Schätzung der Zahl der Todesfälle besteht darin, die Fälle den vorhandenen allgemeinen Todesursachenregistern gemäß folgenden Kriterien auf der Grundlage der Internationalen Klassifikation der Krankheiten der Weltgesundheitsorganisation, 9. Ausgabe –ICD-9 – zu entnehmen (ICD-10 siehe weiter unten).
Es werden Fälle berücksichtigt, bei denen die eigentliche Todesursache Drogenpsychose, Medikamenten- oder Drogenabhängigkeit, Drogenkonsum ohne Abhängigkeit, unbeabsichtigte Vergiftung, Selbstmord und selbst zugefügte Vergiftung oder Vergiftung unter unbestimmten Umständen ist.

Es werden Fälle berücksichtigt, bei denen die Todesursache auf in einer Standardliste aufgeführte spezifische Drogen zurückzuführen ist: Opiate, Kokain, Amphetamine und zugehörige Derivate, Cannabis und Halluzinogene.

Im Einzelnen sind die folgenden ICD-9-Codes zu verwenden:

Kategorie drogenbedingter Todesfälle Ausgewählte(r) ICD-9-Code(s)
Drogenpsychose 292
Medikamenten- und Drogenabhängigkeit 304.0, 304.2–9
Drogen- und Medikamentenmissbrauch ohne Abhängigkeit 305.2–3, 305.5–7, 305.9
Unbeabsichtigte Drogenvergiftung E850.0, E850.8 (1), E854.1-2, E855.2 und E858.8 (1)
Tod durch Selbstmord und selbst zugefügte Drogenvergiftung E950.0 (1),E950.4 (1)
Drogenvergiftung, unklar, ob unbeabsichtigt oder vorsätzlich E980.0 (1), E980.4 (1)
(1) In Verbindung mit den N-Codes (N965.0 und/oder N968.5 und/oder N969.6 und/oder N969.7).

Diese Auswahl wurde von der EBDD-Expertengruppe für drogenbedingte Todesfälle vereinbart. Sie heißt „Auswahl B”.

Was die 10. Ausgabe der Internationalen Klassifikation der Krankheiten anbelangt, wird die Auswahl in enger Absprache mit Experten von Eurostat und der WHO entwickelt, wobei die Arbeiten schon recht weit fortgeschritten sind, und von der EBDD-Expertengruppe im Laufe des Monats Juni 2002 erörtert.

Die (zur Diskussion gestellte) vorläufige Auswahl der ICD-10-Codes für die Schätzung der Zahl der drogenbedingten Todesfälle sieht wie folgt aus:

  • Schädlicher Gebrauch, Abhängigkeit oder andere psychische Störungen oder Verhaltensstörungen aufgrund von:
    • Opioiden (F11)
    • Cannabinoiden (F12)
    • Kokain (F14)
    • anderen Stimulanzien (F15)
    • Halluzinogenen (F16)
    • multiplem Substanzgebrauch (F19).
  • unbeabsichtigte Vergiftung (X41, X42), vorsätzliche Selbstvergiftung (X61, X62) oder Vergiftung, Umstände unbestimmt (Y11, Y12) durch:
    • Opium (T40.0)
    • Heroin (T40.1)
    • andere Opioide (T40.2)
    • Methadon (T40.3)
    • Wird noch erörtert: andere synthetische Betäubungsmittel (T40.4)
    • Kokain (T40.5)
    • Wird noch erörtert: andere, nicht spezifizierte Betäubungsmittel (T40.6)
    • Cannabis (T40.7)
    • Lysergid (T40.8)
    • Wird noch erörtert: andere, nicht spezifizierte Psychodysleptika (T40.9)
    • Psychostimulanzien (T43.6)

Die T-Codes sind in Verbindung mit den jeweiligen X-Codes und Y-Codes auszuwählen.

(2) Eine alternative Methode besteht darin, die Zahl der Todesfälle dadurch zu schätzen, dass man die Fälle den vorhandenen (gerichtsmedizinischen oder polizeilichen) Spezialregistern entnimmt. Die auf den Spezialregistern beruhende Methode wird in Ländern angewandt, in denen die bevorzugte Methode nicht durchgeführt werden kann, wobei sie aber auch – wann immer möglich – herangezogen wird, um mit den entsprechenden Schätzungen die allgemeinen Todesursachenregister zu untermauern.
Es werden Fälle berücksichtigt, wenn der Tod durch unbeabsichtigte Vergiftung, in Selbstmordabsicht oder unter unbestimmten Umständen verursacht wurde.

Es werden Fälle berücksichtigt, wenn der Tod durch Opiate, Amphetamine, Kokain (oder Crack), Cannabis, Halluzinogene, Lösungsmittel oder synthetische Designerdrogen wie Amphetaminderivate verursacht wurde.

Es gibt im Einzelnen die folgenden Gruppen von Todesfällen:

Kategorie drogenbedingter Todesfälle Ausgewählte Gruppen
Vergiftung durch Unfall, in Selbstmordabsicht oder unter unbestimmten Umständen Nur Opiate (nur Methadon ausgenommen)
Nur Methadon Polysubstanzen, einschließlich Opiaten
Polysubstanzen, ausgenommen Opiate Nicht spezifiziert/unbekannt

— In der Kategorie „Polysubstanzen” sollte mindestens eine der oben genannten Substanzen enthalten sein.

— Die Kategorie „nicht spezifiziert/unbekannt” wird verwendet, wenn angenommen wird, dass eine der oben erwähnten Substanzen darin enthalten ist.

Diese Auswahl wurde von der Expertengruppe der EBDD vereinbart. Sie heißt „Auswahl D”.


The production of opium — the raw material for heroin and a major source of revenue for the Taliban insurgency — has halved in Afghanistan due to crop infection this year, but prices have tripled, a UN report released on Thursday said. The sharp drop in output is largely due to bad weather and a plant infection hitting the major poppy-crop growing provinces of Helmand and Kandahar particularly hard, the UN Office on Drugs and Crime (UNODC) said.

“As a result of the damage, yield fell 48 per cent to 29.2 kilograms per hectare, from 56.1 kilograms per hectare compared with the previous year,” it said.

The report said the area of land under poppy cultivation remained stable in 2010 at 123,000 hectares.

Some 98 per cent of the all opium poppy was cultivated in nine provinces in the country’s western and southern regions, it said, adding, “Helmand and Kandahar took the lion’s share with Helmand alone accounting for 53 per cent of total opium cultivation in Afghanistan.” The two provinces, where Taliban are most active, are the focus of a US military surge this year, with the bulk of 30,000 extra US troops moved to Afghanistan this year deployed to Helmand and Kandahar.

“These regions are dominated by insurgency and organized crime networks,” UNODC executive director Yury Fedotov said in a statement.

“This underscores the link between opium poppy cultivation and insecurity in Afghanistan, a trend we have observed since 2007.” Taliban militants are believed to fund their insurgency against the Afghan government and the 150,000 US and NATO troops by collecting tax from opium money.

Fedotov cautioned against “false optimism” because of the drop in production, saying the rising price for opium might make the market again lucrative for growers.

In 2010, the average farm-gate price of dry opium at harvest time was recorded at USD 169 per kilogram, a 164-per-cent increase over 2009, when the price was USD 64 per kilogram, the report found.

The rising prices could also prompt former poppy farmers to think twice about having switched to wheat, an important alternative crop in Afghanistan, Fedotov said.

He said also that any meaningful fight against Afghan opium production would also require the international community to curb demand in the region and western countries. “As long as demand drives this market, there will always be another farmer to replace one we convince to stop cultivating, and another trafficker to replace one we catch.” Afghanistan supplies more than 90 per cent of the world’s opium.

Thursday’s report said that the forced eradication programme led by the government was at its lowest level this year. Afghan forces eradicated 2,316 hectares of poppy crops, more than half of them in Helmand province.

NATO has also stepped up its targeting of opium convoys and traffickers, arresting dozens of suspects and seizing thousands of tons of the illicit drug.

On Wednesday, Baz Mohammed Ahmadi, the deputy interior minister, said nearly 8 tons of opium, heroin and hashish had been seized by Afghan forces in the past six months.

  • Disease keeps prices high despite drop in production
  • Number of households involved in farming drug on rise
  • Industry supports Taliban insurgency against 150,000 troops

The Taliban made £65million last year from Afghanistan’s opium trade despite the presence of thousands of British troops, a damning UN report has found.

In a startling indication that the war on poppy growing is having little effect, insurgents are still reaping the benefits despite the loss of life and huge amounts of money being thrown at the problem.

The report for the United Nations ominously warns that the illegal trade will grow even more.

High: while disease cut the amount of opium produced in Afghanistan by almost half this year compared to last, there was no fall in the number of poppy fields under cultivation and farmers earned far more for their crops
High: while disease cut the amount of opium produced in Afghanistan by almost half this year compared to last, there was no fall in the number of poppy fields under cultivation and farmers earned far more for their crops
Big score: Afghanistan produces 90 per cent of the world's opium, which, in turn, produces heroin
Big score: Afghanistan produces 90 per cent of the world’s opium, which, in turn, produces heroin
Killing fields: Some £63 million is earned by insurgents per year through the opium trade - it helps fund the Taliban's war efforts
Killing fields: Some £63 million is earned by insurgents per year through the opium trade – it helps fund the Taliban’s war efforts

Helmand province, where 9,500 British soldiers are battling the Taliban, produced 53 per cent of the country’s opium, the raw ingredient to make heroin.

The insurgents receive about $100million (£65million) a year from Afghanistan’s illegal opium trade. the report said.

The cash bonanza will continue to fund their fight against British and NATO troops. In the last 12 months, 92 UK servicemen have lost their lives in the country.

This is despite the U.S. and its coalition allies spending more than $250million (£190million) on counter-narcotics programmes in the war-ravaged nation.

In total the amount of poppy cultivated last year was 304,000 acres – the same as in 2009.

The figures are a damaging blow for Britain, whose deployment to the Taliban heartland of Helmand in 2006 intended to smash poppy cultivation and production.

Stash: Though some opium is seized, these latest figures offer are not expected to deter other farmers from cultivating
Stash: Though some opium is seized, these latest figures offer are not expected to deter other farmers from cultivating
Come down: While opium production has decreased, the price has increased so much that farmers are earning more now than they were last year with less stock
Come down: While opium production has decreased, the price has increased so much that farmers are earning more now than they were last year with less stock

Since then the UK death toll has risen to 337 since military action began in 2001.

Afghanistan produces 90 per cent of the world’s opium, said the UN’s Office on Drugs and Crime.

Before the 2001 invasion, the Taliban had managed to drastically reduce the poppy crop.

But since being toppled it has backed poppy growing to finance its insurgency.

Cultivation of the multibillion-dollar crop in 2010 was the same as in 2009 after falling in the previous two years.

Opium production dropped 48 per cent to 3,600 metric tons, mainly due to the spread of a disease that damaged poppy plants.

But low harvest yields caused by blight is likely to lead to an increase in poppy prices – encouraging more poverty-stricken farmers to plant the crop.

In 2009, the average price per kilogram of dry opium at harvest was $64 (£41) per kilogram. It is now about $169 (£114) per kilogram.

UN officials warned three years ago that ‘frightening levels’ of poppy production was threatening the very survival of Afghanistan.

The coalition has poured money into the country to try to stem opium production as part of an effort to undercut funding for insurgent groups fighting the 150,000 coalition forces in the country.

The disappointing figures come despite years of programmes aimed at reducing the poppy crop, by giving farmers subsidised seeds for other crops and vouchers for farmers.

The wheat-distribution programme, where famers receive bags of cereal seeds to persuade them to quit growing narcotics, will begin shortly.

Experts said that if Afghanistan’s discredited government can provide security there would be less incentive for farmers to plant opium to survive.

Robert Watkins, the deputy UN envoy in Afghanistan, said: ‘If there is not going to be security in Afghanistan across the entire country, we are not going to be able to eliminate this problem.’

This is despite the U.S. and its coalition allies spending more than $250million (£190million) on counter-narcotics programmes in the war-ravaged nation.

In total the amount of poppy cultivated last year was 304,000 acres – the same as in 2009.

The figures are a damaging blow for Britain, whose deployment to the Taliban heartland of Helmand in 2006 intended to smash poppy cultivation and production.

Stash: Though some opium is seized, these latest figures offer are not expected to deter other farmers from cultivating
Stash: Though some opium is seized, these latest figures offer are not expected to deter other farmers from cultivating
Come down: While opium production has decreased, the price has increased so much that farmers are earning more now than they were last year with less stock
Come down: While opium production has decreased, the price has increased so much that farmers are earning more now than they were last year with less stock

Since then the UK death toll has risen to 337 since military action began in 2001.

Afghanistan produces 90 per cent of the world’s opium, said the UN’s Office on Drugs and Crime.

Before the 2001 invasion, the Taliban had managed to drastically reduce the poppy crop.

But since being toppled it has backed poppy growing to finance its insurgency.

Cultivation of the multibillion-dollar crop in 2010 was the same as in 2009 after falling in the previous two years.

Opium production dropped 48 per cent to 3,600 metric tons, mainly due to the spread of a disease that damaged poppy plants.

But low harvest yields caused by blight is likely to lead to an increase in poppy prices – encouraging more poverty-stricken farmers to plant the crop.

In 2009, the average price per kilogram of dry opium at harvest was $64 (£41) per kilogram. It is now about $169 (£114) per kilogram.

UN officials warned three years ago that ‘frightening levels’ of poppy production was threatening the very survival of Afghanistan.

The coalition has poured money into the country to try to stem opium production as part of an effort to undercut funding for insurgent groups fighting the 150,000 coalition forces in the country.

The disappointing figures come despite years of programmes aimed at reducing the poppy crop, by giving farmers subsidised seeds for other crops and vouchers for farmers.

The wheat-distribution programme, where famers receive bags of cereal seeds to persuade them to quit growing narcotics, will begin shortly.

Experts said that if Afghanistan’s discredited government can provide security there would be less incentive for farmers to plant opium to survive.

Robert Watkins, the deputy UN envoy in Afghanistan, said: ‘If there is not going to be security in Afghanistan across the entire country, we are not going to be able to eliminate this problem.’

Read more:

Berlin (ots) – Die Deutsche AIDS-Hilfe e.V. (DAH) widerspricht negativen und fachlich teilweise falschen Berichten zur Substitutionsbehandlung von Opiatkonsumenten in der Ärztezeitung und in Medien der WAZ-Gruppe („Junkies nehmen Heroin und dealen mit Methadon“). Zum wiederholten Mal entsteht in der Öffentlichkeit durch solche Berichte der Eindruck, viele Substituierte würden weiterhin Heroin konsumieren und ihr Substitut auf dem Schwarzmarkt weiterverkaufen. Dieses pauschale Bild entspricht nicht der Wirklichkeit. Substitution ist die weltweit erfolgreichste Behandlungsform für Heroinabhängige und rettet in Deutschland Zehntausenden das Leben.

Silke Klumb, Geschäftsführerin der DAH erklärt hierzu: „Substitutionspatienten werden in diesen Berichten diskreditiert, indem sie als Dealer und Betrüger dargestellt werden. Die positiven Effekte der Substitutionsbehandlung fallen unter den Tisch. Substitution ermöglicht den Betroffenen den Ausstieg aus der Drogenszene und die Wiedereingliederung in die Gesellschaft. Viele können zum Beispiel wieder arbeiten.“

Die WAZ-Medien zitieren einen FDP-Landtagsabgeordneten, der sich auf nicht näher bezeichnete Studien bezieht. Die Ärztezeitung nimmt in ihrem Bericht Bezug auf die bekannte ZIS-Studie, zieht aber falsche Schlüsse. Bereits nach Veröffentlichung der Studie im Jahr 2009 erläuterten die Autoren: „Bei den befragten 806 Personen handelt es sich zum großen Teil um sozial desintegrierte, schwer kranke Personen, die im Umfeld von Drogenkonsumräumen kontaktiert wurden, und nicht um reguläre, integrierte Substitutionspatienten.“ Die Wissenschaftler reagierten damit auf fehlerhafte Berichte über die Studie, unter anderem im Spiegel.

Das Thema Beikonsum (Drogenkonsum zusätzlich zum Medikament, das die Droge ersetzt) wird immer wieder falsch dargestellt. Indem etwa Kokain, Medikamente und Alkohol in einem Atemzug mit Heroin genannt werden, entsteht der Eindruck, viele Substituierte würden weiter Heroin konsumieren. Das kommt aber nur relativ selten vor.

Dazu Dirk Schäffer, DAH-Referent für Drogen und Strafvollzug: „Drogenabhängige konsumieren oft viele Substanzen. Die Substitutionsmedikamente wirken ausschließlich gegen die Opiatabhängigkeit. Der missbräuchliche Konsum anderer Substanzen wird nicht beeinflusst. Hier werden unrealistische Erwartungen an die Substitutionsbehandlung gerichtet.“

Auch der reflexartige Ruf nach mehr Kontrolle der Substitutionsbehandlung verkennt die Realität. Substitution ist bereits heute so engmaschig reglementiert, dass viele Ärzte den Aufwand scheuen und aus dieser Behandlungsform aussteigen. Ein Höchstmaß an Regeln und Kontrollen erschwert zugleich vielen Abhängigen den Einstieg in die Behandlung.

Statt Substitution in Frage zu stellen, muss es darum gehen, die Palette der zur Verfügung stehenden Medikamente zu erweitern, um noch mehr Heroinkonsumenten eine für sie passende Behandlung anbieten zu können. Nach den Ergebnissen der „Heroinstudie“ in Deutschland profitieren sowohl bisher nicht erreichte Heroinkonsumenten als auch so genannte „Substitutionsversager“ von einer Behandlung mit Diamorphin (pharmazeutisch reines Heroin).

Darüber hinaus gilt es, den Wiedereinstieg in Arbeit und Beschäftigung weiter zu erleichtern und damit die Fähigkeit zur Eigenverantwortung zu stärken. Beikonsum kann auf diesem Weg reduziert werden.

Unter finden Sie Links zu den genannten Presseberichten. Dort steht auch die zitierte Stellungnahme von den Autoren der ZIS-Studie online.

Den Artikel haben Wir hier:

Beikonsum bei jedem zweiten Methadon-Patienten in NRW?

ESSEN (nös). In Nordrhein-Westfalen gibt es offenbar erhebliche Probleme mit Beikonsum in der Methadon-Substitution. Experten schätzten, dass jeder zweite Substitutionspatient in NRW zusätzlich illegale Betäubungsmittel konsumiert, berichten die Zeitungen der WAZ-Gruppe am Montag.
Beikonsum bei jedem zweiten Methadon-Patienten in NRW? Zitiert wird der FDP-Landtagsabgeordnete und Arzt Dr. Stefan Romberger, der sich auf Studienveröffentlichungen beruft. Diese hätten gezeigt, dass jeder Zweite zusätzlich auf dem Schwarzmarkt beschafftes Heroin oder andere "weiche" Drogen konsumiert. Defizite macht Romberger dem Bericht zufolge in Arztpraxen aus: "Da wird viel zu wenig hingeschaut, insbesondere in den Praxen, die Methadon ausgeben." In Nordrhein-Westfalen befinden sich derzeit dem Bericht zufolge rund 38 000 Menschen in einer Substitutionsbehandlung.
Laut WAZ ist auch die Deutsche Hauptstelle für Suchtfragen (DHS) alarmiert. "Beigebrauch ist ein Riesenproblem", sagte Jost Leune vom DHS-Vorstand der Mediengruppe. Er fordert "viel mehr Kontrolle und zweitens eine bessere Betreuung der Patienten." Dies sei in der Realität bislang aber nur die Ausnahme. "Die Kassen zahlen diese Betreuung nicht, also findet sie auch selten statt", wird der Leiter der Düsseldorfer Drogenhilft, Joachim Alxnat, zitiert. Eine Studie aus dem vergangen Jahr kam zu ähnlichen Ergebnissen, wie sie jetzt von der WAZ berichtet wurden. 46 Prozent der Methadon-Substituierten konsumierten auf dem Schwarzmarkt besorgtes Heroin, berichtete das Zentrum für Interdisziplinäre Suchtforschung der Uni Hamburg (ZIS) im Juli 2009. Bei der Ersatzbehandlung mit Buprenorphin seien es 43,4 Prozent. Das ZIS kam damals außerdem zu dem Schluss, dass zwei Drittel der Süchtigen bereits illegal Substitutionspräparate konsumiert haben. Mit knapp 60 Prozent rangierte Methadon dort an erster Stelle. Etwas mehr als 40 Prozent gaben an, Levomethadon illegal konsumiert zu haben. In Deutschland befinden sich rund etlichen zehntausend Drogenabhängige in einer Substitutionstherapie. In ihrem jüngsten "Jahrbuch Sucht" zählt die Deutsche Hauptstelle für Suchtfragen 72 000 im Substitutionsregister erfasste Patienten (Stichtag 1. Juli 2008). Im Vorjahreszeitraum lag die Zahl laut DHS bei 68 800. Zur Behandlung wird in fast 60 Prozent aller Fälle Methadon einsetzt. An zweiter und dritter Stelle folgen Levomethadon und Buprenorphin mit jeweils rund 20 Prozent. Codein und Diamorphin haben in der Therapie nur einen Stellenwert als Außenseiter.

Viele Jahre stand die liberale Frankfurter Drogenpolitik in der Kritik – doch sie hat sich durchgesetzt.
Ab heute übernehmen nun sogar die Krankenkassen die Kosten der kontrollierten Abgabe von Heroin.
Die Stadt spart dadurch viel Geld.

Von hr-Reporterin Silja Tietz

Wie alle, die in der Frankfurter Heroinambulanz gelandet sind, hat Klaus (Name geändert) einen langen Leidensweg hinter sich. Über 30 Jahre nahm er Drogen, auch Heroin. Er konnte einfach nicht ohne. Durch die Behandlung in der Heroinambulanz im Frankfurter Ostend kam für ihn mit Anfang 50 aber die Zuversicht zurück: „Das ist das erste Mal, dass ich mich so stabil fühle, dass ich mir vorstellen kann, ein normales Leben zu führen, mit Arbeit, unabhängig und selbstständig“. In der Heroinambulanz bekommen schwerstabhängige Menschen wie Klaus künstlich hergestelltes Heroin vom Arzt – so genanntes Diamorphin.

Zurzeit kommen 104 schwerstabhängige Menschen regelmäßig in die Heroinambulanz, keine Therapie half ihnen bislang aus dem Drogensumpf. Drei Mal am Tag bekommen sie von einem Arzt Diamorphin. So sollen sie es schaffen, wieder ein normales Leben zu führen, so Wilfried Köhler, der Leiter der Heroinambulanz. „Viele Menschen kommen von der Straße, allen sozialen Bezügen entrissen. Nach einer Woche sagen sie ‚Guten Tag‘ und ‚Danke schön‘. Das klingt banal – aber es illustriert, was für ein Prozess in Gang kommt.“

Nun übernehmen die Krankenkassen die Kosten für die Behandlung. Das hat der Bundestag im Frühjahr so entschieden. Nach langen Kämpfen hat sich damit die Idee der Heroinambulanz durchgesetzt. Für einige wenige Schwerstabhängige, die mehrere erfolglose Therapien hinter sich haben, ist der kontrollierte Drogenkonsum der einzige Weg zurück zu einem halbwegs normalen Leben. Für die Krankenkassen fallen Kosten von jährlich rund 11.500 Euro pro Patient an. Damit habe sich auch die liberale Frankfurter Drogenpolitik durchgesetzt, so Gesundheitsdezernentin Manuela Rottmann (Grüne). „Es war uns immer klar, dass wir einen kleinen Teil der Ausstiegswilligen mit anderen Programmen nicht erreichen. Für diese kleine Gruppe ist die Diamorphinabgabe der Weg in ein normales Leben.“

Krankenkassen müssen 1,5 Millionen Euro zahlen

Noch im Herbst 2007 drohte der Heroinambulanz im Ostend das Aus. Das auf vier Jahre angelegt Modellprojekt war zu Ende. Die Bundesregierung wollte die Drogenabgabe nicht mehr zulassen. Nach viel Überzeugungsarbeit von Politikern aller Parteien in Frankfurt kam es aber anders. Durch die Bundestagsentscheidung gehört die Abgabe künstlichen Heroins an Schwerstabhängige nun sogar zum Leistungskatalog der Krankenkassen. Die Stadt Frankfurt spart damit 1,5 Millionen Euro im Jahr.

Das sind Kosten, die nun die Krankenkassen tragen müssen. Meinhard Johannidis vom hessischen Verband der Ersatzkassen sieht das kritisch. „Wir sind der Auffassung, dass die Behandlung mit Diamorphin nicht nur Aufgabe der Krankenkassen ist, sondern eine gesamtgesellschaftliche Aufgabe.“

Manche schaffen den Sprung in ein drogenfreies Leben

Für die Schwerstabhängigen in der Frankfurter Heroinambulanz gibt es nun aber eine dauerhafte Perspektive. Die bisherigen Erfolge in Frankfurt machen Gesundheitsdezernentin Rottmann auch für die Zukunft zuversichtlich. „Die soziale Situation der meisten hat sich ganz schnell verbessert, viele sind obdachlos und isoliert und das ändert sich ganz schnell.“ Auch den kompletten Ausstieg schaffen manche: Im vergangenen Jahr hätten immerhin fünf Patienten den Absprung in ein drogenfreies Leben geschafft.


Die Aufnahme in den Regelkatalog der Krankenkassen bedeutet
das Menschen nun das Anrecht auf diese Behandlung haben,
Patienten koennen diese nun einklagen


CNRS-Wissenschaftler des Pasteur Instituts und ein Wissenschaftler-Team des Forschungszentrums für Neuropsychopharmakologie und angewandte Ethologie ETAP (Vandoeuvre-lès-Nancy, Lothringen) haben bei Tieren die schmerzstillenden und antidepressiven Eigenschaften von Opiorphin gemessen. Das Molekül lindert Schmerzen so gut wie Morphium, weist jedoch deutlich weniger Nebenwirkungen auf. Des Weiteren wirkt es genauso gut wie das Antidepressivum Imipramin, aber gänzlich ohne Nebenwirkungen. Die Ergebnisse wurden in der Fachzeitschrift Journal of Physiology and Pharmacology veröffentlicht [1].

Opiorphin – ein im menschlichen Speichel vorkommendes Endorphin (körpereigenes Opioid) – wurde 2006 von Catherine Rougeot und ihrem Team „Struktur- und Zellbiochemie“ des Pasteur Instituts entdeckt. Die Pariser Wissenschaftler konnten kürzlich, in Zusammenarbeit mit dem ETAP-Team vom Technopol Nancy-Brabois, in vivo nachweisen, dass Opiorphin, in identischer Dosierung, die gleiche schmerzstillende Wirkung wie Morphium zeigt und sowohl bei thermischen und mechanischen Schmerzen als auch bei tonischen und chronischen Schmerzen wirkt. Die Nebenwirkungen des Opiorphins sind deutlich geringer als die des Morphiums: Keine Gewöhnung (die Dosis muss nicht progressiv erhöht werden), keine Verstopfung und nur eine geringe Suchtgefahr bzw. psychologische Abhängigkeit.

Auch als Antidepressivum erwies es sich als sehr wirksam. Bei Tierversuchen zeigte das Molekül bei identischer Dosierung die gleiche Wirksamkeit wie Imipramin, ein zur Behandlung depressiver Syndrome eingesetzter Wirkstoff. Opiorphin verursacht jedoch keine Übererregbarkeit, keine sedative Wirkung und keine Auswirkung auf das Langzeitgedächtnis, wie es zuweilen bei Antipressiva der Fall ist.

Schmerzen und Depressionen sind oft miteinander verbunden: Depressive Patienten sind oft besonders schmerzempfindlich und umgekehrt verursachen chronische Schmerzen oft Depressionen. Die Wissenschaftler hoffen nun, ein auf diesem Molekül basierendes Arzneimittel herstellen zu können, das beide Syndrome gleichzeitig behandeln könnte. Im Hinblick auf eine therapeutische Anwendung arbeiten die Forscher nun an der Optimierung ihres synthetisch hergestellten Opiorphins, mit dem Ziel einer größeren Bioverfügbarkeit und einer längeren Wirkungsdauer. Erst im Anschluss an diese notwendigen Schritte können die ersten klinischen Studien durchgeführt und das therapeutische Potenzial von Opiorphin evaluiert werden.

[1] Veröffentlichungen: – „Human Opiorphin is a naturally occurring antidepressant acting selectively on enkephalin-dependant delta-opioid pathways“, Javelot , Messaoudi, Garnier, Rougeot – Journal of Physiology and Pharmacology – 2010, 61(3): 355-362. – „Systemically active human Opiorphin is a potent yet non-addictive analgesic without drug tolerance effects“, Rougeot, Robert, Menz, Bisson & Messaoudi – Journal of Physiology and Pharmacology – 2010, 61(4): 483-490.

Quelle: „Antidouleur, antidépresseur: une molécule tout-en-un“, Pressemitteilung des CNRS – 01.09.2010 <;

September 28, 2010 (Las Vegas, Nevada) — A transdermal application system containing the partial μ-opioid receptor agonist buprenorphine showed analgesic efficacy in the treatment of low back pain in opioid-naive patients, according to clinical trial results presented here at the American Academy of Pain Management 21st Annual Clinical Meeting. Buprenorphine is commonly used for the treatment of acute pain and, in the United States, for opioid dependence. A new transdermal delivery system of the drug (Butrans, Purdue Pharma LP) provides continuous delivery of this drug during a 7-day period and also effectively controls lower back pain, researchers announced. The US Food and Drug Administration recently approved the product for the management of moderate to severe chronic pain in patients requiring an around-the-clock opioid analgesic for an extended period. Purdue reports Butrans is scheduled to be marketed in January 2010. „Butrans is a class 3 opioid and the only 7-day opioid patch on the market,“ said Deborah J. Steiner, MD, medical director at Purdue Pharma LP. The transdermal drug carries a boxed warning and requires a Risk Evaluation and Mitigation Strategy as part of its approval. The double-blind, multicenter, 12-week study involved 1024 opioid-naive patients with moderate to severe chronic lower back pain. Patients received open-label transdermal buprenorphine (BTDS) during a run-in period, and 541 patients who both tolerated and responded to treatment were then randomized to receive either BTDS, 10 μg/h (BTDS 10; n = 120), or BTDS, 20 μg/h (BTDS 20; n = 137), or matching placebo patches (n = 284). The primary efficacy outcome was the „average pain over the last 24 hours“ scores at the end of the 12-week, double-blind phase. Response to treatment was evaluated according to the percentage of improvement in pain scores compared with screening values. The results showed an average improvement in pain in the last 24 hours at week 12 of −0.58 in favor of those treated with the BTDS compared with placebo (P = .0104). On the basis of a responder analysis, the proportion of patients with pain score improvement of 30% or more and 50% or more was larger in the BTDS group compared with the placebo group, Dr. Steiner noted. „We conducted responder analyses, which showed a larger percentage of patients treated with [transdermal buprenorphine] had both a greater than or equal to 30% and 50% improvement in pain from baseline,“ she said. Treatment-emergent adverse events (occurring in ≥5% patients) included nausea, application site rash, and headache. Serious adverse events occurred in 1.2% of BTDS-treated patients and 0.7% of placebo patients. There were no deaths or safety concerns arising from clinical laboratory tests. A treatment for chronic pain that requires only a once-a-week application should represent an important new option in the marketplace, said Perry G. Fine, MD, a professor of anesthesiology at the University of Utah School of Medicine in Salt Lake City. „I think it will be a very welcome addition to the formulary for chronic pain for a number of reasons, not the least of which is the fact that, in terms of a once-a-week treatment for people with some degree of disabling and opioid-responsive pain, there currently is no such thing,“ said Dr. Fine, who is president-elect of the American Academy of Pain Medicine. „The fact that [transdermal buprenorphine] is a low-dose formulation is also good thing, because there are a lot of patients who don’t need high-dose opioid therapy but who need something potent to help beyond drugs that pose other potential dangers, such as acetaminophen in higher doses. „[The patch] could be especially useful in older populations with osteoarthritis who have pain that seriously interferes with either the quality of life or sleep,“ he noted. „So I think this is really a positive event that is a long time coming.“ The study was supported by Purdue Pharma LP. Dr. Steiner is medical director at Purdue Pharma LP. Dr. Fine’s disclosures include that he is on the advisory boards for companies including Alpharma, Forest Laboratories, Ortho McNeil, Purdue Pharma, Endo, Lilly, Cephalon, and King Pharmaceuticals. American Academy of Pain Management (AAPM) 21st Annual Clinical Meeting: Poster Abstract 29. Presented September 23, 2010.

001_ButransPI (This is a File about what it is)

Abwässer der Pharmaindustrie belasten die Umwelt stärker als bislang angenommen. Das ist bedenklich. So können Antibiotika in den Gewässern dazu beitragen, dass Krankheitserreger resistent werden.

Egal ob Antidepressiva oder Zytostatika – vieles aus dem verschreibungspflichtigen Sortiment der Pharmaindustrie gibt es längst rezeptfrei im Badesee. Mehr als 150 verschiedene Arzneiwirkstoffe haben Wissenschaftler mittlerweile in Seen und Flüssen, Sedimenten, Grundwasser und Böden nachgewiesen, berichtet das Umweltbundesamt (UBA) in Dessau. Immer wieder werden sogar im Trinkwasser Medikamente entdeckt, wenn auch in geringen Mengen.

KLÄRANLAGE STUTTGART-MÜHLHAUSEN Bild vergrößern Mehr als 150 verschiedene Arzneiwirkstoffe haben Wissenschaftler in Seen und Flüssen, Sedimenten, Grundwasser und Böden nachgewiesen. (© DPA)

Abwässer der Pharmaindustrie tragen offenbar weit mehr zu dieser flächendeckenden Umweltbelastung bei, als bisher vermutet. Das zeigt eine Studie des US Geological Survey, einer Forschungseinrichtung des US-Innenministeriums (Environmental Science and Technology, Bd.44, S.4910, 2010).

Ein Forscherteam um den Hydrologen Patrick Phillips verglich zwei New Yorker Kläranlagen, die jeweils zu einem Fünftel ihrer Kapazität Abwässer von Arzneimittelherstellern aufnehmen, mit Anlagen aus New York und anderen Bundesstaaten, in die keine Abwässer der Pharmaindustrie fließen.

Wasser aus den Klärwerken, die Abwässer von Arzneimittelherstellern aufbereiten, enthält bis zu 1000-mal so hohe Medikamentenkonzentrationen wie Wasser aus anderen Anlagen. Wohlgemerkt: nach der Klärung.

Die US-Forscher hatten zwischen 2004 und 2009 den Auslauf von insgesamt 26 Klärwerken in den USA auf sieben verschiedene Medikamente untersucht. Am häufigsten entdeckten sie das Barbiturat Butalbital, das in mehr als 80 Prozent aller Proben auftauchte. Gut die Hälfte der Wasserproben enthielt das Opioid Oxycodon, an dritter Stelle folgte ein Mittel zur Muskelentspannung namens Carisoprodol. Bei allen Kläranlagen ohne Pharmaindustrie-Abwässer blieb die Konzentration der einzelnen Substanzen jeweils unter einem Mikrogramm pro Liter.

Anlagen, die auch Abwässer aus Krankenhäusern aufbereiteten, wiesen am Auslauf etwas höhere Arzneimittelrückstände auf als andere, aber der Unterschied war statistisch nicht bedeutsam. Dagegen entließen die beiden Anlagen, die von Arzneimittelherstellern mitbenutzt wurden, je nach Substanz zehn- bis 1000-fach höhere Konzentrationen an Medikamenten in die Umwelt.

Für das Opioid Oxycodon beispielsweise wurden Werte bis zu 1700 Mikrogramm pro Liter gemessen. Würde ein Mensch anderthalb Liter dieses Wasser trinken, hätte er damit schon mehr von dem Schmerzmittel geschluckt, als die kleinste Tablette des Präparats enthält, heißt es in einem Bericht über die Studie im Fachjournal Environmental Health Perspectives.

Nun stillt wohl kaum jemand seinen Durst aus dem Auslauf einer Kläranlage. Flussabwärts verdünnt sich das Opiat bald, und so taugt das Flusswasser weder als Schmerzmittel noch macht es süchtig. Auch alle anderen entdeckten Wirkstoffe werden so stark verdünnt, dass das Wasser keinesfalls verschreibungspflichtig wäre.

Dennoch gelten Medikamentenrückstände in Gewässern als äußerst bedenklich. So können Antibiotika in der Umwelt dazu beitragen, dass Krankheitserreger resistent werden. Das Psychopharmakon Fluoxetin ist hochgiftig für Wasserorganismen. Andere Arzneistoffe beeinflussen deren Fortpflanzung, weil sie ähnlich wie Hormone wirken.

Ein besonderes Risiko für die Umwelt stellen Medikamente zur Krebstherapie dar, die das Erbgut schädigen können. Auch geringste Mengen von weniger als einem hundertstel Mikrogramm pro Liter können eine Umweltgefahr darstellen, daher sind für solche Mittel gesonderte Risikobewertungen nötig, betonten Wissenschaftler des Universitätsklinikums Freiburg im vergangenen Jahr in einer Studie für das Umweltbundesamt.

Die jetzt in den USA durchgeführten Messungen ergaben für eine Reihe von Medikamenten weit höhere Werte, als Modellrechnungen vorhergesagt hatten, erklären Patrick Phillips und seine Kollegen. Denn alle Berechnungen gingen bislang davon aus, dass Medikamente entweder mit Ausscheidungen von Patienten in Gewässer gelangen oder durch Medikamentenreste, die nach einer überstandenen Erkrankung in Haushalten sorglos in die Toilette geschüttet werden.

Dass die Pharmaindustrie Flüsse und Seen erheblich mit Medikamenten belastet, war bisher nur aus Schwellenländern bekannt geworden. So hatten schwedische Forscher im indischen Hyderabad im Jahr 2007 extrem hohe Konzentrationen von Antibiotika und anderen Medikamenten im geklärten Abwasser von Arzneimittelherstellern entdeckt.

Wie stark Abwässer von Pharmafirmen in Deutschland die Gewässer belasten, ist allerdings unbekannt. Dieser Frage ist nach Auskünften des Umweltbundesamtes bisher noch niemand nachgegangen. „Bei der Zulassung von Arzneimitteln werden zwar auch Umweltgesichtspunkte betrachtet“, erläutert Bettina Rechenberg, Leiterin des Fachgebietes Umweltrisikobewertung von Arzneimitteln im UBA. Doch beziehe sich dies nur auf die Anwendung, nicht aber auf die Produktion. „Wenn es also gilt zu bewerten, ob kritische Umweltkonzentrationen erreicht werden oder nicht, bleibt die Produktion ausgenommen.“

Auch hierzulande ging man also bisher davon aus, dass Ausscheidungen von Patienten und die unsachgemäße Entsorgung von Arzneimittelresten weit stärker ins Gewicht fallen als die Abwässer der Pharmaindustrie. „Allerdings gibt es keine systematischen Daten, die diese Annahme belegen“, gesteht Rechenberg. Bei einem Monitoring-Programm Ende der 1990er-Jahre seien viele Arzneimittelrückstände gefunden worden, in abwasserbelasteten Flüssen mehr als in Flüssen ohne solche Einleitungen.

„Es wurde aber nicht rückverfolgt, woher die Abwässer stammten, ob es sich also um kommunale oder industrielle Abwässer handelte“, bedauert Rechenberg. Angesichts der nun veröffentlichten Daten aus den USA sagt sie: „Es wäre durchaus sinnvoll, dem auch in Deutschland nachzugehen und zu prüfen, ob Einleitungen aus der Pharmaindustrie tatsächlich zu vernachlässigen sind.“

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