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by Herbert Elias, MD, Frankfurt/Main, Germany
It is currently possible in Germany for community-based general practitioners to utilize a variety of substitution medications in treating opiate addiction: Methadone (including the pure L-isomer which is marketed under the name L-Polamidon), codeine and buprenorphine. In addition, LAAM had been available until very recently, when it was taken off the market because of cardiac side effects.
Buprenorphine appears to be the weakest of the medications listed above. Although it is good to have this additional medication available, it must be used with great caution because of the relatively low retention rate among patients who receive it. In any event, it probably should only be offered to a small and carefully selected subgroup of patients who have not been addicted for a long period of time, and preferably those who have not progressed to intravenous use. Only a few addicts can be maintained effectively; some 80% of those who are started on buprenorphine leave treatment. Most of them are never heard from again, and presumably return to heroin. Because of this low retention rate it is a mistake to rely on buprenorphine as the treatment of choice; unfortunately, however, there are a number of patients who have been persuaded by glib advertising messages, and it is often difficult to avoid prescribing it.
Codeine is a weaker opiate agonist than methadone. In 1998, when regulatory changes in Germany made it necessary to convert all codeine patients to methadone, it turned out that most patients sooner or later expressed greater satisfaction with the latter even those who, with regular doses of codeine, had been well stabilized. On the other hand, this was not the case with all the patients; about 5-10% did substantially worse with methadone than with codeine, and for some it was simply not possible to continue the methadone treatment.
Intolerance to methadone was generally reflected in a significant depression, with amotivational syndrome being prominent. I had a patient on codeine who had been able to continue to work even while using heroin, but who immediately upon taking the first dose of methadone was unable to remain employed because of an extraordinary lack of drive. Another patient became so incapacitated that he applied for disability; after reinstitution of codeine treatment he is doing his best to rescind this application, because he intends to continue working. For such individuals, who do not adjust to methadone, codeine administration also is associated with less drug use during treatment. I have become personally familiar with a number of patients in this category, and am confident the experience can not be ascribed to a negative placebo effect associated with a change in medication. Nor is it a problem of dosage - i.e., the problems in these patients switched to methadone can not be eliminated by simply increasing the amount prescribed. It seems, indeed, to reflect a true pharmacological effect, and in addressing the issue I think one should be pragmatic. As a matter of fact, it would be surprising if one did not encounter patients who, for whatever reason(s), responded better to one medication than another.
For a very few patients (perhaps 3% of my entire caseload) I use a combination of both methadone and codeine. These are not patients whom I would describe as unable to tolerate methadone, but simply those who exhibit side effects when treated with methadone alone. For instance, I had two young patients who, while on methadone alone, totally lost their libido, but whose interest in sex returned when they were prescribed a combination of methadone and codeine. I would be reluctant to switch them to codeine exclusively, since they demonstrated considerable use of illicit drugs when they received no methadone. One of my patients was a woman being treated with a combination of methadone and codeine, who required hospitalization for treatment of pneumonia. The hospital doctors placed her on an extremely high dose of methadone in order to compensate for their taking away the codeine. Immediately upon discharge she began to supplement the huge dose of prescribed methadone with injectable heroin and cocaine in order to lessen the marked side effects she experienced. The supplemental illegal drug use did not stop until she was once again placed on the combined prescription of methadone and codeine.
I should also add my good experience with morphine as a heroin substitute. This treatment is needed for one of my patients because he has severe chronic pain. He reports that with morphine, not only is the pain considerably lessened, but he feels in general as if he has been reborn. He had previously received extremely high doses of methadone, and was lacking so in energy that he could not make it to the mailbox in the morning. The methadone was brought to his home each day by a home health aide, and once a week he had to present himself to the clinic. After being placed on morphine, he is now once again able to take care of his home and to leave the house each day. He comes to the clinic three times a week and always makes a good impression on the staff. In addition, his previous considerable intake of benzodiazepines has lessened, and he is considering looking for work again.
I suspect that those individuals who, in other countries, require treatment with heroin also represent those who are not able to tolerate methadone. It is that most of them could be treated effectively with oral codeine or morphine, which would have the big advantage of obviating the need for injections.
Based on my experience, I believe it is most appropriate to initially offer patients who request treatment induction onto methadone this option. If it turns out that this leads to a serious amotivational syndrome, one can switch them to dihydrocodeine. And if it then becomes apparent that one can get by with very low doses of codeine, one can try to utilize buprenorphine instead. Such a stepwise individualization of treatment is least likely to cause the patient to be lost to followup.
I personally have never encountered a patient who could be effectively treated with Polamidon (the pure " active" l-isomer of methadone), but not with the racemic methadone preparation. On the other hand, I have heard of such instances from colleagues. All in all, certainly better to have available a range of different medications for substitution treatment, than to rely exclusively on methadone or codeine.
Many patients are turned off by the words, psychosocial counseling. Part of the basis for this reaction harks back to the days before substitution treatment, when there was only compulsory psychotherapy. Today these terrible times are behind us and patients have less cause to fear "rape of their minds" and cunning measures designed to demoralize them and rob them of their dignity.
Despite these abuses of the past, psychotherapy is not contraindicated for most patients, although the effectiveness of such treatment for addicts is grossly over-rated. It is self-evident that these patients require more support compared to most patients in a general medical practice. If such support is made available to patients in a respectful manner, this alone will have a significantly favorable psychotherapeutic effect which is an essential basis for success subsequently. Many require social services, that can be provided by drug counselors. Simply handing out prescriptions is rarely sufficient by itself. Of course, this applies equally to all seriously or chronically ill patients, and addicts are no exception.
A supportive psychotherapy that aims at enhancing the feeling of self-worth of the patients is almost always desirable, while comprehensive, in-depth psychiatric treatment is generally an exercise in frustration and usually terminated by the patients after a few sessions. Such treatment is probably contraindicated. Its striking, though, how commonly addicted patients accept hypnosis when it is offered, perhaps based on experience with self-hypnosis. Such treatment seems to work by strengthening the ego of patients, and raising their frustration tolerance. It would be unusual if they didn't thereby also improve their general prognosis. All in all, I suspect that psychotherapy for addicts will in the future involve primarily hypnotherapeutic measures.