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A naturalistic follow-up study of French-speaking opiate-maintained heroin-addicted patients: Effect on biopsychosocial status

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A naturalistic follow-up study of French-speaking opiate-maintained heroin-addicted patients: Effect on biopsychosocial status
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  Pergamon Journal of Substance Abuse Treatment, Vol. 11, No. 6, pp. 565-568, 1994 Copyright 0 1994 Elsevier Science Ltd Printed in the USA. All rights reserved 0740-5472/94 6.00 + .OO 0740-5472 94)00050-6 INTERNATIONAL PERSPECTIVE A Naturalistic Follow Up Study of French Speaking Opiate Maintained Heroin Addicted Patients: Effect on Biopsychosocial Status MARC AURIACOMBE, MD, MSC,*~ DENIS GRABOT, MA,* JEAN-PIERRE DAULOU~DE, MD,* JEAN-PIERRE VERGNOLLE, MD,* CHARLES O’BRIEN, MD, PhD,? AND JEAN TIGNOL, MD* *Groupe d’Etude des Toxicomanies, Laboratoire de Psychiatric, Universite de Bordeaux 11, Bordeaux cedex, France; tPenn/VA Center for Studies on Addiction, University of Pennsylvania, Philadelphia, Pennsylvania Abstract The purpose of this study was to evaluate the impact of opiate maintenance pharmaco- therapy (OMP) on the biopsychosocialstatus of opiate-addicted patients in a cultural environment (France) that is not favorable to OMP and where methadone is not available. Buprenorphine and laudanum (opium tincture), which, to our knowledge, has not been reported previously in the sci- entific literature for OMP, were used in this study of a group of 18 opioid-dependent subjects. At time of initiation of OMP, mean age was 33 years, sex ratio male:female was 14:4, average duration of drug use was 11.2 years. Six patients received laudanum p.o., 15 g daily; 12 patients received buprenorphine sublingual 2 to 4 mg daily. This group of patients was selected because of persistent relapse and impairment after an average of 5.7 drug-free-oriented treatments over a period of 6.8 years. Initial evaluation and follow-up were made by way of a 150-min semi-structured interview using the Lifetime Retrospective Evaluation Score Table (LREST) and the Addiction Severity Index (ASI). Results showed that body weight and scores for physical and psychological health, socioprofessional status, and family relationships improved significantly after 14 months of OMP. These results show that highly impaired opiate-addicted patients doing poorly in drug- free treatment can respond to OMP even though methadone is not available and the idea of OMP is not favored. Keywords opioid dependence; buprenorphine; Laudanum; maintenance treatment; treatment evaluation. INTRODUCTION THERE IS A GENERAL AGREEMENT that addiction is a multifaceted phenomenon and that it is a chronic sit- uation characterized by relapse and that treatment must be long term and designed to address the multiple Portions of this work were presented at the American Psychiatric Association Annual Meeting, Washington, May 1992, and at the Scientific Annual Meeting of the College on Problems of Drug Dependence, Keystone, June 1992. Requests for reprints should be addressed to Dr. Marc Auria- combe, Groupe d’Etude des Toxicomanies, UniversitC de Bordeaux II, Centre Carreire, HBpital Charles Perrens, 121 rue de la BCchade, 33076 Bordeaux cedex, France. E-mail address: marcauri@frbdxll. cribxl.u-bordeaux.fr Received November 26, 1993; Revised April 10, 1994; Accepted May 12, 1994. 565 problems of the addicted individual. However, there are major disagreements as to how the treatment should be conducted, and particularly as to the utility of opiate maintenance pharmacotherapy (OMP) with metha- done for intravenous (IV) heroin users (Arif & Wester- meyer, 1990; Gossop & Grant, 1991). In the United States, methadone maintenance is considered a major and important treatment (Gerstein & Harwood, 1990). On the other hand, in France, use of methadone maintenance is limited to three restricted experimental programs (totaling less then 50 patients per year in 1993). This treatment is oriented toward short-term maintenance (Laqueille, 1992; OliC et al., 1991). Treatment is essentially drug-free oriented: de- toxification followed by long-term drug-free treatment  566 M. Auriacombe et al. TABLE 1 Sociodemographics and Drug Status at Time of Evaluation n= 18 Jaffe, & Fudala, in press) that support buprenorphine as a good alternative to methadone. Daily dose of bu- prenorphine varied from 2 to 4 mg sublingual. Male/female Age SD) Married/divorced Living with someone/alone Financial support from Social Security Employed Duration of drug use months SD) Number detox before OMP Duration of OMP months SD) OMP agent 1414 33 3.96) 712 1414 8 9 134 30) 5.7 17 14) METHODS This is a cross-sectional evaluation of all the patients on OMP at the private-practice-based clinic at one time point. Eighteen patients were asked by their therapist to participate in this study and were evaluated after acquisition of informed consent. laudanum 1 O-l 5 g/day) 6 buprenorphine 2-4 mg/day) 12 programs. Many studies conducted in the United States have shown the positive results of methadone mainte- nance on outcome of heroin-addicted patients (Ball & Ross, 1991). However, the differences in cultural and social environments and access to treatment have questioned the validity of the United States results for determining treatment of French heroin-addicted patients. In a French private-practice-based clinic, OMP has been offered as a treatment option for highly impaired drug-free treatment resistant IV heroin-addicted pa- tients. Because methadone in France is available from only the three programs in Paris, our program (situ- ated in an area of significant heroin use), started OMP with Laudanum and then buprenorphine. Laudanum is opium tincture (opium powder 110 g, alcohol 30” 920 g, and miscellaneous 52 g, French Codex formula, 1937); to our knowledge, this is the first time that its use is reported for OMP in the Western scientific lit- erature. Average daily dose is 15 g p.o. Buprenorphine, is both an agonist and an antagonist for ~1 and re- ceptors. Jasinski, Pevnick, and Griffith (1978) first suggested that this was a potential alternative to meth- adone. The first clinical study of buprenorphine by Reisinger (1985) in Belgium has been followed by other studies (Fudala, Jaffe, Dax, & Johnson, 1990; John- son, Cone, Henningfield, & Fudala, 1989; Johnson, All subjects were evaluated by the same experimental psychologist during a 150-min, three-part, semi- structured interview. In the first part, sociodemo- graphic data are collected; in the second, the Lifetime Retrospective Evaluation Score Table (LREST; Grabot, Auriacombe, Martin, & Tignol, 1990) is ad- ministered. This instrument was designed to allow a quantitative evaluation of substance abuse patients’ past history when they are first evaluated. It starts with a very comprehensive chronology of the patient’s drug history and is followed by a self-administered 7-point scale (0 = extremely bad; 6 = excellent) quantitative evaluation of the patient at different time points in four areas (physical and psychological well-being, family relationships, and professional activity). In ad- dition, weight and HIV serology were collected for each time point. In the third part, a French language adaptation (IGT, Michel Landry, Centre DomrCmy- MontrCal, Montreal) of the Addiction Severity Index (ASI) was administered (Grabot et al., 1992; McLellan et al., 1985; McLellan, Luborsky, Woody, & O’Brien, 1980). This instrument was designed to evaluate, through a semistructured interview, the impact of drug use in seven areas (general information, medical, employment/support, drug/alcohol use, legal, family/ social, psychiatry) and produces a severity rating for each area. RESULTS Table 1 shows the subjects’ sociodemographic charac- teristics and drug history at the time of evaluation. Table 2 gives the results of the LREST, which provides TABLE 2 LREST: Average Score for Each Item LREST Item Score SD) Before Drug Use Out of Treatment Drug-Free Treatment OMP Duration years) 18.7 3.4) 6.1 3.2) 6.8 6.9) 1.4 1.2) Physical 4.8 1) 3.2 1) 1.5 1.7)C 3.7 1 .l) Psychological 4.2 1.4) 3.2 1 .l) 1.7 1.7)C 3.7 1.3) Sociological 4.2 1 .l)a 2.6 1 .4)a 2.2 1.9)b 3.3 1.8) Family 3.7 2) 2.8 1.7) 2.4 1.7)’ 3.6 1.8) Weight 60 9.3) 57 8.3) 53 11.2)C 61 8.9) = 17. bn = 12. = 13.  Opiate Maintenance 567 physml psychological sociological family LREST items FIGURE 1. LREST scores before/after OMP Student’s test). a retrospective evaluation of the patients’ biopsycho- social status at four time periods: before the beginning of drug use, during drug use but before any treatment, during treatment other than OMP, and since OMP. Five patients were not scored for the period during treatment other than OMP because they only received isolated detoxification with no follow-up treatment be- fore starting OMP. As such, for each subject a score was calculated for before and after OMP. A Student’s c test shows that there was a significant increase of all scores after initiation of OMP except for socioprofes- sional status (Figure 1). To examine if, in addition to improving the biopsychosocial status, patients had de- creased their heroin use after beginning of OMP, we examined the results of the corresponding questions of the ASI. Reported number of days of heroin use over the past 30 days was less than one (which is a dra- matic reduction if it is kept in mind that this group of patients was offered OMP because of daily IV heroin TABLE 3 ASI Composite Scores SD) n= 18 Medical 0.244 0.348) Employment 0.413 0.307) Alcohol 0.087 0.089) Drug 0.236 0.081) Legal 0.011 0.041) Family 0.143 0.136) Psychological 0.292 0.210) Before OMP fter OMI’ use). There was no shift to other drugs as number of days of alcohol use reported was 7 (less than one for alcohol intoxication), 4 days for cannabis use, and no cocaine use. Table 3 gives the composite scores of the ASI. DISCUSSION In this study it is clear that after a period of over 16 months, the introduction of OMP has had a posi- tive effect on the biopsychosocial status and drug use of this group of heavily addicted French heroin IV drug users. It is notable that buprenorphine and Lau- danum were able to be used successfully as alternatives to methadone for OMP. To our knowledge, this is the first study to report on the use of buprenorphine or Laudanum as OMP agents in French heroin users. Pa- tient’s daily heroin use (a requirement for receiving OMP) was dramatically reduced to less than once a month. There was no transfer to other drugs or to alcohol. The major limitation of this study was that the eval- uation of the patients’ status prior to beginning of OMP was done retrospectively. However, it is note- worthy that this was done through an instrument spe- cifically designed for the retrospective evaluation of drug users’ past biopsychosocial history. In addition, to determine patients’ current status while on OMP, we used the ASI. This instrument is a comprehensive, fully validated, standardized, and accepted measure for assessing drug abuse and its consequences. Inter- estingly, it is remarkable that our group of patients has  568 hf. Auriacombe et al. similar or lower AS1 composite scores than a group of treated (mainly methadone) opiate users as reported recently by McLellan et al. (1992) in their normative data study. Urine toxicology was not done because of lack of funds. CONCLUSION This study shows that highly impaired opiate-addicted patients doing poorly in drug-free treatment can re- spond to OMP even though methadone is not avail- able and the idea of OMP is not favored. This is an important finding because it suggests that the benefi- cial effects of OMP reported in U.S.-based studies could apply to France, although the social environment and availability of drugs are very different. REFERENCES Arif, A., Westermeyer, J. (Eds.). (1990). Methadone maintenance in the management of opioid dependence: An international re- view. 1st ed.). New York: Praeger. Ball, J.C., & Ross, A. (1991). The effectiveness of methadone main- tenance treatment. Patients, programs, services, and outcome (1st ed.). New York: Springer-Verlag. Fudala, P.J., Jaffe, J.H., Dax, E.M., & Johnson, R.E. (1990). Use of buprenorphine in the treatment of opioid addiction II. Phys- iologic and behavioral effects of daily and alternate-day admin- istration and abrupt withdrawal. Clinical Pharmacology and Therapeutics, 41, 525-534. Gerstein, D.R., & Harwood, H.J. (Eds.). (1990). Treutingdrugprob- lems (1st ed.). Washington, DC: National Academy Press. Gossop, M., &Grant, M. (1991). A six country survey of the con- tent and structure of heroin treatment programmes using meth- adone. British Journal of the Addictions, 86, 115 l-1 160. Grabot, D., Auriacombe, M., Martin, C., Landry, M., McLellan, A.T., Bergeron, J., O’Brien, C.P., & Tignol, J. (1993). L’Ad- diction Severity Index: Un outil d’evaluation fiable et valide des comportements de dtpendance [The Addiction Severity Index: A validated and reliable tool for evaluation of drug dependence related behavior]. In J.M. Leger (Ed.), Comptes Rendus du Con- gres de Psychiatric et Neurologie de Langue Francaise (pp. 213-219). Paris: Masson. Grabot, D., Auriacombe, M., Martin, C., & Tignol, J. (1990). The Lifetime Retrospective Evaluation Score Table: Instruction man- ual. Bordeaux: GET-Universite de Bordeaux II. Jasinski, D.R., Pevnick, J.S., &Griffith, J.D. (1978). Human phar- macology and abuse potential of the analgesic buprenorphine. Archives of General Psychiatry, 35, 501-516. Johnson, R.E., Cone, E.J., Henningfield, J.E., & Fudala, P.J. (1989). Use of buprenorphine in the treatment of opioid addic- tion I. Physiologic and behavioral effects during a rapid dose induction. Clinical Pharmacology and Therapeutics, 46,335-343. Johnson, R.E., Jaffe, J.H., & Fudala, P. (in press). Buprenorphine: An efficacious treatment for opioid dependence. Journatofthe American Medical Association. Laqueille, X. (1992). Methadone: une utilisation trts confidentielle en France. Journal of the American Medical Association Edi- tion Franqaise), 4 32), 241. McLellan, A.T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M. (1992). The fifth edi- tion of the addiction severity index: Historical critique and nor- mative data. Journalof Substance Abuse Treatment, 9, 199-213. McLellan, A.T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H.L., &O’Brien, C.P. (1985). New data from the Addic- tion Severity Index: Reliability and validity in three centers. Jour- nal of Nervous and Mental Disease, 173, 412-423. McLellan, A.T., Luborsky, L., Woody, G.E., & O’Brien, C.P. (1980). An improved diagnostic evaluation instrument for sub- stance abuse patients, the Addiction Severity Index. Journal of Nervous and Mental Disease, 168, 26-33. OliC, J.P., Kecskemeti, S., Poirier, M.F., Laqueille, J.L., Perron, J.L., & Loo, H. (1991). Heroi’nomanie traitee par methadone. Experience sur 50 malades. La PresseMedicale, 20, 1253-1258. Reisinger, M. (1985). Buprenorphine as new treatment for heroin dependence. Drug and Alcohol Dependence, 16, 257-262.
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