Matching of treatment-resistant heroin-dependent patients to medical prescription of heroin or oral methadone treatment: results from two randomized controlled trials. Blanken P, Hendriks VM, Koeter MWJ, van Ree JM, van den Brink W. Addiction 2005 100:89-95
This re-analysis of the Dutch heroin trials* shows that for most patient variables there was no difference in the proportion of 'responders'. The study randomised complex, 'resistant' opioid dependency cases to either standard oral methadone or medical heroin prescription, injected or nasal forms, depending on individual's usual route of administration. The factors examined included level of education, hospitalisations, psychiatric history, living arrangements, employment, cocaine use and previous abstinence based treatment. Although overall results were significantly better in the heroin groups, only one of these factors was associated with a difference in treatment outcomes when heroin was prescribed. The group reporting a history of abstinence based treatment had a defined 'response rate' in those randomised to 'medical' heroin of 61% versus 39% in the oral methadone group. This is highly significant both statistically (p=0.0003) and also from a dependency point of view. The finding appears to be corroborated since the response rate to standard methadone treatment was substantially lower in those who gave a history of having any abstinence based treatment (24 vs. 38%).
The authors speculate about this finding but no firm conclusion is reached. Workers in the field will be familiar with a group of 'failed' NA/AA subjects who often take methadone reluctantly at low doses and for short periods. Some can be our most frustrating patients, expressing guilt, depression and other negative feelings towards what they consider a poor option, despite the potential and evident benefits.
The study patients all had limited responses to traditional treatments available in Holland, including oral methadone. The mean age was 39; 80% were male and there was a high degree of psychiatric co-morbidity. Overall the 'response' rates in this trial*, were 25% for the oral methadone group and 45% for the others using the Addiction Severity Index (ASI) to 40% improvement levels.
It is depressing for outsiders (and possibly embarrassing for our British colleagues) that the UK has had thousands of patients prescribed injected heroin or methadone for decades, yet it is the Dutch who performed the first large randomised trial of this treatment. It is to the credit of the Addiction journal that it was prepared to publish this item despite its traditional avoidance of items of this nature. Maybe we will soon be reading a section on harm reduction!
In a report from Canadian Press dated 9th Feb 2005, a clinical trial has been approved by Health Canada in which 158 Vancouver addicts will be prescribed pharmaceutical-grade heroin for 12 to 15 months. A second site is being readied for the North American Opiate Medication Initiative (NAOMI) in Montreal, expected to open in April, and Toronto will be added shortly after that.
It now appears possible, or even likely, that banning heroin in the 1950s 'sent the wrong message' to young people. It certainly denied medical patients the benefits of medical heroin in most countries. Far from eliminating heroin problems, the bans have been associated with rampant spread of illicit heroin use. It may be that the bans have contributed to the problems, in part by permitting easy access for minors as well as encouraging hasty and unsupervised use of drugs of uncertain purity. America is still unravelling the mayhem associated with prohibition of alcohol. It is to be hoped that we will be more scientific and methodical in undoing the many problems associated with heroin prohibition in western countries. Although many factors are still uncertain, these trials, injecting rooms, NA and other self help groups, legal diversion, decriminalization and education are all pieces in a larger puzzle of how to reduce drug use as well as reduce the harmful consequences of such use. Australia has scored many successes regarding tobacco and alcohol. Other drugs should follow and society will be the better and more prosperous for it.
Comments by Andrew Byrne ..
Blanken P, Hendriks VM, Koeter MWJ, van Ree JM, van den Brink W. Matching of treatment-resistant heroin-dependent patients to medical prescription of heroin or oral methadone treatment: results from two randomized controlled trials. Addiction (2005) 100: 89-95
*Original report: van den Brink W, Hendriks VM, Blanken P, Koeter MWJ, van Zwieten BJ, van Ree JM. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ 2003;327 310-0