Therapie der opioidabhängigkeit - Ein update

After the heroin-wave in Switzerland in the 1980s and 1990s and the establishment of successful maintenance therapies for harm reduction in many western countries, the first evidence-based guidelines for the treatment of opioid dependence appeared. Prevalence of heroin use in Switzerland has decreased subsequently in recent years with a large proportion of patients enrolled in maintenance therapies. In this review, pharmacological and psychosocial treatment strategies for opioid dependence are described and discussed with particular regard to current guidelines from European and American medical societies. Opioid dependence is a chronic brain disease associated with neuroadaptive processes and structural changes that lead to substance craving and relapses despite of negative consequences. Like all substance use disorders, opioid-related disorders comprise acute intoxication, harmful use, dependency and withdrawal states. These diagnoses are discussed in short. Comorbid psychiatric disorders as well as multiple substance use are frequent among opioid-dependent subjects and may complicate an effective treatment. Diagnosis and treatment of comorbidity are therefore crucial and necessary to fundamentally improve the prognosis of opioid dependence. Standardised questionnaires and interviews can be used for this purpose. Treatment in acute phases usually begins with the assessment of physical complications and detailed drug anamnesis. It is followed by the withdrawal of additionally consumed substances like cocaine, benzodiazepines and alcohol. Opioid withdrawal can be treated with agonists as well as other medication directed at specific symptoms. Already at this stage, patients should be motivated to begin maintenance treatment, although abstinence can be a reasonable goal for patients with a short history of opioid abuse as well as in subsequent stable phases of the disorder. Agonist maintenance treatment with methadone or buprenorphine constitutes the first-line therapy at this time. Maintenance treatment with slow-release morphine is currently still carried out as "off-label use". Maintenance with diacetylmorphine (Heroin) is regarded as an important treatment alternative after aborted or failed maintenance therapy and has been established in diverse European countries. Motivational interviewing and contingency management are well-examined psychotherapeutic interventions effective in the treatment of substance-related disorders. Furthermore, disorder-specific psychotherapies enable the integrated treatment of comorbid personality disorders or depressive disorders in parallel to substance use and show positive effects on the course of opioid dependence. Further research is needed to improve our understanding of the neurobiological mechanisms underlying this disorder. Moreover it should aim to advance the efficacy of medical and psychotherapeutic treatments and identify subgroups of patients that can be targeted by specific interventions. Innovative techniques like neuroimaging will provide new options and insights.