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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Drug addiction and AIDS: highlights of the 1st European congress N. Loimer
a
a
University of Vienna, Department of Psychiatry , Vienna, Austria Published online: 25 Sep 2007.
To cite this article: N. Loimer (1992) Drug addiction and AIDS: highlights of the 1st European congress, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:1, 111-114, DOI: 10.1080/09540129208251625 To link to this article: http://dx.doi.org/10.1080/09540129208251625
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 4, NO.
1, 1992
111
CONFERENCE REPORT
Drug Addiction and AIDS: highlights of the 1st European Congress N. LOIMER Downloaded by [McGill University Library] at 22:16 01 February 2015
University of Vienna, Department of Psychiahy, Vienna, Austria
Abstract The 1st European Congress on ‘Drug Addiction and AIDS’ was held in Vienna, Ausm’a, February 21-23 1991. This conference represented scientists from all areas of Europe and North America. The co-ordinators and the international scientific board offered an exciting programme with eight workshops in clinical, medical and management tracts; there were four plenary sessions with international, national and local experts, exhibits and receptions. With the impact of AIDS and the changes in Eastern Europe, we must now, more than ever before, rethink our strategies to improve effective treatment for substance abusing patients. Introduction There have been few attempts so far to organize European meetings of experts to discuss drug addiction and AIDS. There has certainly been no attempt until now to find a European answer to the dilemmas associated with drug treatment in the face of HIV infection and AIDS. AIDS first appeared amongst injecting drug users in Europe in 1984,3 years after the first cases were seen amongst gay men. However, this epidemic has spread more rapidly amongst injecting drug users than in any other population at risk. High rates of HIV-1 seroprevalence amongst drug users in France, Italy and Spain resulted in 85% of the total number of AIDS cases being seen in injecting drug users in Europe. It is anticipated that HIV infected drug users will soon place a heavy burden on both drug treatment facilities and specialized health care units. The HIV epidemic will also cross the borders into central and eastern Europe. This conference was therefore one of the first opportunities for researchers to get background information on the spread of HIV and AIDS among injecting drug users, and also on the clinical and psychological effects of HIV infection and AIDS. Participants were not selected by governments, but came on the basis of scientific experience. It was not the aim of the conference to establish guidelines, but it was intended to generate international co-operation between central and eastern Europe and the rest of the continent on the one hand and on the other to exchange information and work together towards the ultimate goal of preventing further spread of AIDS. Drug treatment programmes are the first line of defence in the prevention of HIV amongst injecting drug users, whether in treatment or not, and also in their sexual partners. The problems associated with this second wave of the HIV
Address for correspondence: Norbert Loimer, University of Vienna, Department of Psychiatry, Waehringerguertel 18-20, 1090 Vienna, Austria.
112 N. LOIMER
epidemic are only beginning to be addressed; much can be learned from the experiences of the USA, although some models may be more useful than others and unexpected challenges will undoubtedly arise.
Downloaded by [McGill University Library] at 22:16 01 February 2015
Highlights Planning for AIDS prevention activities requires an understanding of the long term trends in risk behaviours and HIV transmission among injecting drug users. Don C. Des Jarlais (USA) examined trends in New York City, Amsterdam, San Francisco and Bangkok. Emphasis was given to the New York situation as data on HIV infection rates are available for a 13-year period for that city. All four cities show a period of low HIV-1 incidence, followed by a period of rapid incidence, which in turn has been followed by a large scale behaviour change and a stabilization of HIV seroprevalence. In New York, a period of stabilization has now lasted for 7 years. This period combines risk reduction and a moderate new infection rate within a dynamic population (with a disproportionate loss of seropositives and entry of seronegatives). New infections are particularly likely among seronegatives who continue high risk behaviour, and amongst new drug injectors. The transition from non-injecting to injecting drug use was examined in a separate substudy reported by Dr Des Jarlais. This transition is not a single irreversible event of a first injection leading to injection as the dominant mode of drug administration, but rather there may be a prolonged period of time experimenting with injection while continuing noninjected drug use. The continued entry of new persons into the drug injecting population and the possibility of heterosexual transmission presents difficult challenges for long-term HIV prevention efforts. According to Kreek (USA), since 1983 the prevalence of HIV infection has plateaued at around 50-60% of all injecting drug users in the New York area. A study demonstrated that those heroin addicts who had entered an effective methadone maintenance programme prior to HIV arriving in New York in 1978, remained free of HIV infection when studied in 1984. Less than 10% of those long-term methadone maintained patients were HIV positive in 1984, at a time when more than 50% of street heroin addicts were seropositive. Recent studies have shown that during long-term methadone maintenance treatment, multiple indices of immune function normalised during treatment. Improvement of immune function may have positive implications for HIV infection and on progression to symptomatic disease. Brewer (UK) suggested that for injecting drug users, the mode of administration of a drug, with its associated cues and rituals can often be as important to the IDU as its pharmacology. Intravenous injection is reportedly a highly addictive behaviour and those who are strongly addicted to it would not find conventional oral methadone maintenance in reduction programmes helpful, even if the dosage is generous. Intravenous methadone (Physeptone) maintenance appears to make treatment acceptable to at least a proportion of injectors who would not otherwise come forward. Dr Brewer discussed some of the experiences and practices of one of the largest injectable methadone programmes in Britain, providing demographic data, assessment, dosage, safeguards, problems, bureaucratic requirements and monitoring. Methadone doses of up to 1,000 mg daily can be compatible with regular skilled employment. Both hair analysis and intravenous medication can assist the ‘therapeutic bargaining’ which is an intrinsic and very useful feature of methadone programmes, despite being often neglected or undervalued. There were reports from other European countries. Berenyi (Hungary) reported that the number of clients is continuously increasing and injecting drug use is common, although this has been hidden for decades. The experiences of Debrecen have shown that drug centres
Downloaded by [McGill University Library] at 22:16 01 February 2015
CONFERENCE REPORT
113
should be established all over Hungary to provide services again and to allow rapid response as was done in the suicide field. Scully (Ireland) reported on 433 clients of a newly established needle-exchange in Dublin. Sharing needles was reported by 30% initially, but fell to 12%, a positive result of introducing the scheme; however, although initially 50% reported condom use, this fell to 27%. In summary, the low uptake of condoms indicates that sexual transmission of HIV remains a potential risk. In Belgium, AIDS cases amongst injecting drug users are still remarkably low compared to neighbouring countries and less than 10% of IDUs are positive for HIV according to Rousseax. It was argued that the easy access to methadone maintenance through general practitioners has played a major role in keeping the infection at this level; in addition, it was reported that needle sharing is limited only to closely related individuals in Belgium. Methadone maintenance treatment was started in Uppsala in Sweden in 1986, but was temporarily closed for admission between 1979 and 1984 (Blix, Sweden). HIV entered the drug using population in 1983. When the methadone maintenance clinic was re-introduced, 67 patients admitted prior to its close were in treatment. Two of these (3%) were found to be HIV antibody positive. During the following 5 years, 270 patients were admitted. The prevalence of HIV infection amongst new admissions showed a dramatic increase, peaking at 59% in 1988. Guidetti (Italy) explained that the antithetical health-care personnel/AIDS patient relationship was one of the most severe problems in the difficult initial management of an AIDS ward. Fear from personnel caused patients to withdraw further into themselves, refusing clinical and psychological help. The study showed that the patients themselves have self-perceptions as untrustworthy, poisonous and aggressive. Health care personnel prefer to work in group settings so that they could better control emerging stressors. It was suggested that psychosocial counselling could be used to manage difficult patientlhealth-care personnel relationships. Furthermore, counselling resulted in a decrease in patients lost to followup and less staff absenteeism. Loimer (Austria) reported on recent HIV seroprevalence data in Vienna. A standardized method to monitor HIV infection levels and trends amongst injecting drug users was periodically administered at the drug addiction outpatient ward of the Psychiatric University Clinic of Vienna. A total of 838 injecting drug users was examined. HIV antibodies were found in 8.5% in 1985/86, in 14.5% in 1986/87, in 27.7% in 1988, in 29.7% in 1989, in 26.9% in 1990 and 28.5% in 1991. In spite of this, sharing was reportedly below 40%, but extensive in infected drug users. After introduction of methadone maintenance in Austria, more than 50% of the drug users were under methadone treatment; in 1990 88% of the infected drug users were treated with methadone and in 1991 this treatment reached 94.4% of all infected IDUs. The main problems that may occur in methadone substitution programmes are poly drug use, social problems and progress of HIV associated disease. A lesser known problem that may occur is the appearance of psychotic states demanding inpatient treatment at a psychiatric hospital. The cases of psychosis that occurred during our methadone programme were presented at the conference; there was discussion over whether there is a relationship between methadone treatment and psychiatric outcomes. Does methadone enhance psychosis or does it stabilise psychiatric illness? Heckmann, reporting from Germany, said that since the late 1970’s, outreach work has become increasingly important in that country, particularly as traditional abstinence-oriented approaches in counselling and treatment have had to be supplemented by low threshold strategies. Although of considerable practical importance, there have only been a few attempts to conceptualize outreach work and to explore its possibilities and limits. Drug users with a minimum of motivation to dispense with drug consumption may be assisted by
Downloaded by [McGill University Library] at 22:16 01 February 2015
114
N. LOIMER
streetworkers in developing perspectives beyond dependence. Others may be helped to survive the risks of drug injecting and drug use. Outreach work has to be part of a network of facilities to supply basic needs; housing, medical care, food, hygiene, recreation. In order to support attempts to realize a drug-free life, streetworkers should be in a position to arrange access to treatment institutions and self-help groups, without necessity for waiting periods. Outreach work remains pointless, unless embedded in an extensive institutional network to provide material, medical and psychological support. The higher number of HIV infections amongst injecting drug users requires an extension of the street workers’ tasks. Since 1986, important contributions to HIV-prevention have been made by personal communication as well as through the distribution of disposable syringes and condoms. A pilot programme funded by the Federal Ministry of Health to promote safer sex and safer drug user allowed workers to experiment with some interesting projects in several cities. Different styles and examples of outreach work, as developed in this context, were presented and discussed. Tagliamonte (Italy) reported on the source of confusion in the distinction between legal and illegal substances of abuse. Such a distinction has two consequences: firstly, it leads to a restriction of the term ‘drug addict’ to consumers of illicit drugs. Secondly, in the evaluation of behavioural modifications produced by drug use, it results in uncertainty in distinguishing between pure psychiatric symptoms and crimes. Recently, legislators have complicated further this issue by punishing those who carry illicit substances independently of the amount. The drug addict may be defined either as a patient criminalized for his disease or as a criminal who tries to take advantage of disease status. This confused situation weighs heavily in the evaluation of different approaches and the need for further treatment in rehabilitation of drug addicts. It is difficult to accept a therapeutic protocol that cannot exclude relapsing, i.e. possible future crime, unless the patient can be considered responsible for such outcomes. The need for a radical solution to this problem brings the community to prefer a therapeutic approach, aimed at a completely drug-free condition and to refuse the pragmatism of the methadone maintenance programme. In this cultural context, assistance to drug addicts in Italy has developed via different models of service provision, depending on the professional backgrounds of staff.
Conclusions Efforts at prevention and treatment should primarily address addiction, and in this conference the apparently never-ending discussion of methadone maintenance treatment was replaced by long and intensive discussions on new aspects of this treatment. In particular, the biological basis of methadone treatment in opiate addiction reported by M. J. Kreek and suggestions regarding the prescription of injectable methadone by Dr Brewer, and perhaps also the Viennese method of investigating quantitatve methadone in saliva may have implications for the medical treatment of opiate addiction with methadone. Participants from countries with needleexchange programmes discussed some problems with implementation which have arisen. All participants reported unsolved problems in prisons. Major regional variations in HIV prevalence were reported, but there was consensus for a need for a standardized European research project so that comparable data on HIV can be collected. It would be possible to begin such a project remembering that it is necessary to include all European countries, particularly those of Central and Eastern Europe. National and regional agencies require increased funding to deal with the dual diagnoses of drug dependency and HIV infection. Reference LOIMER,N., SCHMID,R. & SPRINGER, A. (Eds) (1991) Drug Addiction and AIDS (Wien-New York, Springer Verlag).
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Drug addiction and AIDS: highlights of the 1st European congress N. Loimer
a
a
University of Vienna, Department of Psychiatry , Vienna, Austria Published online: 25 Sep 2007.
To cite this article: N. Loimer (1992) Drug addiction and AIDS: highlights of the 1st European congress, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:1, 111-114, DOI: 10.1080/09540129208251625 To link to this article: http://dx.doi.org/10.1080/09540129208251625
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 4, NO.
1, 1992
111
CONFERENCE REPORT
Drug Addiction and AIDS: highlights of the 1st European Congress N. LOIMER Downloaded by [McGill University Library] at 22:16 01 February 2015
University of Vienna, Department of Psychiahy, Vienna, Austria
Abstract The 1st European Congress on ‘Drug Addiction and AIDS’ was held in Vienna, Ausm’a, February 21-23 1991. This conference represented scientists from all areas of Europe and North America. The co-ordinators and the international scientific board offered an exciting programme with eight workshops in clinical, medical and management tracts; there were four plenary sessions with international, national and local experts, exhibits and receptions. With the impact of AIDS and the changes in Eastern Europe, we must now, more than ever before, rethink our strategies to improve effective treatment for substance abusing patients. Introduction There have been few attempts so far to organize European meetings of experts to discuss drug addiction and AIDS. There has certainly been no attempt until now to find a European answer to the dilemmas associated with drug treatment in the face of HIV infection and AIDS. AIDS first appeared amongst injecting drug users in Europe in 1984,3 years after the first cases were seen amongst gay men. However, this epidemic has spread more rapidly amongst injecting drug users than in any other population at risk. High rates of HIV-1 seroprevalence amongst drug users in France, Italy and Spain resulted in 85% of the total number of AIDS cases being seen in injecting drug users in Europe. It is anticipated that HIV infected drug users will soon place a heavy burden on both drug treatment facilities and specialized health care units. The HIV epidemic will also cross the borders into central and eastern Europe. This conference was therefore one of the first opportunities for researchers to get background information on the spread of HIV and AIDS among injecting drug users, and also on the clinical and psychological effects of HIV infection and AIDS. Participants were not selected by governments, but came on the basis of scientific experience. It was not the aim of the conference to establish guidelines, but it was intended to generate international co-operation between central and eastern Europe and the rest of the continent on the one hand and on the other to exchange information and work together towards the ultimate goal of preventing further spread of AIDS. Drug treatment programmes are the first line of defence in the prevention of HIV amongst injecting drug users, whether in treatment or not, and also in their sexual partners. The problems associated with this second wave of the HIV
Address for correspondence: Norbert Loimer, University of Vienna, Department of Psychiatry, Waehringerguertel 18-20, 1090 Vienna, Austria.
112 N. LOIMER
epidemic are only beginning to be addressed; much can be learned from the experiences of the USA, although some models may be more useful than others and unexpected challenges will undoubtedly arise.
Downloaded by [McGill University Library] at 22:16 01 February 2015
Highlights Planning for AIDS prevention activities requires an understanding of the long term trends in risk behaviours and HIV transmission among injecting drug users. Don C. Des Jarlais (USA) examined trends in New York City, Amsterdam, San Francisco and Bangkok. Emphasis was given to the New York situation as data on HIV infection rates are available for a 13-year period for that city. All four cities show a period of low HIV-1 incidence, followed by a period of rapid incidence, which in turn has been followed by a large scale behaviour change and a stabilization of HIV seroprevalence. In New York, a period of stabilization has now lasted for 7 years. This period combines risk reduction and a moderate new infection rate within a dynamic population (with a disproportionate loss of seropositives and entry of seronegatives). New infections are particularly likely among seronegatives who continue high risk behaviour, and amongst new drug injectors. The transition from non-injecting to injecting drug use was examined in a separate substudy reported by Dr Des Jarlais. This transition is not a single irreversible event of a first injection leading to injection as the dominant mode of drug administration, but rather there may be a prolonged period of time experimenting with injection while continuing noninjected drug use. The continued entry of new persons into the drug injecting population and the possibility of heterosexual transmission presents difficult challenges for long-term HIV prevention efforts. According to Kreek (USA), since 1983 the prevalence of HIV infection has plateaued at around 50-60% of all injecting drug users in the New York area. A study demonstrated that those heroin addicts who had entered an effective methadone maintenance programme prior to HIV arriving in New York in 1978, remained free of HIV infection when studied in 1984. Less than 10% of those long-term methadone maintained patients were HIV positive in 1984, at a time when more than 50% of street heroin addicts were seropositive. Recent studies have shown that during long-term methadone maintenance treatment, multiple indices of immune function normalised during treatment. Improvement of immune function may have positive implications for HIV infection and on progression to symptomatic disease. Brewer (UK) suggested that for injecting drug users, the mode of administration of a drug, with its associated cues and rituals can often be as important to the IDU as its pharmacology. Intravenous injection is reportedly a highly addictive behaviour and those who are strongly addicted to it would not find conventional oral methadone maintenance in reduction programmes helpful, even if the dosage is generous. Intravenous methadone (Physeptone) maintenance appears to make treatment acceptable to at least a proportion of injectors who would not otherwise come forward. Dr Brewer discussed some of the experiences and practices of one of the largest injectable methadone programmes in Britain, providing demographic data, assessment, dosage, safeguards, problems, bureaucratic requirements and monitoring. Methadone doses of up to 1,000 mg daily can be compatible with regular skilled employment. Both hair analysis and intravenous medication can assist the ‘therapeutic bargaining’ which is an intrinsic and very useful feature of methadone programmes, despite being often neglected or undervalued. There were reports from other European countries. Berenyi (Hungary) reported that the number of clients is continuously increasing and injecting drug use is common, although this has been hidden for decades. The experiences of Debrecen have shown that drug centres
Downloaded by [McGill University Library] at 22:16 01 February 2015
CONFERENCE REPORT
113
should be established all over Hungary to provide services again and to allow rapid response as was done in the suicide field. Scully (Ireland) reported on 433 clients of a newly established needle-exchange in Dublin. Sharing needles was reported by 30% initially, but fell to 12%, a positive result of introducing the scheme; however, although initially 50% reported condom use, this fell to 27%. In summary, the low uptake of condoms indicates that sexual transmission of HIV remains a potential risk. In Belgium, AIDS cases amongst injecting drug users are still remarkably low compared to neighbouring countries and less than 10% of IDUs are positive for HIV according to Rousseax. It was argued that the easy access to methadone maintenance through general practitioners has played a major role in keeping the infection at this level; in addition, it was reported that needle sharing is limited only to closely related individuals in Belgium. Methadone maintenance treatment was started in Uppsala in Sweden in 1986, but was temporarily closed for admission between 1979 and 1984 (Blix, Sweden). HIV entered the drug using population in 1983. When the methadone maintenance clinic was re-introduced, 67 patients admitted prior to its close were in treatment. Two of these (3%) were found to be HIV antibody positive. During the following 5 years, 270 patients were admitted. The prevalence of HIV infection amongst new admissions showed a dramatic increase, peaking at 59% in 1988. Guidetti (Italy) explained that the antithetical health-care personnel/AIDS patient relationship was one of the most severe problems in the difficult initial management of an AIDS ward. Fear from personnel caused patients to withdraw further into themselves, refusing clinical and psychological help. The study showed that the patients themselves have self-perceptions as untrustworthy, poisonous and aggressive. Health care personnel prefer to work in group settings so that they could better control emerging stressors. It was suggested that psychosocial counselling could be used to manage difficult patientlhealth-care personnel relationships. Furthermore, counselling resulted in a decrease in patients lost to followup and less staff absenteeism. Loimer (Austria) reported on recent HIV seroprevalence data in Vienna. A standardized method to monitor HIV infection levels and trends amongst injecting drug users was periodically administered at the drug addiction outpatient ward of the Psychiatric University Clinic of Vienna. A total of 838 injecting drug users was examined. HIV antibodies were found in 8.5% in 1985/86, in 14.5% in 1986/87, in 27.7% in 1988, in 29.7% in 1989, in 26.9% in 1990 and 28.5% in 1991. In spite of this, sharing was reportedly below 40%, but extensive in infected drug users. After introduction of methadone maintenance in Austria, more than 50% of the drug users were under methadone treatment; in 1990 88% of the infected drug users were treated with methadone and in 1991 this treatment reached 94.4% of all infected IDUs. The main problems that may occur in methadone substitution programmes are poly drug use, social problems and progress of HIV associated disease. A lesser known problem that may occur is the appearance of psychotic states demanding inpatient treatment at a psychiatric hospital. The cases of psychosis that occurred during our methadone programme were presented at the conference; there was discussion over whether there is a relationship between methadone treatment and psychiatric outcomes. Does methadone enhance psychosis or does it stabilise psychiatric illness? Heckmann, reporting from Germany, said that since the late 1970’s, outreach work has become increasingly important in that country, particularly as traditional abstinence-oriented approaches in counselling and treatment have had to be supplemented by low threshold strategies. Although of considerable practical importance, there have only been a few attempts to conceptualize outreach work and to explore its possibilities and limits. Drug users with a minimum of motivation to dispense with drug consumption may be assisted by
Downloaded by [McGill University Library] at 22:16 01 February 2015
114
N. LOIMER
streetworkers in developing perspectives beyond dependence. Others may be helped to survive the risks of drug injecting and drug use. Outreach work has to be part of a network of facilities to supply basic needs; housing, medical care, food, hygiene, recreation. In order to support attempts to realize a drug-free life, streetworkers should be in a position to arrange access to treatment institutions and self-help groups, without necessity for waiting periods. Outreach work remains pointless, unless embedded in an extensive institutional network to provide material, medical and psychological support. The higher number of HIV infections amongst injecting drug users requires an extension of the street workers’ tasks. Since 1986, important contributions to HIV-prevention have been made by personal communication as well as through the distribution of disposable syringes and condoms. A pilot programme funded by the Federal Ministry of Health to promote safer sex and safer drug user allowed workers to experiment with some interesting projects in several cities. Different styles and examples of outreach work, as developed in this context, were presented and discussed. Tagliamonte (Italy) reported on the source of confusion in the distinction between legal and illegal substances of abuse. Such a distinction has two consequences: firstly, it leads to a restriction of the term ‘drug addict’ to consumers of illicit drugs. Secondly, in the evaluation of behavioural modifications produced by drug use, it results in uncertainty in distinguishing between pure psychiatric symptoms and crimes. Recently, legislators have complicated further this issue by punishing those who carry illicit substances independently of the amount. The drug addict may be defined either as a patient criminalized for his disease or as a criminal who tries to take advantage of disease status. This confused situation weighs heavily in the evaluation of different approaches and the need for further treatment in rehabilitation of drug addicts. It is difficult to accept a therapeutic protocol that cannot exclude relapsing, i.e. possible future crime, unless the patient can be considered responsible for such outcomes. The need for a radical solution to this problem brings the community to prefer a therapeutic approach, aimed at a completely drug-free condition and to refuse the pragmatism of the methadone maintenance programme. In this cultural context, assistance to drug addicts in Italy has developed via different models of service provision, depending on the professional backgrounds of staff.
Conclusions Efforts at prevention and treatment should primarily address addiction, and in this conference the apparently never-ending discussion of methadone maintenance treatment was replaced by long and intensive discussions on new aspects of this treatment. In particular, the biological basis of methadone treatment in opiate addiction reported by M. J. Kreek and suggestions regarding the prescription of injectable methadone by Dr Brewer, and perhaps also the Viennese method of investigating quantitatve methadone in saliva may have implications for the medical treatment of opiate addiction with methadone. Participants from countries with needleexchange programmes discussed some problems with implementation which have arisen. All participants reported unsolved problems in prisons. Major regional variations in HIV prevalence were reported, but there was consensus for a need for a standardized European research project so that comparable data on HIV can be collected. It would be possible to begin such a project remembering that it is necessary to include all European countries, particularly those of Central and Eastern Europe. National and regional agencies require increased funding to deal with the dual diagnoses of drug dependency and HIV infection. Reference LOIMER,N., SCHMID,R. & SPRINGER, A. (Eds) (1991) Drug Addiction and AIDS (Wien-New York, Springer Verlag).
