Through the eyes of a doctor, life is the most important value. The preservation of life is the aim of doctor’s treatment. As in the past, addiction to opioids is an illness with a largely avoidable mortality rate and somatic morbidity, (BAG, Expertenkommission 1996). In Germany, approximately 2'000 `Drug-deaths` are registered per year; the true number could be much higher. In Switzerland 750 to 1'000 people die due to the consequences of illegal drug- especially opioid consumption. 350 to 400 deaths due to overdosing were registered by the police, ( Estermann 1996), 300 deaths due to Aids (Spuhler 1995, Gebhart 1996) plus a considerable, still very uncertain number of deaths due to hepatitis and infections. Addicts rarely die due to a car accident or due to Cocaine- or Amphetamine caused cerebro- and cardiovascular events. Illegal drug consumption is the most common cause of death in the age range 25- to 44-year old Swiss with a value of 45 to 60 on 10‘000 (Seidenberg 1996). Even though this shockingly high number partly incorporates the HIV infections from the 80‘s, there is still a great need for action and treatment.

The need for treatment, both qualitatively and in quantitively, has increased due to the new possibilities of treating HIV- and HCV-infections. Qualified, constant treatment and care is the best way to combat the high death and mortality rate amongst drug-addicts (Dole 1988). The most likely way is through prescribed, outpatient, opioid care and treatment (Uchtenhagen 1983, Ball 1991).

This book deals mainly with the somatic, medical aspects of drug-addiction and it’s consequences. In order to ensure the survival of drug-addicted patients, somatic questions must be pushed to the forefront, in both theory and practice.

Psychotherapeutic and psychiatric aspects will only be discussed marginally as they have been the main topic in almost all other publications concerning opioid-supported treatments (Dole and Nyswander 1965, Parrino 1993, McLellan 1993, Bühringer 1995). In the past years, there has been a general relativity concerning the psychotherapeutic aims in favour of life, survival and physical integrity. We welcome this paradigm change in the direction of harm reduction. The psyche, the soul-healing is not always the primary aim of medical treatment, and in addition, an often too easy plaything for ideological syndicates.

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Compliance characterises the willingness and ability to cooperate. From a doctor’s view, compliance focuses mainly on the collaboration of the patient. When treating drug-addicts, the relationship between doctor and patient must be pushed into the forefront. Here, this concerns not only the doctor but all other personell within the medical system. The co-operation of the drug addict between himself and his social workers is made mutually more difficult due to the many facets of drug addiction itself. ‘Druggies’ are often seen as more of a burden in private surgeries, policlinics and hospitals; the association with each other is on one hand difficult for the drug-dependent person and on the other hand also difficult for the medical personnel (Westdijk 1996). For drug-addicts, the medical system and all other social services are seen as a threat and are, sometimes, to be overcome through drug consumption. Drug addicts often push people and the structure of the medical system to their limits.

In view of the restricted co-operation from all parties, treatment of individual drug addicts and treatment-concepts must be realistically thought through. Theoretical methods of treatment and other procedures practised on other patients are often not applicable when treating drug-addicts. Only too easily can a doctor shirk off his/her responsibilities by blaming the failure of treatment on the lack of compliance from the drug-addicted patient . Failure must also be anticipated as a possible outcome of treatment within a treatment concept.

• Failure and falling back are especially likely results within every abstinence treatment. Abstinence is hardly directly life-threatening but abstinence and the following loss of tolerance can cause conditions for a deadly overdose to be taken. At least a quarter of sudden deaths due to an overdose follow a failed treatment.(Heckmann 1993, Gazareth 1996). These deaths after failed therapies have to be considered and consequently avoided using proper concepts of therapy. These deadly overdoses have to be seen as a undesired but always a possible result of every abstinence therapy.
• The time before a patient is accepted into therapy is often an especially risky time, full of dangerous ambivalences, therefore a careful indication certainly increases, without a doubt, the safety and quality of the treatment. The time involved on the indication procedure and the effort put into background information must be in fair relation to one another. The possible profit gained as a result of a costly indication processes can be ruined through the serious consequences resulting from hesitant acceptance onto a therapy.
• The differences between contraception requirements and sexually infectious diseases amongst female drug addicts will be discussed in more detail in chapter 28. Considering the compliance of many drug-addicted patients, it is , when weighing up the risks, more important to prevent deadly, but often occurring infections as pregnancy.
• Treatments against the HIV-virus must, when possible, be continued because the reduction of treatment with, for example, Retovir, can lead to a Rebound effect meaning an increase in the virus cells. The demands for the latest antiretroviral treatment are often too high for drug-addicts meaning that treatments for drug-addicts have to be conceived with as few demands as possible.
• The lack of compliance detracts from the many scientific statements made about treatments with opioids. Researched are usually patient collectives with fairly good motivation and compliance and statements about success in therapy tend to relate to a group of patients who, independent from the invested methods of therapy, are especially successful. Trials and trials-statements are rarely directed at looking at the full extent of the effect of treatment and the effect on the majority of drug-addicts.

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A large choice of therapy possibilities makes it easier for the individual to find the one more likely to be successful. Differential indications criteria and a therapy that works for all opioid-addicts does not exist. (Gmür, 1989, Fuchs 1989, 1995).

Thamm (1995) guessed that in Europe, 1.5 Mio people were addicted to heroin; added to the are another 2 Million poppy seed and opioid-consuming people in eastern Europe. Numbers in the range of 60'000 to100'000 have been given for the number of drug-addicts in Germany. The total number of drug-addicts within Switzerland has been, after many investigations been approximated at 30'000 (Rehm 1995, BAG 1995, Estermann 1996) and still the majority of drug-addicts is not in any form of treatment or care.

Abstinence orientated therapies are not the therapies of choice and they are only able to promise a larger success rate for the minority of drug-addicts. Most of the attempts at cold turkey and abstinence fail and are only successful after many attempts (Gossop 1987, 1989). The whole concept of abstinence therapies has to weigh up the moderate success rate against the avoidable, vital risks, and strategies to prevent deadly overdoses must become a central part of the concept.

Methadone-supported treatments are for drug-addicts, who have otherwise not been successful, a necessity and the most tried and tested method to reduce the large risks in the largest number of patients. (Dole 1988, Ball 1991, Rezza 1992, van Brussel 1995). In Germany, the number of patients staying in treatment increased drastically to almost 20'000 due to the introduction in the 90‘s, widely across the country, of methadone-supported treatment. The Swiss drug politics made it possible for 12'000 to 14'000 patients to enter into methadone-supported treatment (Eidgenössische Betäubungsmittelkommission 1995); this corresponds to an exceptionally large chunk of the, compared internationally,approximately 30'000 opioid-dependent people in Switzerland with it’s population of 7 million. A loss in quality was accounted for in the methadone-supported psychotherapeutic treatment but at least a minimum amount of medical and social care was offered for as many threatened patients as possible. (Seidenberg 1986, Christen 1996). The success of the Swiss drug politics can be measured by the number of recorded HIV infections due to drug injections which since 1985 at 69% has gone down to 19% in 1995 (Gebhardt 1996). The optimal care for a possible large number has been in the last years placed higher than maximum quality for a small minority.

A diversified prescription of opioids form of treatment is indicated for patients where other methods have failed. The aim is to get as many opioid-dependent people consistently in a form of treatment and care. This method of treatment, including heroin and morphine, has proven to be the most successful amongst patients where other forms of treatment have failed. (Uchtenhagen 1994, 1995, 1996).

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The difference between substance-limited and application-limited effects is, in relation to medical dangers and the therapy for drug-addicts, crucial. The application-limited effects and the circumstances of consumption are far more important than the substance-limited effects, in relation to death rate and mortality. Forms of application, regularity of consumption and the substances used make opioid consumption more or less attractive for the addicts. For the drug addicts, are the subjective forms of consumption more important than the static properties of the substances. The precise analysis of the substance-limited and application-limited effects are individual and are for the general therapy planing, essential. For example, the most economical way is fixing, injecting drugs, which means it is also the cheapest form of application; it is also the riskiest form of consumption but simple and most effective technique to achieve the blissful ‚flash‘

The difference between acute and chronic opioid effects is theoretically and practically from large, usually very underestimated, importance. At the beginning, respectively during a lengthy treatment with opioid medication one sees subjectively as well as within laboratory parameters, very varying effects. (re. i.e. Immunological effects Chapter 5.4).

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This book is supported largely by numbers in Switzerland and the experiences made there. In Switzerland, despite it being a small country, there are competent, reliable epidemiological figures available especially about drug-addiction, HIV and death-rates. Die breite Darstellung der Mortalität oder der epidemiologischen Situtation bei viralen Erkrankungen ist deshalb modellhaft auch über die Switzerland hinaus interessant.

Within the frame of the experimental ‚Project zur ärztlichen Verschreibung von Betäubungsmitteln, Prove‘ ( Project for the Prescription of Opioids), were opioids and opioid-preparations prescribed, to addicts, in over 16 outpatient clinics in Switzerland from 1994 to 1996 from the government health department, BAG. (Uchtenhagen 1994, 1995, 1996). Used were intravenous heroin, heroin-containing cigarettes, intravenous morphine, morphine in retard form, methadone peroral and intravenous; cigarettes containing cocaine were tried out in a small pilot trial.(Zarotti 1994). The guidelines and recommendations for opioid-supported treatment and it’s institutional requirements were partly worked out within an work-group (doctor’s workgroup 1996, Seidenberg 1997).

The legal licences for the different prescriptions and indications for opioid-supported treatment is in many places very different and will not be discussed here.

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Therapy guidelines and concepts for care have to be set so that, with one recognised method, a broad amount of success is guaranteed. Distributing the method and insuring a quality of care can stand in conflict with one another and must therefore be carefully weighed up against one another In view of death and serious damage caused through illegal drug consumption are initially real help and active competent people needed, not an abstract, professional quality. Preventing treatment through high demands is not the aim of this book.

We would like to deliver practical basics and instructions for outpatient treatment of drug addicts. The book is aimed at doctors but will certainly be understandable for other personnel. It should be a teaching instrument which can be used by the people working in a drug specific environment.

We are still far from being able to present a completed doctrine. The reader must make his/her own thoughts about their own surgery which si why we have paid particular attention to transparent derivatives and basic thoughts behind the practical instructions. In foreground are the long term treatments (Maintenance treatments) and the therefore outpatient treatment situation.