BOCA RATON, FLA. – Supervised access to heroin improved the physical and mental well-being of chronic heroin addicts who were refractory to methadone maintenance treatment in Dutch and Candian studies.
In the Dutch studies, heroin-assisted treatment consisting of inhalable or injectable heroin prescribed over a 12-month period along with methadone was significantly more effective in improving physical health, mental status, and social functioning than was treatment with methadone alone, Dr. Wim van den Brink said at the annual meeting of the American Academy of Addiction Psychiatry.
These parameters improved in 50% of patients who got heroin plus methadone, compared with 27% of patients who got methadone maintenance alone in the inhalable study group, and in 56% of patients who got heroin plus methadone, compared with 31% of patients who got methadone maintenance alone in the injectable study group, said Dr. van den Brink, professor of psychiatry at the University of Amsterdam.
To be included, patients had to be chronic treatment-resistant heroin addicts. Their mean age was 39 years and 80% were male. They had been addicted to heroin for at least 16 years and had been using heroin 26 days of the last 30 days before entering the study. They had also been on methadone maintenance treatment for at least 12 years and had been using it 29 days out of the last 30 days before entry into the study. Ninety-two percent also were cocaine addicts and had used cocaine within 18 days of study entry. Of the total, 60% had physical problems, 60% had psychiatric problems, and 72% had social problems.
Patients randomized to heroin-assisted treatment with inhalable heroin (375 patients) or intravenous heroin (174 patients) could visit one of six clinics in Amsterdam three times a day, 7 days a week, and receive up to 1,000 mg/day of heroin plus 150 mg of oral methadone. Those in the methadone-only group received 150 mg of oral methadone daily.
Patients were deemed responders if they experienced a 40% or greater improvement in their physical health, mental status, or social functioning. In addition, rates of illegal activity, contact with other illicit drug users, and cocaine use declined, Dr. van den Brink reported.
At 12 months, the study finished, and about 82% of responders deteriorated again. “They had improved their physical health during [the study], but within 2 months [of it finishing] they were back to where they started. So 12 months of heroin treatment is not enough.”
A study in Canada showed similar results with prescribed heroin in addicts refractory to methadone treatment.
In the North American Opiate Medication Initiative study, heroin-assisted treatment plus methadone maintenance produced marked improvements in the subjects' health and reduced illegal activity, leading the investigators to conclude that heroin-assisted treatment is effective in North America as well as Europe.
However, whether such a strategy would work in the United States is questionable right now, he said. “Supervised heroin-assisted treatment is potentially applicable in the [United States], but an important requirement is full acceptance of the harm reduction concept. Without such acceptance, it is difficult to imagine that you could do something like this. We do not arrest people for taking drugs in the Netherlands, but in the U.S. there is a very high rate of prosecution–which is also very expensive,” he said.
The key thing is to begin to think about heroin addiction as a chronic, relapsing disease, Dr. van den Brink said. “There is no one treatment for all patients. Methadone and buprenorphine are very effective treatments, but there are patients who do not respond, so we have to think about additional options. This is how we see heroin-assisted treatment–as a last treatment option for those who've tried everything and didn't succeed.”
Dr. van den Brink disclosed relationships with several pharmaceutical companies, including Eli Lilly & Co., Merck Serono International, Alkermes Inc., H. Lundbeck A/S, Organon/Schering-Plough, and Solvay.