**4.4. Substitution treatment**

All the patients in the group have been administered a substitute treatment with methadone. A single patient with a 15-year drug consumption has been changed on Suboxone instead of Methadone.

The analysis of the group of patients reveals that the average dose of methadone is approximately 56 mg, varying between 15 and 125 mg, enough for the stabilization and avoidance of the abstinence syndrome (**Figure 6**). This is in accordance with the data in the literature, which recommends a test dose of methadone of 20 mg, at the beginning of the substitute treatment. Till the end of the hospitalization, the doses of methadone were generally increased with approximately 10 mg in 2 days; for the outpatients, the level of methadone was increased to 125 mg/methadone/day in some patients.

Some patients have required the reduction or the increase of the doses, but this depended on the symptomatology.

During the methadone substitution treatment, they often prescribe different medicines to improve anxiety, agitation, and severe muscular contractions; generally, phenothiazines and benzodiazepines are used to treat agitation, to stabilize the patients' sleep and muscular contractions. They also take into account the somatic and psychic comorbidities of the patients. The co-medication makes possible different medical interactions. Thus, the data in the literature suggest that the benzodiazepines (they themselves being medicines with potential of abuse consumption), especially for the fact that the diazepam interferes with the normal metabolization of the methadone. To be more precised, the individual treatment has a different graphic according to: the test results, symptomatology, and comorbidities. At the beginning of the treatment, patients are informed on the condition to remain under treatment, notably the negative tests of the heroin and combinations. Otherwise, they are removed from the program.

Methadone Treatment for Heroin Dependence http://dx.doi.org/10.5772/intechopen.78066 129

**Figure 6.** Proportion of the patients according to the methadone dose.

Together with the treatment with methadone, over 80% of the patients have accepted the individual or group psychological therapy. We consider that, without this type of therapy, the situation of the patients would be more dramatic. The study shows that 40% of the patients have confessed their relapses, because of their bad company or some dramatic events in their family. For this reason, the methadone doses have been adjusted and the treatment has been extended. The relapses have been confessed and marked out at the heroin presence in the tests. The rehospitalizations have been done out of the patients own initiatives, because of their syndrome of withdrawal. Their motivation of the relapse was depression, the lack of

Our study shows that the patients' stabilizing is done with moderate methadone doses (approx. 50–60 mg/zi), compared to those reported in the literature (approx. 90–100 mg); this is an advantage, taking into account the possible interactions with other medicines, under the circumstances of the associations of the necessary medicines during the substitute treatment, as well as the somatic comorbidities of the patients (mainly the liver chronical problems caused by HCV infection).

**Figure 5.** Proportions in the patient group according to the concentration of heroin and metabolites (ng/mL) in the urine tests.

**Figure 6.** Proportion of the patients according to the methadone dose.

In the present study, the quantitative toxicological analysis aimed at determining the levels of the heroin and the metabolites in the urine of the heroin consumers, applying the technique of the fluorescent antibody, and using an automatic analyzer. The heroin and metabolite levels in their urine tests have been placed to a large extent, from approximately 700 to over

During the treatment, not only the initial one, they do tests (which are marked as follows: negative, slightly positive, positive), no matter the patients' declarations. At the assumption or the declaration of relapses, tests grow in number, especially when we speak about the combinations of opiates and heroin or other medicines. The maximum number of tests along

All the patients in the group have been administered a substitute treatment with methadone. A single patient with a 15-year drug consumption has been changed on Suboxone instead of

The analysis of the group of patients reveals that the average dose of methadone is approximately 56 mg, varying between 15 and 125 mg, enough for the stabilization and avoidance of the abstinence syndrome (**Figure 6**). This is in accordance with the data in the literature, which recommends a test dose of methadone of 20 mg, at the beginning of the substitute treatment. Till the end of the hospitalization, the doses of methadone were generally increased with approximately 10 mg in 2 days; for the outpatients, the level of methadone was increased

Some patients have required the reduction or the increase of the doses, but this depended on

Our study shows that the patients' stabilizing is done with moderate methadone doses (approx. 50–60 mg/zi), compared to those reported in the literature (approx. 90–100 mg); this is an advantage, taking into account the possible interactions with other medicines, under the circumstances of the associations of the necessary medicines during the substitute treatment, as well as the somatic comorbidities of the patients (mainly the liver chronical problems

**Figure 5.** Proportions in the patient group according to the concentration of heroin and metabolites (ng/mL) in the urine

30,000 ng/mL (**Figure 5**).

128 Drug Addiction

**4.4. Substitution treatment**

Methadone.

the symptomatology.

caused by HCV infection).

tests.

a whole year for a single patient has been 27.

to 125 mg/methadone/day in some patients.

During the methadone substitution treatment, they often prescribe different medicines to improve anxiety, agitation, and severe muscular contractions; generally, phenothiazines and benzodiazepines are used to treat agitation, to stabilize the patients' sleep and muscular contractions. They also take into account the somatic and psychic comorbidities of the patients. The co-medication makes possible different medical interactions. Thus, the data in the literature suggest that the benzodiazepines (they themselves being medicines with potential of abuse consumption), especially for the fact that the diazepam interferes with the normal metabolization of the methadone. To be more precised, the individual treatment has a different graphic according to: the test results, symptomatology, and comorbidities. At the beginning of the treatment, patients are informed on the condition to remain under treatment, notably the negative tests of the heroin and combinations. Otherwise, they are removed from the program.

Together with the treatment with methadone, over 80% of the patients have accepted the individual or group psychological therapy. We consider that, without this type of therapy, the situation of the patients would be more dramatic. The study shows that 40% of the patients have confessed their relapses, because of their bad company or some dramatic events in their family. For this reason, the methadone doses have been adjusted and the treatment has been extended. The relapses have been confessed and marked out at the heroin presence in the tests. The rehospitalizations have been done out of the patients own initiatives, because of their syndrome of withdrawal. Their motivation of the relapse was depression, the lack of a positive emotional support on behalf of the people close to them and inability to prevent from not using drugs. Even if they have not restarted all of a sudden (with heroin) they have used NPS (such as Magic/Supergold, Pure). Three patients who gave up the substitution treatment were hospitalized at Psychiatric Hospitals. The evaluations which maintain or change the methadone doses are made in accordance with the clinical behavior, psychological and paraclinical monitoring. We state that, an important proportion of the patients have confessed self-medication with methadone, before their onset in the program. The methadone was used in order to stop the state of withdrawal with heroin (a short term detoxification), and also, as an agent for long term substitution.

• These aspects, together with the typical profile of the drug addicts, represent essential data, as they contribute to the accurate identification of the target groups who would have to be targeted at the beginning of a prevention or therapeutic program within the phenomenon

• The methodology of the toxicological analysis provides with a useful support to initiate a

• The integrated care programs of assistance should involve both therapeutic programs and

• The results of the study contribute to the extension of information area in terms of consumption phenomenon and its breadth; the identification of the onset ages in the case of heroin consumption; establishing the prevalence and types of comorbidities with drug addicts; the identification and description of the multiple facts involved in the consumption (biological, emotional, psychological, familial, interpersonal, educational, social, environmental, and within the community) including the precursors, associated with or favorable to the drug consumption; the identification of the determinant elements to enroll in the treatment program. • In spite of monitoring the treatment carefully, there are relapses, which impede the personal and social reintegration. They point out the necessity to increase the patients' awareness, in terms of their health, and to enroll them in a substitution program, and they also highlight the complicated situation in case of a dual diagnosis (emotional and personality

substitution treatment as well as to detect the relapses during the treatment.

psychological ones in order to prevent relapses.

of drug addiction.

disturbance).

**Author details**

Mirela Nedelescu3

Baconi Daniela Luiza<sup>1</sup>

Pharmacy, Bucharest, Romania

Medicine and Pharmacy, Bucharest, Romania

**Conflict of interest**

The authors declare no conflict of interest.

\*, Anne Marie Ciobanu2

and Miriana Stan<sup>1</sup>

\*Address all correspondence to: daniela\_baconi@yahoo.com

University of Medicine and Pharmacy, Bucharest, Romania

, Robert Daniel Vasile<sup>1</sup>

1 Toxicology Department, Faculty of Pharmacy, "Carol Davila" University of Medicine and

3 Department of Hygiene and Environmental Health, Faculty of Medicine, "Carol Davila"

2 Medicine Control Department, Faculty of Pharmacy, "Carol Davila" University of

, Ana-Maria Vlasceanu<sup>1</sup>

Methadone Treatment for Heroin Dependence http://dx.doi.org/10.5772/intechopen.78066 131

,

All the patients in the group have been included in the program for years, because of their relapses. Their periods of abstinence have lasted for only several days, months, but not years. For instance, one patient had repeated attempts of abstinence during a year, as follows: four times of 1–7 days, two times of about 1 month, and one time (but interrupted) of approximately 4 months.

In spite of monitoring the treatment carefully, there are relapses which impede the personal and social reintegration. Current literature data indicate that sustained remission occurs in a significant minority of heroin users and the treatment does not cure this addiction, but it can contribute to prevent the heroin use and reduce its adverse effects [22].

The results of the study show that the complex correlative, clinical, laboratory, and psychological evaluation is essential to start and supervise the methadone substitution maintenance. This is in line with the recent data from the literature emphasizing the need for multidisciplinary evaluation of candidates for opioid agonist therapy, including a careful medical history, physical and psychiatric examination, psychosocial evaluation, as well as the determination of the patient's readiness to change [23].
