Opioid dependency is a chronic relapsing disease, with danger of overdose when the tolerance is lost. What is optimal handling in a mess of confusing factors? I have found clues to this from the annual reports on drug issues of the European Union (EU) with its 28 member countries – from their drug addiction agency (EMCDDA), based in Lisbon, Portugal. Norway has a costly opioid substitution treatment (OST) program with very high drug related death (DRD) rate, and due to my personal experience as a general practitioner (GP), I have been curious to find out why this is the case. I have elaborated EU statistics on DRD, in order to compare trends, related to populations and the type of OST in 20 out of 28 EU countries. I have included non-member Norway, which also reports drug statistics to EU. After 1990 with the HIV-epidemic, heroin substitution with a safe opioid drug was mobilized to combat injecting practice and criminality. The traditional methadone (MDN) became challenged by buprenorphine (BPN), first in France from 1996; 10 years later the BPN alternative with naloxone (BPN-X) became a supplement in Europe. All types of different methods were evolved, each country sticking only to one. OST differ mainly in two aspects:

1) The treatment started by a general practitioner (GP) or a “special unit” (SU)
2) Buprenorphine (BPN) or methadone (MDN) as the medication of choice

The EU has for many years only warned against detoxification as an alternative to OST because of the much increased DRD [1]. I have gone further and will argue for this:

GP can independently start to prescribe BPN and tranquilizers (benzodiazepines (BZD)), while the more dangerous MDN is started by SU, like in France/Portugal. The Portuguese decriminalization of user doses also seems optimal.

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