Arud Centre for Addiction Medicine
Recent publications
Background and aims Legal regulations for dispensing in Swiss heroin‐assisted treatment were relaxed during the COVID‐19 pandemic, allowing prolonged take‐home of up to 7 days instead of two to reduce patient contact and the risk of infection. Our study aimed to measure the consequences of this new practice. Design, setting and participants This was a retrospective cohort study set in Switzerland’s largest outpatient centre for opioid agonist therapy. One hundred and thirty‐four (72.4%) of the 185 patients receiving oral diacetylmorphine (DAM) participated in the study. Measurements Through the utilization of electronic medication prescription and dispensing software, as well as the electronic medical record, the following data were extracted to explore the potential consequences: dose of DAM, the number of antibiotic therapies, emergency hospitalizations and incarcerations. Age, gender, prescriptions for psychotrophic drugs and additional prescription for injectable DAM were tested to assess an increased risk of losing prolonged take‐home privileges. Data in the year since prolonged take‐home (period 2) were compared with data from the equivalent prior year (period 1). Findings DAM take‐home was not associated with a change in DAM dose ( P = 0.548), the number of emergency hospitalizations ( P = 0.186) or the number of incarcerations ( P = 0.215); 79.1% of all patients were able to maintain their extended take‐home privileges. However, patients who had injectable DAM experienced significant reductions in their prolonged take‐home privileges. Conclusion Allowing patients to take home oral diacetylmorphine for up to 7 days as treatment for opioid use disorder does not appear to pose any demonstrable health risk. It is generally manageable for the large majority of patients. However, careful consideration of prolonged take‐home for patients with additional injectable diacetylmorphine is recommended, as these patients are more likely to lose take‐home privileges.
Mental health problems are highly prevalent among people living with HIV/AIDS (PLWHA), yet mental health care in African countries is scarce. There is growing interest in understanding the effect of group therapy delivery models and task-shifting to support mental health care in African settings. We conducted a scoping review following the PRISMA-ScR statement on group therapy in PLWHA in Africa. We searched PubMed/Medline, Embase, and Google Scholar for articles published before October 2023 on evidence for effectiveness and acceptance of group therapies in PLWHA, and evidence of task-shifting approaches. A narrative synthesis approach for data analysis was used. We included 17 studies, which comprised 26 different outcome measures across seven countries in sub-Sahara Africa. The majority (72%) of the assessed single outcomes demonstrated a positive impact of group therapy delivery models on outcome measures, particularly depression, alcohol use, overall functioning, and social support in sub-Sahara Africa. High acceptance was demonstrated by quantitative and qualitative approaches. Task shifting approaches generally were shown to be effective, cost-effective, and accepted, and may support burdened healthcare systems in rural settings. The current evidence, albeit scarce, supports the use of group therapy and task shifting in addressing mental health among PLWHA living in sub-Sahara Africa.
Objective Patients with ‘late presentation’ (LP) of chronic hepatitis C infection (HCV) have already developed advanced liver disease before receiving direct-acting antiviral (DAA) treatment. Even after successful treatment, the risk of morbidity and premature death remains elevated, leading to an unnecessary disease burden. This study aimed to assess the prevalence of LP within the prospective observational Swiss Hepatitis C Cohort (SCCS) and evaluate risk factors as determinants of LP. Methods Treatment-naïve participants of SCCS who received DAA treatment between 2014 and 2019 were included. Demographic, clinical and behavioural data were compared between the LP and non-LP strata. LP prevalence was calculated over time and by year. LASSO regression was used to identify potential risk factors for LP, and odds ratios were calculated by refitting logistic regression models. Results In this explorative, retrospective case–control study using data of n = 5829 SCCS members, a total of 21.3% received their first HCV treatment. The cumulative LP prevalence decreased from mid-2015 and stabilised at 46.5% ( n = 579) by the end of 2019. Male gender, higher age and a history of alcohol overuse were associated with a higher risk of LP. Conclusion Despite the study’s limitations, LP prevalence was higher than anticipated, considering Switzerland’s availability period and universal access to DAAs. Therefore, any HCV LP should be viewed as a healthcare system failure, primarily in high-income economies. As LP is directly linked to the disease burden, it must be included as a mandatory parameter in surveillance response systems of HCV elimination programs.
The first Harm Reduction DACH Conference [DACH = D (Germany), A (Austria), CH (Switzerland)] took place in Vienna on June 23rd, 2023, and focused on tobacco harm reduction. It is the first conference bringing together various experts of all three German-speaking countries to shed light on the subject of destigmatization and tobacco harm reduction and to share their experiences with the audience. All in all, the first German-speaking harm reduction con- ference has the goal to discuss and expand harm reduction in the German-speaking countries. This meeting report gives a brief overview of the conference.
Aim: In Switzerland, the first access to interferon-free direct-acting antivirals (DAAs) for hepatitis C virus (HCV) treatment was in 2014. This study aimed to analyze the effects of DAAs on the yearly listed numbers of HCV RNA-positive (RNA+) patients and their mortality on the Swiss organ transplantation waiting list (SOWL). Methods: In this retrospective secondary time series analysis of yearly aggregated data on listed and delisted patients from a subset of HCV RNA+ patients on the SOWL, listed patients were grouped by the requested organ, and delisted patients by reason. Time series were split into two periods of equal length, the phases before and after DAA implementation, and the mean difference was tested using the Mann-Whitney U test. Results: From 2008 to 2019, 328 HCV RNA+ patients were listed on SOWL, 86.6% requesting liver, 11.6% kidney, and 1.8% other organ transplantations. A total of 285 RNA+ patients were delisted from SOWL: 14.7% died, 75.4% had been transplanted, and 9.8% were delisted without surgery. There were significant reductions of patients listed for requesting any organ (-21.7, P = 0.004), liver (-18.3, P = 0.004), or kidney (-3.0, P = 0.031) comparing the periods before and after DAA launch. The mean number of delistings after transplantation (-11.2, P = 0.010), or death (-4, P < 0.001) show a significant reduction. Conclusions: With DAAs, the rising trend of HCV RNA+ people waiting for organs was broken, as was the increasing trend of mortality on the SOWL among HCV RNA+ individuals.
Purpose Little is known about the reasoning behind the desire to have children in non-heterosexual individuals. This study compares the motives of different sexual–romantic orientations and their preferred ways of fulfilling this desire. Methods This was a monocentric cross-sectional study. Subjects were recruited via social media, personal contacts and queer organisations in Switzerland. An anonymous questionnaire comprised general questions about the participant's background, a validated survey about the desire to have children and additional non-validated questions addressing the impact of sexual–romantic orientation on the desire to have children. The inclusion criteria were adults without children and a completed questionnaire. Results Of 837 participants, 642 were included in the study. Four groups of sexual–romantic orientations consisted of more than 35 participants: bisexual–biromantic (n = 38), heterosexual–heteroromantic (n = 230), homosexual–homoromantic (n = 159) and pansexual–panromantic (n = 55). Subgroups with a positive wish for a child rated all motives in the same order and with minimal numeric difference. The most important aspect seemed to be emotional involvement. Non-heterosexual–heteroromantic showed concerns about adverse reactions regarding their wish for a child. All orientations hoped for a biological child. Conclusion Our findings about bi-, hetero-, homo- and pansexual people and their motives for a desire to have children agree with the existing literature about hetero, homo and bisexual. The impact of the fear of adverse reaction and discrimination has been discussed before and is supported by our data. We suggest better support before and during the realization of the wish for a child as well as support for non-traditional aspiring parents.
Objectives Our objective was to obtain long‐term data on the incidence of sexually transmitted infections (STIs) and their association with behavioural factors after widespread pre‐exposure prophylaxis (PrEP) implementation. Methods This was a time‐to‐event analysis of a national PrEP cohort in Switzerland (SwissPrEPared study). Participants were people without HIV interested in taking PrEP with at least two STI screening visits. Primary outcomes were incidence rate of gonorrhoea, chlamydia, and syphilis. The association between behavioural factors and STI diagnosis was expressed using hazard ratios. We adjusted for testing frequency and calendar year. Results This analysis included 3907 participants enrolled between April 2019 and April 2022, yielding 3815.7 person‐years of follow‐up for gonorrhoea (15 134 screenings), 3802.5 for chlamydia (15 141 screenings), and 3858.6 for syphilis (15 001 screenings). The median age was 39 years (interquartile range [IQR] 32–47), 93.8% (n = 3664) identified as men who have sex with men (MSM). The incidence was 22.8 (95% confidence interval [CI] 21.3–24.4) per 100 person‐years for gonorrhoea, 26.3 (95% CI 24.7–28.0) for chlamydia, and 4.4 (95% CI 3.8–5.1) for syphilis. Yearly incidence rates decreased between 2019 (all bacterial STIs: 81.6; 95% CI 59.1–109.9) and 2022 (all bacterial STIs: 49.8; 95% CI 44.6–55.3). Participants reporting chemsex substance use were at higher risk of incident STIs, as were those reporting multiple sexual partners. Younger age was associated with a higher risk of gonorrhoea and chlamydia. Conclusions Incidence rates of bacterial STIs decreased over time. Young MSM, those with multiple partners, and those using chemsex substances were at increased risk of STIs.
Introduction: The number of backcountry skiers and snowboarder surged in the last years, especially during the COVID-19 pandemic, as ski resorts shut down. Inevitably, this led to an increase in avalanche-related injuries and death. As avalanche rescue device, avalanche airbags are increasingly becoming part of the standard winter mountaineering equipment. Method: This study provides a review of available data and an updated perspective on avalanche airbags, discussing their function and efficacy to reduce mortality and their limitations. Results: Causes of death in individuals caught by avalanches are multiple. Airbags seem to reduce mortality by decreasing chances of critical burial, the most determining risk factor. However, there is scarcity of reliable scientific research on the topic, and the way in which airbags reduce mortality and to what extent is still debated. Several elements seem to influence airbags efficacy, and their use still yields several limitations linked to manufacturing, proper use, users education, and risk compensation. Conclusion: Avalanche airbags seem to be an important tool in reducing mortality in backcountry expeditions. However, more research and standardized data collection is needed to fill the knowledge gap, mountain communities should promote adequate education of winter-recreationists on how to prevent and react to an avalanche, and on the correct use of airbags in combination with already available tools such as transceivers, probes and shovels, and manufacturing companies should ensure higher efficacy of the survival avalanche equipment for better prevention of burial, asphyxia, and trauma.
The World Health Organization (WHO) aims to reduce HCV mortality, but estimates are difficult to obtain. We aimed to identify electronic health records of individuals with HCV infection, and assess mortality and morbidity. We applied electronic phenotyping strategies on routinely collected data from patients hospitalized at a tertiary referral hospital in Switzerland between 2009 and 2017. Individuals with HCV infection were identified using International Classification of Disease (ICD)-10 codes, prescribed medications and laboratory results (antibody, PCR, antigen or genotype test). Controls were selected using propensity score methods (matching by age, sex, intravenous drug use, alcohol abuse and HIV co-infection). Main outcomes were in-hospital mortality and attributable mortality (in HCV cases and study population). The non-matched dataset included records from 165,972 individuals (287,255 hospital stays). Electronic phenotyping identified 2285 stays with evidence of HCV infection (1677 individuals). Propensity score matching yielded 6855 stays (2285 with HCV, 4570 controls). In-hospital mortality was higher in HCV cases (RR 2.10, 95%CI 1.64 to 2.70). Among those infected, 52.5% of the deaths were attributable to HCV (95%CI 38.9 to 63.1). When cases were matched, the fraction of deaths attributable to HCV was 26.9% (HCV prevalence: 33%), whilst in the non-matched dataset, it was 0.92% (HCV prevalence: 0.8%). In this study, HCV infection was strongly associated with increased mortality. Our methodology may be used to monitor the efforts towards meeting the WHO elimination targets and underline the importance of electronic cohorts as a basis for national longitudinal surveillance.
BACKGROUND AND AIMS: The prevalence of chronic hepatitis C in Switzerland is currently estimated at approximately 32,000 affected individuals (0.37% of the permanent resident population). An estimated 40% of affected individuals in Switzerland is undiagnosed. The Swiss Federal Office of Public Health requires laboratories to report all positive hepatitis C virus (HCV) test results. Approximately 900 newly diagnosed cases are reported annually. The number of HCV tests performed, however, is not collected by the Federal Office of Public Health and positive rates are therefore unknown. The aim of this study was to describe the longitudinal course of the numbers of hepatitis C antibody tests and of positive rates in Switzerland for the years 2007 to 2017. METHODS: Twenty laboratories were asked to provide the number of HCV antibody tests performed and the number of positive antibody tests per year. Using data from the Federal Office of Public Health reporting system for the years 2012 to 2017, we calculated a factor to correct our values for multiple tests of the same person. RESULTS: The annual number of HCV antibody tests performed tripled linearly from 2007 to 2017 (from 42,105 to 121,266) while the number of positive HCV antibody test results increased by only 75% over the same period (from 1,360 to 2,379). The HCV antibody test positive rate steadily decreased from 3.2% in 2007 to 2.0% in 2017. After correction for multiple tests per person, the person-level HCV antibody tested positive rate decreased from 2.2% to 1.7% from 2012 to 2017. CONCLUSION: In the Swiss laboratories considered, more HCV antibody tests were performed each year in the period (2007–2017) before and during the approval of the new hepatitis C drugs. At the same time, the HCV antibody positive rates decreased, both on the per-test as well as the per-person level. This study is the first to describe the evolution of tests performed and of positive rates for HCV antibody in Switzerland at the national level over several years. In order to more accurately guide future measures to achieve the goal of eliminating hepatitis C by 2030, we recommend annual collection and publication of positive rates by health authorities, along with mandatory reporting of numbers of tests and people treated.
BACKGROUND AND AIMS: Chronic hepatitis B infection (defined as sustained detection of hepatitis B virus [HBV] surface antigen [HBsAg] protein in serum) is a leading cause of cirrhosis, hepatocellular carcinoma and liver-related deaths. A situation analysis carried out by the Swiss Federal Office of Public Health estimated the HBsAg prevalence in Switzerland to be 0.53% (95% CI: 0.32–0.89%) in 2015 (~44,000 cases). A lower prevalence of chronic HBV in the younger generation and the adoption of universal coverage in the first year of life are expected to decrease the burden of HBV; however, a number of people in key populations (including migrants) remain undiagnosed and untreated, and infected individuals remain at risk of progressing to cirrhosis, hepatocellular carcinoma and death. Our primary objective was to examine the current and estimate the future disease burden of HBV in Switzerland and the impact of migration. The secondary objective was to estimate the impact of changing future treatment numbers. METHODS: A modelling study was performed using an existing, validated model (PRoGReSs Model) applied to the Swiss context. Model inputs were selected through a literature search and expert consensus. Population data from the Federal Statistical Office were used alongside prevalence data from the Polaris Observatory to estimate the number of HBV infections among people born abroad. The PRoGReSs Model was populated with and calibrated to the available data and what-if scenarios were developed to explore the impact of intervention on the future burden of disease. A Monte Carlo simulation was used to estimate 95% uncertainty intervals (95% UIs). RESULTS: In 2020, there were an estimated 50,100 (95% UI: 47,500–55,000) HBsAg+ cases among people born abroad. Among people born in Switzerland, there were approximately 62,700 (UI: 58,900–68,400) total HBV infections (0.72% [UI: 0.68–0.79%] prevalence). Prevalence among infants and children under the age of 5 were both
Background ‘Image- and performance-enhancing drugs’ (IPEDs) in sports are widely used to improve body image and performance goals worldwide. Regarding the growing research interest and use of these substances, which often does not include Switzerland, we conducted a scoping literature review on evidence of the use of these substances and substance users in Switzerland. Methods A scoping review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement. We searched PubMed/Medline, Embase and Google Scholar for articles published before August 2022. Primary outcomes were evidence of IPED use and users in Switzerland. We used a narrative synthesis approach for data analysis. Results Overall, 18 studies were reviewed, which in total comprised 11,401 survey participants, 140 interviews and 1,368 toxicologically analyzed substances. Articles were mostly peer-reviewed (83%) and mostly included evidence from professional athletes (43%). Mean publication year was 2011. In most articles both outcomes (78%) were evaluated simultaneously. We demonstrate that IPEDs appear to be prevalent among athletes and non-athletes in Switzerland. A wide variety of different substances exist, and the type of substances used could vary by age, motivation, gender, and sports discipline. The main motivation to use these substances was for image- and performance-enhancement purposes among others. The main route of acquisition of these substances appears to be the Internet. Furthermore, we demonstrate that substantial proportions of these substances, as well as supplements, may be counterfeit. Information on IPED use was acquired from different sources. Conclusions Although evidence of IPED use and its users in Switzerland is scarce and major gaps were established, we demonstrate that these substances are also prevalent among athletes and non-athletes in Switzerland. Furthermore, major proportions of substances acquired from unregulated drug markets are counterfeit, which puts users in a situation of unpredictable risk when consuming them. Overall, the use of these substances may pose a substantial risk to individual and public health among this possibly growing, and often insufficiently informed and medically neglected user community in Switzerland. There is a great need for future research, as well as prevention, harm reduction, and treatment programs for this hard-to-reach user community. Doping policies in Switzerland should be critically reviewed as simple medical care, as well as the evidence-based treatment for non-athlete IPED users is excessively criminalized under the current legislature, leaving possibly over 200,000 IPED users in Switzerland with inadequate medical care.
Background: Heroin-assisted treatment (HAT) is a proven effective treatment option for individuals with severe opioid use disorder (OUD). In Switzerland, pharmaceutical heroin (diacetylmorphine, DAM) is available in tablet form or as injectable liquid. This creates a large barrier for individuals who require the rapid onset of effect but are either unable or do not want to inject, or who primarily snort opioids. Early experimental data has demonstrated that intranasal DAM administration can be a viable alternative to the intravenous or intramuscular route of administration. The purpose of this study is to assess the feasibility, safety, and acceptability of intranasal HAT. Methods: This study will assess intranasal DAM using a prospective multicentre observational cohort study design in HAT clinics across Switzerland. Patients will be offered to switch from oral or injectable DAM to intranasal DAM. Participants will be followed-up over 3 years, with assessments at baseline, and after 4, 52, 104 and 156 weeks. The primary outcome measure (POM) is retention in treatment. Secondary outcomes (SOM) include prescriptions and routes of administration of other opioid agonists, illicit substance use, risk behaviour, delinquency, health and social functioning, treatment adherence, opioid craving, satisfaction, subjective effects, quality of life, physical health, and mental health. Conclusions: The results derived from this study will generate the first major body of clinical evidence on the safety, acceptability, and feasibility of intranasal HAT. If proven to be safe, feasible and acceptable, this study would increase the accessibility of intranasal OAT for individuals with OUD globally as a critical improvement in risk reduction.
Objectives: People who inject drugs (PWID) are at high risk of hepatitis C virus (HCV) infection. HCV cure is associated with improved patient reported outcomes (PROs), but there are little data among PWID. The aim of this study was to assess the change in PROs during and after HCV direct-acting antiviral (DAA) treatment. Methods: This analysis utilised data from two clinical trials of DAA treatment in PWID. PROs assessed included health-related quality life (HRQoL), social functioning, psychological distress, housing and employment. Generalised estimating equations (GEE) and group-based trajectory modelling (GBTM) were used to assess changes in PROs over time. Results: No significant changes in EQ-5D-3L scores, EQ-VAS scores, social functioning, psychological distress, and housing were observed over the 108-week study period. There was a significant increase in the proportion of participants employed (18% [95% CI, 12 - 23%] at baseline to 28% [95% CI, 19 - 36%] at the end of the study). Participants were more likely to be employed at 24 weeks and 108 weeks following commencing treatment. Having stable housing increased the odds of being employed (OR= 1.70, [95% CI, 1.00 - 2.90]. The GBTM demonstrated that most outcomes remained stable during and after DAA treatment. Conclusions: Although no significant improvement in HRQoL following HCV DAA treatment was identified, there was a modest, but significant increase in employment during study follow-up. The study findings support the need for multifaceted models of HCV care for PWID addressing a range of issues beyond HCV treatment to improve quality of life.
Background Heroin-assisted treatment (HAT) is effective for individuals with severe opioid use disorder (OUD) who do not respond sufficiently to other opioid agonist treatments. It is mostly offered with injectable diacetylmorphine (DAM) or DAM tablets creating a barrier for individuals who need the rapid onset of action but are either unable or unwilling to inject, or primarily snort opioids. To explore another route of administration, we evaluated the safety and feasibility of intranasal (IN) DAM. Methods This is a multicentre observational cohort study among patients in Swiss HAT. All patients planning to receive IN DAM within the treatment centres were eligible to participate. Participants were either completely switched to IN DAM or received IN DAM in addition to other DAM formulations or opioid agonists. Patients were followed up for four weeks. Sociodemographic characteristics, current HAT regimen, reasons for starting IN DAM, IN DAM doses, number of injection events in the sample, IN DAM continuation rate, and appearance of adverse events and nose-related problems were evaluated. Results Participants ( n = 52) reported vein damage, preference for nasal route of administration, and desire of a stronger effect or for a less harmful route of administration as primary reasons for switching to IN DAM. After four weeks, 90.4% of participants ( n = 47) still received IN DAM. Weekly average realised injection events decreased by 44.4% from the month before IN DAM initiation to the month following. No severe adverse events were reported. Conclusions After four weeks, IN DAM was a feasible and safe alternative to other routes of administration for patients with severe OUD in HAT. It addressed the needs of individuals with OUD and reduced injection behaviour. More long-term research efforts are needed to systematically assess efficacy of and patient satisfaction with IN DAM.
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27 members
Luis Falcato
  • Research
Philip Bruggmann
  • General Internal Medicine
Thilo Beck
  • Psychiatry & Psychotherapy
Claudia Bernardini
  • Infectiology
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Zürich, Switzerland