Treatment of heroin addiction in the netherlands: history, results and developments
Treatment of heroin addiction in the Netherlands: history, results and developments Wim van den Brink Professor of Psychiatry and Addiction Academic Medical Center University of Amsterdam
Methadone treatment was introduced in the Netherlands as early as 1968. During the first few years, methadone was prescribed to morphine dependent patients. Following the introduction of heroin in the Netherlands in 1972, treatments with methadone were primarily directed towards achieving abstinence from heroin addiction. Generally, these methadone reduction programs suffered from high drop-out rates, and there was a serious threat that they would loose contact with many addicts. Paralleling the rapid increase in the number of heroin addicts during the mid 1970s, and the introduction of HIV/AIDS in the mid 1980s, the aim of oral methadone prescription in the Netherlands shifted from abstinence towards stabilization and harm reduction. Most of the programs developed into low-threshold programs with low dosages of methadone (30-50 mg/day), extensive take-home regimens, no mandatory psychosocial treatments and no sanctions on illegal drug use. Currently about 50-60% of all heroin addicts in the Netherlands are in methadone maintenance treatment. Of these, approximately 40% is well functioning without illegal drug use and without any criminal involvements. In contrast, approximately 25% is still using illicit drugs and is involved in frequent (acquisitive) crimes. In order to improve the outcomes for these non-responding patients, two studies were performed: one study on the effect of higher dosages of methadone and the other on the effectiveness of the medical prescription of heroin to chronic treatment-resistant methadone patients. Higher dosages of methadone in low-threshold methadone maintenance treatments are feasible and acceptable and result in better outcomes (Driessen et al. submitted). In addition, heroin assisted treatment in chronic methadone-resistant heroin dependent patients is feasible, safe, effective and cost-effective (Van den Brink et al., 2003; Dijkgraaf et al., 2005). Together with an analysis of the historical development of the treatment situation in the Netherlands, these results can provide the basis of a more comprehensive and more effective treatment system. However, some serious problems remain to be solved. First, most of the heroin addicts are also dependent on cocaine and many of them also are heavy alcohol users. New experiments and new studies are needed to investigate the best ways to tackle these complex problems using new medications (e.g. modafinil, rimonabant) or new psychosocial interventions (e.g. contingency management) in combination with methadone, buprenorphine or even heroin maintenance programs. Other problems refer to the simultaneous presence of depression, ADHD and schizophrenia. Again, new integrated treatments need to be developed and tested using existing knowledge on the treatment of co-morbid depression (SSRIs), ADHD (methylphenidate, dexamphetamine) and schizophrenia (clozapine) as an important starting point. Finally, more and continuous attention should be paid to the treatment of co-occurring physical ailments such as hepatitis B and C, HIV and AIDS.
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