N. Loimer, R. Schmid, A. Springer (eds.) Drug Addiction and AIDS Springer-Verlag Wien New York DDr. Norbert ~imer Univ.-Doz. Dr: Rainer Schmid Univ.-Prof. Dr. Alfred Springer Department of Psychiatry, University Hospital of Vienna Austria The printing of this publication has been supported by a grant of the Austrian Ministary of Science and Research. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machines or similar means, and storage in data banks. @) 1991 by Springer-VedaglWien Printed on acid-free paper With 52 Figures ISBN-13:978-3-211-82298-2 e-ISBN-13:978-3-7091-9173-6 DOl: 10.1007/978-3-7091-9173-6 Foreword Drug abuse and AIDS present a new and unparalleled challenge to our society. The fatal combination of the two calls for an urgent incentive for new ideas and strategies to be developed in the fight against this until ,recently seemingly indomitable enemy. mY-prevalence among drug abusers has increased markedly during the late eighties. Whereas the proportion of AIDS cases among that population had been 1% in 1984, it had jumped up to 29% in 1989. This percentage, as we know from epidemiological studies, varies greatly for different countries. The highest percentage of cumulative AIDS cases among drug abusers in Europe has been found in the southern region, while in Scandinavian countries, with the exception of Denmark, this percentage is very low. Austria belongs to those countries with a relatively high prevalence. This development has had a strong impact on the social response towards drug abuse and has caused a marked change among health authorities: WHO experts, for instance have proposed that, controlling drug abuse and pro moting a healthy life style should remain the long term objectives with highest priority but that otherwise, in the short term, the priority should be prevention of AIDS transmission. Most European countries have adopted new goals in the direction of harm reduction in line with this new approach. Strategies most prominently used in harm reduction include: low treshhold counseling and treatment facilities to attract as many drug users as possible at an early stage in their career; - the availability of clean needles and syringes; - AIDS counseling, counseling in safe sex and safe use practices; - the availability of condoms; and - substitution treatment to limit risk-taking behavior. Not all European countries have adopted all of these objectives but most of them have implemented at least one or the other, according to their needs and possibilities. In contrary in the United States the goal of drug policy is to keep people away from drugs and to fight a war on drugs rather than to shift towards harm reduction strategies. Clearly enough these new objectives are accelerating a change of paradigms. To implement them one has to shift from the sociological/criminological VI Foreword paradigm of deviancy to a medical paradigm, identifying the former "drug fiend" as a ~medical case and accepting him as a patient. A certain "re medicalization" in the treatment of drug abusers proves that these major changes have taken place. In most countries health professionals are not well equipped for these new tasks which they are confronted with. There is a desperate need for further information and postgraduate training. Meetings such as the Vienna Sympo sium on Drug Abuse and AIDS therefore may act as important mediators to bring together outstanding experts to present their results and to discuss their experience in front of a large audience of scientists and practitionars in a very open way. Information about even radical treatment schemes and discussion of different strategies in the fight against drug abuse and AIDS is of vital importance at a time when much more research is needed to understand the epidemiology of drug use and of HN-infection among drug users and the relationship between mV-prevalence and certain behavioral patterns of drug users. Moreover, discussion is, particularly important in a situation where no common philoso phy about priorities exists and, last but not least, no effective cure for AIDS is in sight. Discussions such as we have attended in Vienna are stimulating our intellectual capacities, support unconventional thinking and, on the whole, are highly motivating. They will definitely help us to develop ideas, which in the long run may prove helpful to the individuals we are caring for and to the society we are part of. Prof. Alfred Springer, M. D. Director, Ludwig Boltzmann Institute for Addiction Research, Vienna Contents Epidemiology Des Jariais, D. C.: Observations on the Stabilization of mv Sero- prevalence Among Injecting Drug Users ..................' . . 1 Welle-Strand, G.: mY-Antibody Testing and Risk-Prone Behaviour Amongst i. v .-DU's in Oslo, Norway . . . . . . . . . . . . . . . . . . . . . 8 Annell, A., Fugelstad, A., Agren, G.: HIV- Prevalence and Mortality in Relation to Type of Drug Abuse Among Drug Addicts in Stockholm 1981-1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Fugelstad, A., Rajs, J.: HIV-Related Drug Addict Deaths Outside Medical Institutions in Stockholm . . . . . . . . . . . . . . . . . . . . . . . 23 Tirelli, U., Spina, M., Rezza, G., Vaccher, E., Caprilli, F., Giuliani, M., Saracco, A., Lazzarin, A., Serraino, D., Gentili, G., Accurso, V., Mancuso, S., De Marcato, R.: mv Infection in 403 Female Prostitutes in Italy . . . . . . . . . . . . . . . . . . . . . . . . . 35 Roussaux, J.-P., Jacques, J.-P.: How to Explain the Low Figures of AIDS Cases Among Intravenous Drug Addicts in Belgium? . . . . . . 40 Sakoman, S., HeCimovic, A.: Drug Addiction and AIDS in Republic of Croatia and Yugoslavia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Alvarez, F. J., Carmen Del Rio, M.: Drug Abuse in Spain: Epidemiol- ogy, Policy and Health Structure. . . . . . . . . . . . . . . . . . . . . . . . 70 Staniaszek, M.: Drug Abuse and HIV-Infection in Poland . . . . . . . . . 80 Piischel, K., Mohsenian, F.: HIV-1-Prevalence Among Drug Deaths in Germany. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Triibner, K., Polywka, S., Piischel, K., Laufs, R.: Hepatitis B, Hepatitis C and AIDS in Drug Deaths . . . . . . . . . . . . . . . . . . . . 97 Bschor, F., Bornemann, R., Borowski, Ch., Schneider, V.: Monitoring of mY-Spread in Regional Populations of Injecting Drug Users - The Berlin Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 102 Uhl, A., Springer, A., Maritsch, F., Pfersmann, V.: 5 Years Follow-up on Viennese Heroin Addicts ......... . . . . . . . . . . . . . . . .. 110 Pont, J., Neuwald, C., Salzner, G.: Antibody Prevalence of Parenter- ally Transmitted Viruses (HIV-1, HTLV-I, HBV, HCV) in Austrian Intravenous Drug Users . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 117 Risser, D., Vycudilik, W., Bauer, G., Reiter, Ch.: Statistical Investiga- tion on the Relation of Intravenous Drug Addiction and HIV- VIII Contents Infection. A Survey of the Years 1985 to 1989 by the Institute of Forensic Medicine in Vienna . . . . . . . . . . . . . . . . . . . . . . . . .. 126 Loimer, N., Presslich, 0., Werner, E., Pakesch, G., Hollerer, E., Pfersmann, V., Vedovelli, H.: HIV-1 Infection Among Intravenous Drug Users in Vienna 1986-1991. . . . . . . . . . . . . . . . . . . . . . .. 132 Methadone Treatment Schmidhammer, H.: Opioid Receptors. . . . . . . . . . . . . . . . . . . . .. 143 Beubler, E.: Addiction Potential of Opiates in Medical Use . . . . . . .. 149 Kreek, M. J.: Methadone Maintenance Treatment for Harm Reduction Approach to Heroin Addiction. . . . . . . . . . . . . . . . . . . . . .. . .. 153 Tagliamonte, A., Maremmani, I., Meloni, D.: Methadone Mainten- ance: A Medical Approach to Heroin Addiction. . . . . . . . . . . . .. 178 Brewer, C.: Intravenous Methadone Maintenance: A British Response to Persistent Opiate Injectors. . . . . . . . . . . . . . . . . . . . . . . . .. 187 Blix, 0., Gronbladh, L.: The Impact of Methadone Maintenance Treatment on the Spread of HIV Among i. v. Heroin Addicts in Sweden. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 200 Blennow, G.: Methadone Maintenance Treatment (MMT) in Stock- holm, Sweden. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 206 Niederecker, M., Naber, D., Garwers, C., Volkl, G., Soyka, M., Hippius, H.: Methadone Treatment for Opiate-Addicted Patients. First Experiences of a Prospective Trial . . . . . . . . . . . . . . . . . .. 210 Bocker, F. M.: HIV and Methadone Treatment: The German Experi- ence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 216 Maremmani, I., Zolesi, 0., Cirillo, M., Nardini, R., Castrogiovanni, P., Tagliamonte, A.: Drug Addiction Treatment in Italy in the 80s: Fear of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 223 Maremmani, I., Zolesi, 0., Castrogiovanni, P.: Psycho-Social and Psychopathological Features as Predictors of Response to Long Term and High Dosages Methadone Treatment . . . . . . . . . . . . .. 230 Pfersmann, D., Prosche, W., Werdenich, W., Pakesch, G., Pfers mann, V., Presslich, 0., Loimer, N., Neider, M.: Methadone Maintenance and Delinquency Rates of Opioid Drug Users. . . . . .. 238 Rittmannsberger, H., Bayer, Ch., Ruschak, M., Silberbauer, Ch., Geit, M., Simma, R., Binder, L., Mittermayer, H.: Course and Outcome of HIV-Positive Drug Addicts in a Methadone Treatment Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 249 Management and Treatment Guzei, K., Kenis, P.: Managing AIDS: The European CentreIWHO Collaborative Study and Database Project. . . . . . . . . . . . . . . . .. 257 Contents IX Karamustafali~glu, K. 0., Agargiin, M. Y., Karamustasfalloglu, N., Alpkan, L.; Eradamlar, N., Beyazyiirek, M.: AIDS Fear and Risk Behavior in Intravenous Drug Users . . . . . . . . . . . . . . . . . . . .. 267 Dobler-Michola, A., Zimmer Hofler, D., Korbel, R., Uchten hagen, A.: mY-Risk and Social Integration in Groups of Drug- Addicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 272 Nilsen, B., Welle-Strand, G.: Assessment of the Work with Pregnant i. v. Drug Users in Oslo . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 286 Serraino, D.: Treatment of Heroin Abuse and AIDS in Italy. . . . . . .. 291 Nasierowski, T., Matsumoto, H, Kaminska-Kopicz, E., Babiuch, L.: Neuropsychiatric Problems and Psychotropic Medication in Patients with AIDS. Data from Warsaw. . . . . . . . . . . . . . . . . . . . . . . .. 298 Zangede, R., Fuchs, D., Reibnegger, G., Fritsch, P., Wachter, H.: Neopterin to Predict Disease Progression in Intravenous Drug Users Infected with HIV- 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 305 Pohl, P., Banged, J., Milly, E., Kemmler, G., Rossler, H., Deisenham mer, F., Schmutzhard, E.: Spect and Transcranial Doppler Sono graphy for the Assessment of Cerebral Perfusion in Intravenous Drug Users with AIDS Encephalopathy . . . . . . . . . . . . . . . . . .. 313 Koyuncuoglu, H.: The Treatment with Dextromethorphan of Heroin Addicts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 320 Bansinath, M., Shukla, V. K., Goldfrank, L. R., Turndorf, H.: Bu prenorphine: An Opioid Mixed Agonist-Antagonist as Possible Antidote for Acute Cocaine Toxicity . . . . . . . . . . . . . . . . . . . .. 330 Bottke, W.: Criminal Law and AIDS. . . . . . . . . . . . . . . . . . . . . .. 340 Strang, J.: The Crisis and Opportunity of AIDS and Drug Misuse. . . .. 355 Prevention Scully, M., Pomeroy, L., Johnson, Z., Johnson, H., Barry, A.: Ob served Patterns of mv Related Risk Behaviour Amongst Intravenous Drug Users Attending a Dublin Needle Exchange in Its First Year .. 368 Heckmann, W., Krauss, G., Gusy, B., Schott-Ben Redjeb, G., Seyrer, Y.: Outreach Work as a Strategy for Risk Reduction in Hard-to-Reach Populations. For Example: Injecting Drug Users. .. 372 Bondolfi, G., Bovet, P.: AIDS Risk Behavior Among Intravenous Drug Users Hospitalized in a Public Psychiatric Hospital . . . . . . .. 384 Sherr, L.: Campaigns of Fear and Behaviour Change in UK Drug Users. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 388 Wille, R., Siegismund, H., Pels Leusden, R.: Resocialization and AIDS-Prevention by Remedacen Substitution . . . . . . . . . . . . . .. 398 x Contents Avico, U., Castrogiovanni, P., Dell'Utri, A., Maremmani, 1., Meloni, D., Mancbni, P. E., Zolesi, 0., Tagliamonte, A.: A Treatment Modelto Heroin Addicts in Italy. . . . . . . . . . . . . . . . . . . . . . .. 412 Da Silveira, D. X., Da Silva Jr., N.: The Importance ofi.v. Drug Users Personality Traits in AIDS Prevention . . . . . . . . . . . . . . . . . . .. 426 Observations on tbe Stabilization of HIV Seroprevalence Among Injecting Drug Users D. C. DES JARLAIS Beth Israel Medical Center, 11, Beach Street, New York 10013, NY USA Introduction HIV seroprevalence among injecting drug users (IDUs) has stabilized in a large number of cities, including New York,1 Stockholm,2 Vienna,3 Amsterdam,4 San Francisco,S and Innsbruck.6 This stabilization has occurred at very different levels of HIV seroprevalence, from the 50% in New York to the 12% in San Francisco. The precise reasons why the stabilization has occurred at such differing levels have yet to be determined, but probably include: the extent to which HIV had already spread among the local group of IDUs (prior to large-scale AIDS risk reduction); and the extent to which the local legal, geographic, and social organization of the "community" of IDUs facilitates the multi-person use of injection equipment. Stabilization of HIV seroprevalence among IDUs in various cities has now occurred often enough that it can be considered a "normal" outcome of an HIV epidemic among IDUs. The question then arises as to how long such stabilization is likely to endure. Should it be considered a cresting of the epidemic to be followed by substantial declines in seroprevalence-as was the case with traditional epidemics of infectious diseases? Or should it