BMJ  2003;327:310 (9 August), doi:10.1136/bmj.327.7410.310

Paper

Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials

Wim van den Brink, professor1, Vincent M Hendriks, senior researcher3, Peter Blanken, researcher1, Maarten W J Koeter, assistant professor2, Barbara J van Zwieten, delegate to CPMP4, Jan M van Ree, professor5

1 Central Committee on the Treatment of Heroin Addicts (CCBH), Stratenum, Universiteitsweg 100, 3584 CG Utrecht, Netherlands, 2 Amsterdam Institute for Addiction Research, Tafelbergweg 25, 1105 BC Amsterdam, Netherlands, 3 Parnassia Addiction Research Centre, PO Box 2505 AA The Hague, Netherlands, 4 Netherlands Medicines Evaluation Board, Kalvermarkt 53, The Hague, Netherlands, 5 Rudolf Magnus Institute of Neuroscience, Utrecht University, Utrecht, Netherlands

Correspondence to: W van den Brink w.vandenbrink{at}amc.uva.nl

Objective To determine whether supervised medical prescription of heroin can successfully treat addicts who do not sufficiently benefit from methadone maintenance treatment.

Design Two open label randomised controlled trials.

Setting Methadone maintenance programmes in six cities in the Netherlands.

Participants 549 heroin addicts.

Interventions Inhalable heroin (n = 375) or injectable heroin (n = 174) prescribed over 12 months. Heroin (maximum 1000 mg per day) plus methadone (maximum 150 mg per day) compared with methadone alone (maximum 150 mg per day). Psychosocial treatment was offered throughout.

Main outcome measures Dichotomous, multidomain response index, including validated indicators of physical health, mental status, and social functioning.

Results Adherence was excellent with 12 month outcome data available for 94% of the randomised participants. With intention to treat analysis, 12 month treatment with heroin plus methadone was significantly more effective than treatment with methadone alone in the trial of inhalable heroin (response rate 49.7% v 26.9%; difference 22.8%, 95% confidence interval 11.0% to 34.6%) and in the trial of injectable heroin (55.5% v 31.2%; difference 24.3%, 9.6% to 39.0%). Discontinuation of the coprescribed heroin resulted in a rapid deterioration in 82% (94/115) of those who responded to the coprescribed heroin. The incidence of serious adverse events was similar across treatment conditions.

Conclusions Supervised coprescription of heroin is feasible, more effective, and probably as safe as methadone alone in reducing the many physical, mental, and social problems of treatment resistant heroin addicts.


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Rapid Responses:

Read all Rapid Responses

Conclusion ignores dose-response relationship
Andy Ashworth
bmj.com, 9 Aug 2003 [Full text]
A multi-faceted approach to treatment required
Iain B Craighead
bmj.com, 9 Aug 2003 [Full text]
Multisubstance Abuse
Nancy K O'Connor
bmj.com, 12 Aug 2003 [Full text]
Coprescription of heroin and methadone for treatment resistant heroin addicts
Sudhir Kumar
bmj.com, 12 Aug 2003 [Full text]
An examination rather than an experiment
Trudy Dehue
bmj.com, 13 Aug 2003 [Full text]
This article only demonstrates that the authors do not use effective methadone doses
Marc Shinderman, MD
bmj.com, 15 Aug 2003 [Full text]
Prejudice in the field of the addictions.
David H Marjot
bmj.com, 19 Aug 2003 [Full text]
Conclusions contradicted by findings
John R Caplehorn
bmj.com, 19 Aug 2003 [Full text]
Insufficient Comparison
Darius A. Rastegar
bmj.com, 19 Aug 2003 [Full text]
heroin prescribing: compared to what?
robert g newman
bmj.com, 27 Aug 2003 [Full text]
Heroin trials - an abridged history - and a Dutch addition.
Andrew Byrne
bmj.com, 7 Sep 2003 [Full text]
Not a level playing field
Laurence J Reed, et al.
bmj.com, 18 Sep 2003 [Full text]
New approaches to the management of heroin addiction
Rebecca A Grant, et al.
bmj.com, 18 Sep 2003 [Full text]
New approaches to the management of heroin addiction
Rebecca A Grant, et al.
bmj.com, 18 Sep 2003 [Full text]
Heroin Handouts are Flawed Policy
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bmj.com, 2 Oct 2003 [Full text]
Re: New approaches to the management of heroin addiction
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bmj.com, 1 Oct 2006 [Full text]
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