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Acute psychological effects of 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”) are attenuated by the serotonin uptake inhibitor citalopram
P.5 Addiction
other sample of 80 medical doctors (MD) and 85 police and probation officers (P and PO) were also interviewed by the same questionnaire. Among the findings o f interest were attitudes such as: a. 50% of users and 45.2% of ex- users consider fashion as a primary cause for their starting drugs. Other reasons reported, as a cause for their initial drug involvement are personal problems and "others" (U = 35%, and 38.3% respectively), (EU = 45.7% and 29.4% respectively). b. The majority of the professional workers (MI), P and PO) believe that immediate family and addicts' personality are the two main factors which are responsible for the initiation of drug use (MD = 68.7% and 86.2% respectively, P and PO = 89.2% and 84.5% respectively. c. The vast majority of users and ex- users consider themselves responsible for their involvement with drugs (U = 95%, EU = 90.5%). The results from this study show that different groups involved in drug addiction phenomenon express different perceptions about its nature and etiology. An interesting point, which all the subjects who have been interviewed may tend to underestimate, is the importance of psychological and/or psychiatric problems, which go in parallel with drug addiction behaviour. These findings confirm the fact that drug abuse remain a multifactorial and complicated problem. To face effectively this problem, co-operation of different groups of professional workers is need.
$341
Patients who stopped completely and patients who only reduced their use differed significantly on the mean duration of treatment with benzodiazepines (8.5 years vs. 13.3 years, p < .001), and on dosage (0.61 vs. 0.87 DDD diazepam, p < .001). There were no differences in duration of treatment or on dosage between people who reduced and who maintained their use. As evaluated by the GP, unsuccessful efforts to reduce or stop benzodiazepine consumption were hindered by the following complaints: sleeping problems (40%), anxiety (18%), physical of psychological dependence (6%), co-morbidity (1%), other reasons (10%) or a combination of already mentioned complaints (25%). Conclusion: These preliminary results indicate that a personal letter from the general practitioner has a considerable effect on benzodiazepine use.
•
Acute psychological affects of 3,4methylenedioxymethamphetamine (MDMA, "ecstasy") are attenuated by the serotonin uptake inhibitor citalopram
M.E. Liechti, Ch. Baumann, D. Hell, EX. Vollenweider. Psychiatric
•
Reduction of benzodiazapine use by letter in primary care: first results of the Benzoredux-study stage I
R.C. Oude Voshaar1, W. Gorgels 1, A.J.J. MolI , M.H.M. Breteler2, E. van de Lisdonk3, A.J.L.M. van Balkom 4, EG. Zitman 1. 1Departments
of Psychiatry," 2Psychology," 3primary Care," University of Nijmegen; 4Department of Psychiatry, EU Amsterdam, The Netherlands Purpose: The Benzoredux-study is a large study in the Netherlands evaluating different strategies to reduce chronic benzodiazepine use in primary care. Within the first stage the impact of a personal letter from the general practitioner (GP), suggesting patients to stop their use is evaluated. In the second stage patients who maintain their use will be randomly assigned to one of the following three groups, a gradually reduction programme by the GP one with and one without group therapy and a control group. In this abstract we present the preliminary results of the first stage. Methods: Twenty-seven general practices coveting primary care of approximately 100.000 patients were enrolled in this study. Using their computerised prescription database 2.739 patients who used at least three months benzodiazepines were selected. Thirty-ftve percent of the subjects were excluded by their GP, leaving 1.817 patients (65.1%) in the study (36% male). Reasons for exclusion were: psychiatric treatment at the moment of sending the letter (30%), dependence on alcohol or drugs (8%), psychoses in the past (8%), terminal disease (6%), epilepsy in the past (6%), not mastering the Dutch language (3%), and otherwise (39%, specified by the GP). All included patients received a personal letter from their GP suggesting to gradually reduce and if possible, in time, completely stop benzodiazepine use. After three months, all patients received a second letter in which they were invited to visit their GP to share their experiences of the past three months. The results presented below are based on the reported consumption during that visit. Data of recorded consumption are not available yet. Results: The following preliminary results are based on the first 439 people who already visited their GP to evaluate the actions taken as a result of receiving the first letter. The poster will contain the results of all participating patients. Three months after receiving the first letter 23% of the patients reported to have stopped, 38% reduced, 38% maintained and 1% increased their use. The reported mean daily dose in diazepam equivalents before receiving the letter was 0.81 DDD diazepam (sd 0.76 DDD) and three months after receiving the letter 0.49 DDD diazepam (sd 0.65 DDD), a significant reduction of 40% (p < .001).
University Hospital Zarich, Research Department, p.o. Box 68, CH-8029 Zfirich, Switzerland Introduction: We recently demonstrated that a moderate recreational dose of 3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy") produces an affective state of enhanced mood associated with mild derealisation phenomena, moderate thought disorder, and mostly without marked stimulation of psychomotor drive (Vollenweider et al. 1998). In animals, MDMA releases serotonin (5-HT) and to a lesser extent dopamine (DA). This effect could be blocked by selective 5-HT uptake inhibitors, suggesting that MDMA primarily acts at the presynaptic 5HT uptake site. It is unclear, however, which neurochemical receptors mediate the psychoactive effect of MDMA in humans and whether the 5-HT carrier is involved. Methods: To elucidate the putative contribution of the 5-HT uptake site in the mediation of MDMA's effects in humans, a double-blind placebo-controlled cross-over design was used to investigate the pretreatment effects of either placebo or citalopram (40 mg iv) on the psychological effects of MDMA (1.5 mg/kg po). 16 healthy subjects (12 male, 4 female) were examined four times at a 2-4 week interval after either placebo, citalopram, MDMA or citalopram plus MDMA administration. The Altered State of Consciousness Questionnaire (ASCOAV), the EWL mood rating scale (EWL) were used 120 minutes after drug intake to assess the effect of citalopram pre-treatment on the subjective effects of MDMA. Data were analysed using ANCOVA and post hoc analysis. Results: Citalopram pre-treatment attenuated MDMA-induced "positive mood" (59%, p < .0001), "mania-like experience" (75%, p < .001) and "derealisation" (62%, p < .0001) as measured by the ASC-OAV scale. ASC-OAV scores for "Altered meaning of percepts" (62%, p < .0001), "facilitated imagination" (76%, p < .04) as well as "anxious derealisation" (75%, p < .001), "thought disorder" (65%, p < .0001) and "fear of loss of self-control" (80%, p < .001) were also reduced. The EWL scores "well-being" (68%, p < .04), "self-confidence" (87%, p < .04), "extraversion" (73%, p < .02) and "activity" (96%, p < .04) were all markedly reduced by citalopram as compared to MDMA alone. Conclusion: Citalopram pre-treatment reduced MDMA-induced alterations of consciousness and mood about 70% in this study. This finding provides strong evidence that the 5-HT transporter plays a key role in mediating psychological effects of MDMA in humans. Moreover, the present finding is in line with the view that MDMA releases 5-HT via the 5-HT transporter. Therefore, MDMA could be used as a useful tool to study the function of 5-HT in the modulation of mood and its role in affective disorders. However, other receptors (D2, 5-HT2, a2) might contribute to the psychoactive effect of MDMA and should be evaluated in similar designs.
17.5Addiction
$342
References [1] Vollenweider,EX., Gamma, A., Liechti, M., Huber, T. (1998). Psychological and cardiovasculareffects and short-term sequelae of MDMA ("Ecstasy") in MDMA-naive healthy volunteers. Neuropsychopharmacology19, 241-251.
•
Drug-addiction and criminal activity. A preventive treatment with methadone?
E. Resinger1, M. Kopeinig1, G. Knecht1, J. Scharfetter1, M. Neider2, S. Kasper I . /Department of General Psychiatry, Univ. Vienna; 2Bundesministerium far Justiz, Vienna, Austria At the University Hospital for Psychiatry in Vienna was established in October 1992 a forensic Outpatient clinic for substance disorders, a model of cooperation between the medical and the prison system. The Outpatient clinic offers client centred counselling, substitution treatment and psychiatric care. In the period 1992-1997, 308 males and 78 females with problems of addiction and before or after imprisonment were seen in the institution. This study describes and reviews 244 (197 m:47 f) patients over a period of 5 years, their sociographic data, forensic history, psychiatric status and kind of treatment. All of them were substituted with methadone. Data were collected by exPerienced psychiatrists using the official records of conviction until I st October, 1997 to calculate conviction rates in the periods of treatment. Diagnoses of drug addictions were made according to ICD-10. 89.3% were diagnosed with politoxicomania, 10.7% with opiate addiction. 40.2% (98) of the patients were treated over a period of 3 months (Group 1) and 29.9% (73) subjects for more than 1 year (Group 4). There is a significant decrease in conviction rates in Group 1 in comparison to Group 4. The highest conviction rate was represented in the age group of the 19-25 years (83.7%) at the time of entering the treatment. Advancing in years the conviction rate decreases (aging-out-effect). We found no significant differences between sex and criminal convictions. 33.1% of the patients in a running treatment (in the forensic clinic or in other institutions) had no more convictions in comparison to those, who left the treatment with only 22.1% of subjects with no more convictions. Retention in treatment is one way to reducing the criminal involvement of addicts. Facts about our treatment with substitution therapy - orientated towards encouraging clients to remain in treatment will be reported and discussed.
~ H i g h dosage buprenorphine In primary care. A preliminary survey J. Beauvillain, P. Petit, I. Grailles °, A.H. Pho, J. Catteau, P. Chevalier, P.
Beauvillain, G. Legal. ELSM, C. N. A. M. T. S, Bd Allende Arras, France French general practitionners (GPs) are now able to prescribe High Dosage Buprenorphine (HDB), which has revolutionised the treatment of heroin-addicts outside hospitals. HDB maintenance has not been widely evaluated, leaving aside the studies made of patients that visit specialised care centers. In order to describe the conditions that governed the prescribing of HDB by GPs between May 96 and April 97, 88 patients that had been prescribed this drug were selected randomly from the archives of the Health Insurance Fund of the town of Arras. Their 63 prescribing GPs were traced and the 40 who accepted, were asked to reply to a coded questionnaire on their methods and the prescriptions (N = 913 of which 705 for HDB) were analysed. Clinical and epidemiological characteristics of the patients showed an average age of 25 years, a predominance of males (75%), unemployed (84%) and urban residents (66%). Comorbidity to heroin-dependance was limited to 2 eases of chronic hepatitis and 7 of personality disorders. The examination of medical services consumed revealed that the patients consulted an average of 3.2 GPs during the observation period and that
31.8% visited more than 3 GPs. 63% of them saw their doctors regularly, 27% obtained more than 5 prescriptions every month and 10% less than one per month implying that they take HDB discontinuously. 37 of the 82 (41.5%) attended a doctor's surgery for no more than 6 months. The average annual cost of ambulant HDB care, including consultations and drug prescriptions, amounts to 2000~, which is three times more than the average of this age bracket in the general population. The GP's habits when prescribing, included no adjunctive psychosocial program, usually with no doctor-pharmacist-patient written agreement (64%), few urinary tests, no working in specialized networks, and the obligations of taking HDB in from of dispensing pharmacist not applied systematically. The dosages customarily prescribed during the induction stage are higher than those recommanded by the authorities agreement (M = 8.05 mg/d) contrary to those of the maintenance stage (6.76 mg/d). Monotherapy is customary (75%) but an association with benzodiazepine is found in 16.9% of cases in spite of its dangerous nature. This investigation emphasizes the difficulties encountered by GPs when prescribing for drug addicts and imply that wide-ranging epidemiological studies should be performed to determine the prognostic factors of successful maintenance in terms of the patient's sociodamographic characteristics and also of the GP's experience. For such enquiries to be reliable, attention should be given to the behaviour of heroin-dependant subjects likely to consult several GPs successively and/or concomitantly.
~ D o e s the success of maintenance depend on the gp's methods and his personal commitment to substitution? I. Grailles, A.H. Pho, J. Catteau, C. Loiseau, J.Y. Forestier, P. Petit, J. Beauvillain, P. Beauvillain, G. Legal, P.J. Parquet. Clinique Michel Fontan, 6 rue du Professeur Laguesse, Lille, France High dosage buprenorphine (HDB) has been widely use in France since February 1996 in the primary-care treatment of heroin-drpendant subjects. There is however little data available on the factors that affect correct prognosis of this maintenance treatment by doctors in private practice. In order to list the factors that depend on the habits and experience of General Practitionners (GPs), we analysed the prescriptions for HDB given by 69 randomly-selected doctors to 203 patients between February 1996 and February 1998. Doctors who prescribe HDB are rarely family doctors (26.1%), most of them are doctors only recently involved in the treatment of these subjects (74.9%). Most regard themselves as initiators of substitution treatment (60.1%) and a minority as occasional prescribers (23.2%) of it. Family doctors are rarely initiators (22.2%). Most doctors (62.6%) involved in maintenance are apparently regarded - by themselves and by others - as specialists in substitution. 66.1% of these doctors believe that HDB treatment is suitable for private pratice ant that it is beneficial or very beneficial to 63.5% of patients. Among the criteria of so-called "up-threshold practice" are daily doses taken in front of the pharmacist (73.4%), urinary testing for opioids (44.8%), doctor-patient contracts and networking (38.6%). The 4 criteria are present in 14.3% of cases, and 3 of the 4 in 17.2%. There is significant correlation between such "up threshold practice" and successful maintenance (p < 0.05). We furthermore see similar correlation between the doctor's personal committment revealed by time of consultation in excess of 20 minutes, intimate knowledge of the patient, practice of meetings with the family, and successful substitution (p < 0.05). The doctor's personal committment to maintenance is apparently at least as important that "up threshold practice".
other sample of 80 medical doctors (MD) and 85 police and probation officers (P and PO) were also interviewed by the same questionnaire. Among the findings o f interest were attitudes such as: a. 50% of users and 45.2% of ex- users consider fashion as a primary cause for their starting drugs. Other reasons reported, as a cause for their initial drug involvement are personal problems and "others" (U = 35%, and 38.3% respectively), (EU = 45.7% and 29.4% respectively). b. The majority of the professional workers (MI), P and PO) believe that immediate family and addicts' personality are the two main factors which are responsible for the initiation of drug use (MD = 68.7% and 86.2% respectively, P and PO = 89.2% and 84.5% respectively. c. The vast majority of users and ex- users consider themselves responsible for their involvement with drugs (U = 95%, EU = 90.5%). The results from this study show that different groups involved in drug addiction phenomenon express different perceptions about its nature and etiology. An interesting point, which all the subjects who have been interviewed may tend to underestimate, is the importance of psychological and/or psychiatric problems, which go in parallel with drug addiction behaviour. These findings confirm the fact that drug abuse remain a multifactorial and complicated problem. To face effectively this problem, co-operation of different groups of professional workers is need.
$341
Patients who stopped completely and patients who only reduced their use differed significantly on the mean duration of treatment with benzodiazepines (8.5 years vs. 13.3 years, p < .001), and on dosage (0.61 vs. 0.87 DDD diazepam, p < .001). There were no differences in duration of treatment or on dosage between people who reduced and who maintained their use. As evaluated by the GP, unsuccessful efforts to reduce or stop benzodiazepine consumption were hindered by the following complaints: sleeping problems (40%), anxiety (18%), physical of psychological dependence (6%), co-morbidity (1%), other reasons (10%) or a combination of already mentioned complaints (25%). Conclusion: These preliminary results indicate that a personal letter from the general practitioner has a considerable effect on benzodiazepine use.
•
Acute psychological affects of 3,4methylenedioxymethamphetamine (MDMA, "ecstasy") are attenuated by the serotonin uptake inhibitor citalopram
M.E. Liechti, Ch. Baumann, D. Hell, EX. Vollenweider. Psychiatric
•
Reduction of benzodiazapine use by letter in primary care: first results of the Benzoredux-study stage I
R.C. Oude Voshaar1, W. Gorgels 1, A.J.J. MolI , M.H.M. Breteler2, E. van de Lisdonk3, A.J.L.M. van Balkom 4, EG. Zitman 1. 1Departments
of Psychiatry," 2Psychology," 3primary Care," University of Nijmegen; 4Department of Psychiatry, EU Amsterdam, The Netherlands Purpose: The Benzoredux-study is a large study in the Netherlands evaluating different strategies to reduce chronic benzodiazepine use in primary care. Within the first stage the impact of a personal letter from the general practitioner (GP), suggesting patients to stop their use is evaluated. In the second stage patients who maintain their use will be randomly assigned to one of the following three groups, a gradually reduction programme by the GP one with and one without group therapy and a control group. In this abstract we present the preliminary results of the first stage. Methods: Twenty-seven general practices coveting primary care of approximately 100.000 patients were enrolled in this study. Using their computerised prescription database 2.739 patients who used at least three months benzodiazepines were selected. Thirty-ftve percent of the subjects were excluded by their GP, leaving 1.817 patients (65.1%) in the study (36% male). Reasons for exclusion were: psychiatric treatment at the moment of sending the letter (30%), dependence on alcohol or drugs (8%), psychoses in the past (8%), terminal disease (6%), epilepsy in the past (6%), not mastering the Dutch language (3%), and otherwise (39%, specified by the GP). All included patients received a personal letter from their GP suggesting to gradually reduce and if possible, in time, completely stop benzodiazepine use. After three months, all patients received a second letter in which they were invited to visit their GP to share their experiences of the past three months. The results presented below are based on the reported consumption during that visit. Data of recorded consumption are not available yet. Results: The following preliminary results are based on the first 439 people who already visited their GP to evaluate the actions taken as a result of receiving the first letter. The poster will contain the results of all participating patients. Three months after receiving the first letter 23% of the patients reported to have stopped, 38% reduced, 38% maintained and 1% increased their use. The reported mean daily dose in diazepam equivalents before receiving the letter was 0.81 DDD diazepam (sd 0.76 DDD) and three months after receiving the letter 0.49 DDD diazepam (sd 0.65 DDD), a significant reduction of 40% (p < .001).
University Hospital Zarich, Research Department, p.o. Box 68, CH-8029 Zfirich, Switzerland Introduction: We recently demonstrated that a moderate recreational dose of 3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy") produces an affective state of enhanced mood associated with mild derealisation phenomena, moderate thought disorder, and mostly without marked stimulation of psychomotor drive (Vollenweider et al. 1998). In animals, MDMA releases serotonin (5-HT) and to a lesser extent dopamine (DA). This effect could be blocked by selective 5-HT uptake inhibitors, suggesting that MDMA primarily acts at the presynaptic 5HT uptake site. It is unclear, however, which neurochemical receptors mediate the psychoactive effect of MDMA in humans and whether the 5-HT carrier is involved. Methods: To elucidate the putative contribution of the 5-HT uptake site in the mediation of MDMA's effects in humans, a double-blind placebo-controlled cross-over design was used to investigate the pretreatment effects of either placebo or citalopram (40 mg iv) on the psychological effects of MDMA (1.5 mg/kg po). 16 healthy subjects (12 male, 4 female) were examined four times at a 2-4 week interval after either placebo, citalopram, MDMA or citalopram plus MDMA administration. The Altered State of Consciousness Questionnaire (ASCOAV), the EWL mood rating scale (EWL) were used 120 minutes after drug intake to assess the effect of citalopram pre-treatment on the subjective effects of MDMA. Data were analysed using ANCOVA and post hoc analysis. Results: Citalopram pre-treatment attenuated MDMA-induced "positive mood" (59%, p < .0001), "mania-like experience" (75%, p < .001) and "derealisation" (62%, p < .0001) as measured by the ASC-OAV scale. ASC-OAV scores for "Altered meaning of percepts" (62%, p < .0001), "facilitated imagination" (76%, p < .04) as well as "anxious derealisation" (75%, p < .001), "thought disorder" (65%, p < .0001) and "fear of loss of self-control" (80%, p < .001) were also reduced. The EWL scores "well-being" (68%, p < .04), "self-confidence" (87%, p < .04), "extraversion" (73%, p < .02) and "activity" (96%, p < .04) were all markedly reduced by citalopram as compared to MDMA alone. Conclusion: Citalopram pre-treatment reduced MDMA-induced alterations of consciousness and mood about 70% in this study. This finding provides strong evidence that the 5-HT transporter plays a key role in mediating psychological effects of MDMA in humans. Moreover, the present finding is in line with the view that MDMA releases 5-HT via the 5-HT transporter. Therefore, MDMA could be used as a useful tool to study the function of 5-HT in the modulation of mood and its role in affective disorders. However, other receptors (D2, 5-HT2, a2) might contribute to the psychoactive effect of MDMA and should be evaluated in similar designs.
17.5Addiction
$342
References [1] Vollenweider,EX., Gamma, A., Liechti, M., Huber, T. (1998). Psychological and cardiovasculareffects and short-term sequelae of MDMA ("Ecstasy") in MDMA-naive healthy volunteers. Neuropsychopharmacology19, 241-251.
•
Drug-addiction and criminal activity. A preventive treatment with methadone?
E. Resinger1, M. Kopeinig1, G. Knecht1, J. Scharfetter1, M. Neider2, S. Kasper I . /Department of General Psychiatry, Univ. Vienna; 2Bundesministerium far Justiz, Vienna, Austria At the University Hospital for Psychiatry in Vienna was established in October 1992 a forensic Outpatient clinic for substance disorders, a model of cooperation between the medical and the prison system. The Outpatient clinic offers client centred counselling, substitution treatment and psychiatric care. In the period 1992-1997, 308 males and 78 females with problems of addiction and before or after imprisonment were seen in the institution. This study describes and reviews 244 (197 m:47 f) patients over a period of 5 years, their sociographic data, forensic history, psychiatric status and kind of treatment. All of them were substituted with methadone. Data were collected by exPerienced psychiatrists using the official records of conviction until I st October, 1997 to calculate conviction rates in the periods of treatment. Diagnoses of drug addictions were made according to ICD-10. 89.3% were diagnosed with politoxicomania, 10.7% with opiate addiction. 40.2% (98) of the patients were treated over a period of 3 months (Group 1) and 29.9% (73) subjects for more than 1 year (Group 4). There is a significant decrease in conviction rates in Group 1 in comparison to Group 4. The highest conviction rate was represented in the age group of the 19-25 years (83.7%) at the time of entering the treatment. Advancing in years the conviction rate decreases (aging-out-effect). We found no significant differences between sex and criminal convictions. 33.1% of the patients in a running treatment (in the forensic clinic or in other institutions) had no more convictions in comparison to those, who left the treatment with only 22.1% of subjects with no more convictions. Retention in treatment is one way to reducing the criminal involvement of addicts. Facts about our treatment with substitution therapy - orientated towards encouraging clients to remain in treatment will be reported and discussed.
~ H i g h dosage buprenorphine In primary care. A preliminary survey J. Beauvillain, P. Petit, I. Grailles °, A.H. Pho, J. Catteau, P. Chevalier, P.
Beauvillain, G. Legal. ELSM, C. N. A. M. T. S, Bd Allende Arras, France French general practitionners (GPs) are now able to prescribe High Dosage Buprenorphine (HDB), which has revolutionised the treatment of heroin-addicts outside hospitals. HDB maintenance has not been widely evaluated, leaving aside the studies made of patients that visit specialised care centers. In order to describe the conditions that governed the prescribing of HDB by GPs between May 96 and April 97, 88 patients that had been prescribed this drug were selected randomly from the archives of the Health Insurance Fund of the town of Arras. Their 63 prescribing GPs were traced and the 40 who accepted, were asked to reply to a coded questionnaire on their methods and the prescriptions (N = 913 of which 705 for HDB) were analysed. Clinical and epidemiological characteristics of the patients showed an average age of 25 years, a predominance of males (75%), unemployed (84%) and urban residents (66%). Comorbidity to heroin-dependance was limited to 2 eases of chronic hepatitis and 7 of personality disorders. The examination of medical services consumed revealed that the patients consulted an average of 3.2 GPs during the observation period and that
31.8% visited more than 3 GPs. 63% of them saw their doctors regularly, 27% obtained more than 5 prescriptions every month and 10% less than one per month implying that they take HDB discontinuously. 37 of the 82 (41.5%) attended a doctor's surgery for no more than 6 months. The average annual cost of ambulant HDB care, including consultations and drug prescriptions, amounts to 2000~, which is three times more than the average of this age bracket in the general population. The GP's habits when prescribing, included no adjunctive psychosocial program, usually with no doctor-pharmacist-patient written agreement (64%), few urinary tests, no working in specialized networks, and the obligations of taking HDB in from of dispensing pharmacist not applied systematically. The dosages customarily prescribed during the induction stage are higher than those recommanded by the authorities agreement (M = 8.05 mg/d) contrary to those of the maintenance stage (6.76 mg/d). Monotherapy is customary (75%) but an association with benzodiazepine is found in 16.9% of cases in spite of its dangerous nature. This investigation emphasizes the difficulties encountered by GPs when prescribing for drug addicts and imply that wide-ranging epidemiological studies should be performed to determine the prognostic factors of successful maintenance in terms of the patient's sociodamographic characteristics and also of the GP's experience. For such enquiries to be reliable, attention should be given to the behaviour of heroin-dependant subjects likely to consult several GPs successively and/or concomitantly.
~ D o e s the success of maintenance depend on the gp's methods and his personal commitment to substitution? I. Grailles, A.H. Pho, J. Catteau, C. Loiseau, J.Y. Forestier, P. Petit, J. Beauvillain, P. Beauvillain, G. Legal, P.J. Parquet. Clinique Michel Fontan, 6 rue du Professeur Laguesse, Lille, France High dosage buprenorphine (HDB) has been widely use in France since February 1996 in the primary-care treatment of heroin-drpendant subjects. There is however little data available on the factors that affect correct prognosis of this maintenance treatment by doctors in private practice. In order to list the factors that depend on the habits and experience of General Practitionners (GPs), we analysed the prescriptions for HDB given by 69 randomly-selected doctors to 203 patients between February 1996 and February 1998. Doctors who prescribe HDB are rarely family doctors (26.1%), most of them are doctors only recently involved in the treatment of these subjects (74.9%). Most regard themselves as initiators of substitution treatment (60.1%) and a minority as occasional prescribers (23.2%) of it. Family doctors are rarely initiators (22.2%). Most doctors (62.6%) involved in maintenance are apparently regarded - by themselves and by others - as specialists in substitution. 66.1% of these doctors believe that HDB treatment is suitable for private pratice ant that it is beneficial or very beneficial to 63.5% of patients. Among the criteria of so-called "up-threshold practice" are daily doses taken in front of the pharmacist (73.4%), urinary testing for opioids (44.8%), doctor-patient contracts and networking (38.6%). The 4 criteria are present in 14.3% of cases, and 3 of the 4 in 17.2%. There is significant correlation between such "up threshold practice" and successful maintenance (p < 0.05). We furthermore see similar correlation between the doctor's personal committment revealed by time of consultation in excess of 20 minutes, intimate knowledge of the patient, practice of meetings with the family, and successful substitution (p < 0.05). The doctor's personal committment to maintenance is apparently at least as important that "up threshold practice".