Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Conclusion ignores dose-response relationship
- Andy Ashworth (9 August 2003)
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A multi-faceted approach to treatment required
- Iain B Craighead (9 August 2003)
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Multisubstance Abuse
- Nancy K O'Connor (12 August 2003)
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Coprescription of heroin and methadone for treatment resistant heroin addicts
- Sudhir Kumar (12 August 2003)
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An examination rather than an experiment
- Trudy Dehue (13 August 2003)
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This article only demonstrates that the authors do not use effective methadone doses
- Marc Shinderman, MD (15 August 2003)
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Prejudice in the field of the addictions.
- David H Marjot (19 August 2003)
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Conclusions contradicted by findings
- John R Caplehorn (19 August 2003)
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Insufficient Comparison
- Darius A. Rastegar (19 August 2003)
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heroin prescribing: compared to what?
- robert g newman (27 August 2003)
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Heroin trials - an abridged history - and a Dutch addition.
- Andrew Byrne (7 September 2003)
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Not a level playing field
- Laurence J Reed, Cornelis de Wet and Jennifer Bearn (18 September 2003)
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New approaches to the management of heroin addiction
- Rebecca A Grant, Dr Ken Checinski, Senior Lecturer in Addictive Behaviour, St George's Hospital Medical School, London (18 September 2003)
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New approaches to the management of heroin addiction
- Rebecca A Grant, Dr Ken Checinski, Senior Lecturer in Addictive Behaviour, St George's Hospital Medical School, London (18 September 2003)
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Heroin Handouts are Flawed Policy
- Eric A Voth, M.D, Ernst Aeschbach, M.D (2 October 2003)
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Re: New approaches to the management of heroin addiction
- jake lamatta (1 October 2006)
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Andy Ashworth, Director Tbag Ltd & GP Non-principal Bonhard House, Bo'ness, EH51 9RR
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As the treatment of opiate addiction turns into a burgeoning industry, it is noteworthy that yet another study demonstrates that biological interventions have more effect on psychosocial outcomes in opiate users than the expensive psychosocial interventions used with them. This would have been a conclusion that the data presented would have supported: it is a pity that it is mentioned only in "Discussion". Unfortunately, the conclusion claimed in the paper version of Brink et al’s report is subject to an alternative interpretation by the data provided in the longer electronic version. While it is acknowledged that the experimental groups received a slightly lower dose of Methadone, the difference appears only to have been in the order of 10mg daily. Since the experimental group took, on average 548mg of Heroin, their overall daily opiate dose was increased by at least 27mg of Methadone according to UK government guidelines (1) and probably more since the Heroin provided was of pharmacuetical quality and “sexed up” with caffeine to increase bioavailability. Thus the control groups got lower (by at least 17mg methadone equivalent) overall opiate doses than the experimental groups and had poorer outcomes. This begs the question as to whether the previous treatment failures had simply been the result of inadequate Methadone dosage. It would be a pity if, on the basis of this study which demonstrates that outcomes in opiate users are dose related, Heroin co-prescribing gains the same mythological status as psychosocial interventions whose status is now so high that the trial that could demonstrate their value would now be considered unethical by the “industry”. (1) Drug Misuse & Dependence – guidelines on clinical management UK Departments of Health HMSO 1999. Competing interests: I offer detoxification and follow up based on reduction of endogenous opiate kappa drive rather than substitution of mu agonists |
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Iain B Craighead, GP Principal Faringdon Health Centre, Volunteer Way, Faringdon, SN7 7YU
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I welcome the publication of van den Brink’s paper as there has been a lack of published data on this subject. It was disappointing to see that ‘45-88% of the participants did not respond to the co-prescription of heroin’ 1. As a GP we see daily the interaction between patients well-being and their social circumstances. Poor housing, unemployment and chronic relationship difficulties are well recognised contributors to the illness behaviour. In the treatment of heroin addicts we need to take a multi- faceted approach to their treatment. My anecdotal experience has been that those addicts who are either in employment or who are able to find employment whilst in treatment fare better than those who remain unemployed. I long to see the day when we are able to provide a community based drug treatment programme which offers the provision of housing, sheltered employment, drug therapy and psychological support together. If rehabilitation is our serious aim we need to provide a much more co- ordinated treatment programme or we will be forever disappointed with the long-term results. 1. Van den Brink W, Hendricks 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;327:310-2 Iain B Craighead GP Principal Fern Hill Medical Practice Volunteer Way Faringdon Oxon, SN7 8BB Craighead@doctors.org.uk Competing interests: None declared |
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Nancy K O'Connor, Pawhuska Indian Health Center Pawhuska OK 74056
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One is happy that 40-70 percent of Dutch heroin addicts stablize when given heroin. One does see "burn out" in addicts where they are willing to stop getting high but unwilling to go through withdrawal, and there is a need to enable these people to re enter normal society. However, one wonders about poly substance abuse in such patients, as well as sociopathic lying. I've seen too many US Methadone patients trade their pills for another drug in order to get a better high... Doctors need to distinguish between drugs that allow their patients to function,and drugs (often the same drug) used to get euphoria for the sake of euphoria. This is why many are skeptical about medical marijuana. We read of patients with self diagnosed vague syndromes who get this drug from self proclaimed "practitioners" in California who prescribe "medical marijuana" (as opposed to physicians giving medical marijuana to cancer, HIV, or patients with neurological diseases). Now, perhaps we will see a study showing that medicating alcohol pills will stablize our alcoholics. But what about "crank"? Methamphetamine is a poorly publicized epidemic in the heartland of the US... However, in the last few months I have seen numerous television commercials telling people to "ask their doctor" about treatment of their Attention deficit disorder, so any day now I expect my substance abusing patients to start insisting that their only problem is "ADD", and that this is why they "need" an open prescription for amphetamine. Competing interests: None declared |
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Sudhir Kumar, Consultant Neurologist, Department of Neurological Sciences Christian Medical College Hospital, Vellore, Tamilnadu, India- 632004
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Sir, I read with interest the recent article by Van den Brink W et al. (1) They observe a better response rate in the group with medical prescription of heroin and methadone as compared to the group that was prescribed methadone alone. However, I would like to make certain observations. Firstly, it is important to consider whether the subjects included in this study were mentally competent to give consent (for this trial). Similar concerns have been raised earlier. (2) It would be unethical to conduct a trial requiring administration of heroin to heroin-addicts with significant mental problems (likely to be present in treatment-resistant addicts). The second concern is regarding the route of administration of ‘prescription heroin’. Although authors in the current study have found no difference in the frequency of adverse effects between the injection and inhalation groups, intravenous administration of heroin under medical supervision has been noted to cause a transient decrease in systemic and cortical oxygenation, probably secondary to respiratory depression. (3) Therefore, inhalation route should be preferred as it eliminates the side effects such as infections (at the site of injection and HIV, HCV, HBV etc) in addition to the one mentioned above. The cost would also be less. Lastly, the required duration of medical prescription of heroin has not been identified in this study. However, it seems that heroin may have to be prescribed long-term for sustained benefit as the patients in heroin plus methadone group worsened to the baseline level at the end of two- month discontinuation period of heroin. In another six-year follow up study, however, the heroin-assisted treatment was found to be still effective after termination of treatment with respect to living conditions and use of illicit substances. (4) Adverse effects of long-term administration of heroin under medical supervision are unknown. In conclusion, medical coprescription of heroin seems to be a promising option in the treatment of medically resistant heroin addicts. However, there is a need for further randomised controlled trials regarding the route, dose and duration of such therapy. References 1.Van Den Brink W, Hendriks VM, Blanken P, Koeter MW, Van Zwieten BJ, Van Ree JM. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ. 2003; 327: 310. 2.Charland LC. Cynthia's dilemma: consenting to heroin prescription. Am J Bioeth. 2002; 2: 37-47. 3.Ladewig D, Dursteler-MacFarland KM, Seifritz E, Hock C, Stohler R. New aspects in the treatment of heroin dependence with special reference to neurobiological aspects. Eur Psychiatry. 2002; 17: 163-6. 4.Guttinger F, Gschwend P, Schulte B, Rehm J, Uchtenhagen A. Evaluating long-term effects of heroin-assisted treatment: the results of a 6-year follow-up. Eur Addict Res. 2003; 9: 73-9. Competing interests: None declared |
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Trudy Dehue, Professor of Theory and History of Psychology University of Groningen, The Netherlands, 9712 TS Groningen
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As mentioned in the Discussion, experiments with heroin maintenance cannot be double blind. This problem is much more serious than the authors acknowledge, particularly because there were considerable sanctions connected to the participants’ responses. The participants in the control groups knew that the promise of heroin-maintenance later on could be withdrawn if they would improve during the control period without heroin on prescription. Moreover, the participants in the experimental groups knew that they could be expelled from the experiment if they would deteriorate while receiving heroin. Finally, the participants who improved while receiving heroin were aware that they would have a fair chance of continued heroin on prescription provided that they would deteriorate in an interim period without heroin provision. Even if improvement could have been measured fully unobtrusively rather than with self-reports, this would have created serious problems. However, it is not sure that the results are positively biased because of this. It means that heroin-experiments are tests in the sense of examinations rather than scientific experiments. If much is at stake in examinations people might fail not because they lack skills but because the tests are too nerve wrecking. This may well have suppressed the results. A gulf of expensive and demanding heroin-maintenance experiments is currently coming over Europe. Even if these experiments could be conducted double blind there are quite some other reasons why experimental studies are inappropriate in cases like this (Dehue, 2002a; 2002b). Dehue T. A Dutch Treat. Randomized controlled experimentation and the case of heroin maintenance in the Netherlands. History of the Human Sciences 2002a; 15; 75-98. Dehue T. Antwoord op de brief van Minister Borst. Maandblad voor Geestelijke Volksgezondheid 2002b; 9; 806-811. Competing interests: None declared |
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Marc Shinderman, MD, Medical Director Center for Addictive Problems, Chicago, Il US, 60610
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The mean or average methadone doses cited in the article, are below 80 mg of methadone, which has been characterized in the literature as the minimum blocking dose. In our three clinics, with a current census of 2200 patients, illicit opioid abuse, and this includes newly admitted patients, is 10 percent, more or less, as determined by a monthly urine screen. The dose averages range from 130 to 160 mg among the clinics. When inadequate doses of methadone are prescribed, patients need to supplement the dose, in one way or another. In this study, inadequate dosage appears to be supplemented by prescribed heroin. It is has been demonstrated by Chin B. Eap that methadone doses resulting in (R)- methadone serum levels of 250 ng/ml are associated with heroin or other supplemental opioid abuse levels of less than 10 percent and trough levels of 400 ng/ml are highly predictive on no illcit opioid use, whatsoever. This article should not have been published without an explication of the limitations of what can be inferred from it. Better still, it should not have been published, at all Competing interests: None declared |
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David H Marjot, Counsultant Psychiatrist 16, Walton Lane, Weybridge. KT13 8NF
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Sir, I was startled then shocked by your headline on the front of the isue of 9th August, 'Heroin for treatment resistant addicts'. The headline is condensed prejudice against those who are dependent on or are addicted to heroin.It is no justification that the headline was taken directly from a paper.( Wim van den Brink et al. (2003). To label patients by their illness is stigmatising hence alcoholic, addict, neurotic, schizophrenic etc. Surely the British Medical Journal must forswear all such labels. Thses labels identify a common prejudice that the subjects of such afflictions suffer from a defect of or an unwillingness to use their will power. In addition the 'addict' is perceived as having brought the illness on themselves while other such as those who smoke or suffer from wieght gain are not so stigmatised. The is a general belief among the medical profssion including those who work in the drug field that 'addicts'are importunate, lying, drug seeking deviants. These deviants have to be controlled by regulation, over elaborate assessment care and treatment systems with draconian measures such as discharge for their inablity to manage with the inadequate treatments on offer. The tail of the fear of diversion of prescribed drugs wagging the dog of the proper treatment of heroin users is the touchstone of these prejudices against drug users. The 'gold standard' of care of heroin users with methadone is the work of Dole and Nyswander (1965,1967). The dose of methadone they usually prescribed was 80-120mg a day. Sadly because of these prejudices this dosage was reduced both in the United States, the United Kingdom and perhaps in most of the World to an effective upper limit of 80mg a day. This has lead to nearly forty years of gross under-treatment of heroin users with methadone. It is NOT that those dependent on heroin are necessarily treatment resistant but that they have been subject to ineffective and at times dreadful care. It is typical of our prejudicial attitudes that the patients is blamed. The proper title of the paper should have been 'The medical prescription of heroin to patients who have either been given inadequate doses of methadone or who have not been able to respond to adequate doses of methadone'. I applaud much this excellent study carried out by our Dutch colleagues but I am sad they appear still to be trapped by our prejudices. These prejudices create an orthodoxy , which in turn brings about heresy. A few consultant psychiatrists in the addiction field in England have long advocated the use of heroin treatment for heroin users but they were anathematised and treated as heretics. It is clear from this current study that we have been thoroughly vindicated and that there has ben a grotesque mistreatment of addicts in the UK for nearly four decades. It is a scandal that the United Kingdom has failed to carry out adequate trials of the prescrbing of heroin for those dependent on heroin. Perhaps we can now start to take a critical look at ourselves and at our treatment services.Unless we treat our patients without prejudice and with competence and compassion we deserve neither the respect of our patients nor their acceptance of our treatment services. Dole V.P. and Nyswander, M. 1965. A medical treatment for diamorphine(heroin) addiction. JAMA. 193: 646-650 Dole V.P. and Nyswander. M. 1967. Successful treatment of 750 criminal addicts. JAMA. 206: 2708-2711 Wim van den Brink et al. 2003. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ. 327: 310- 312. Competing interests: None declared |
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John R Caplehorn, Senior Lecturer, Clinical Epidemiology School of Public Health, A27 University of Sydney, Sydney, NSW, 2006, Australia
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Van den Brink et al.'s (2003) conclusion that "medical coprescription of heroin to treatment resistant heroin addicts was more effective than ... methadone alone" is not supported by their data (1). Rather, they show the Swiss-Dutch model of allowing methadone patients to use heroin in clinics is a failure. It is time to properly evaluate the "British System" of allowing patients to use heroin in places and at times of their choosing (2). The trialists report two outcomes: retention and performance on a "dichotomous, multidomain outcome index". Retention measures compliance and is a pre-condition for any maintenance treatment to have an effect. As the performance index is essentially subjective and assessors were not blinded, there was probably a significant measurement bias in favour of the heroin co-prescription group (3). Moreover, the cutoff for "improved performance" was set arbitrarily and missing data were imputed using a "black box" procedure. As data were missing for more heroin co-prescription than methadone-only subjects (21 vs. 7), this may have introduced another bias favouring the heroin group. Consequently, the performance data are best ignored, particularly as they are contradicted by the more objective outcome, retention. It is unlikely the biases in the retention data produced the observed advantage of methadone-only treatment. The lack of blinding probably favoured the heroin group because addicts would be expected to prefer being given their drug of choice. Transferring the heroin subjects to special, new clinics probably also improved their retention through a Hawthorne-like effect. However, it is also possible the transfer broke therapeutic relationships and caused some in the heroin group to leave treatment. Van den Brink et al.'s (2003) two sets of retention results can be combined in a meta-analysis using both rate ratios and risk differences as outcomes. The combined data show methadone-only subjects were 23 percent more likely to be in treatment at the end of 12 months (95% CI RR increase 11% to 37%, p=0.0001). It is necessary to give only seven methadone patients access to heroin to cause one premature loss in the first 12 months of treatment, (95% CI NNH 4.2 to 12.0, p=0.00005). The two Dutch trials show methadone patients attending a clinic an average two times a day to use heroin are significantly more likely to be lost to treatment than other methadone patients. Patients should be properly informed of this risk when being offered heroin under similar conditions. Subsequent trials should investigate the effects of providing daily supplies of heroin, particularly the harms caused by diverted heroin. References: 1. Van den Brink W, Henricks 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: 310-312. 2. Strang J, Sheridan J. Heroin prescribing in the "British System" of the mid 1990s: data from the 1995 national survey of community pharmacies in England and Wales. Drug Alcohol Rev 1997; 16: 7-16. 3. Juni P, Altman DG, Egger M. Assessing the quality of randomised controlled trials. In: Egger M, Smith GD, Altman DG, editors. Systematic reviews in health care: meta-analysis in context. London: BMJ Books; 2001. p. 87-108. Competing interests: None declared |
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Darius A. Rastegar, Assistant Professor of Medicine Division of Chemical Dependence, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224 USA
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The authors provide some evidence supporting the feasibility and effectiveness of providing heroin to addicts who continue to use while on methadone maintenance. However, their study is limited by the moderate dose of methadone used (mean dose of 67-71 mg per day). Previous research shows that opioid dependent individuals do better at higher doses of methadone (80-100 mg per day) (1). It is quite possible that the subjects in this study would have done just as well (or better) on higher doses of methadone. (1) Strain EC, Bigelow GE, Liebson IA, Stitzer ML. Moderate- vs high- dose methadone in the treatment of opioid dependence: a randomized trial. JAMA 1999;281:1000-5. Competing interests: None declared |
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robert g newman, director, Baron Edmond de Rothschild Chem Dep Inst NYC 555 W 57th St ny ny usa 10028
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This protocol compares an experimental condition (heroin plus methadone) to a "control" (methadone alone) that was judged a failure. What's surprising is not that 25% who got heroin did better, but that 10% of those who received the same treatment with methadone alone (deemed by the authors to be therapeutically ineffective) did better! Moreover, the authors' statement that a "substantial number [of methadone patients]do not experience any benefit" may (or may not) be true, but the subjects of this trial do not meet this description. After all, they continued to seek and accept methadone treatment on a voluntary basis, which seems to demonstrate that they perceived benefits, even if the authors did not. Patients, like all consumers, vote with their feet. Competing interests: None declared |
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Andrew Byrne, Dependency Physician 75 Redfern St, Redfern, NSW, Australia, 2016
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Dear Colleagues, It is fascinating to track the history of heroin prescription over the past 25 years (see references below). We first find an English report in an American journal. Next, almost 20 years later came another English description in an Australian journal. After that the major Swiss trials were reported in Anglo-American journals while this latest Dutch trial is in the British Medical Journal. It is indeed a global problem. Most of these trials took treatment resistant heroin addicts and permitted pharmaceutical heroin to be injected with supervision under trial conditions. Some used comparisons with methadone but one used a six month delay as a ‘chronological control’ group. Patients were permitted realistically high doses of heroin, consistent with their pre-treatment street use, up to one gram daily. There were small trials of 30 to 50 patients such as Perneger and Hartnoll, while the main Swiss trial enrolled 1146 subjects. There was a practice of prescribing morphine and heroin to addicted patients in the US, England and probably Australia prior to the 1940s but records have been lost and details are mired in history and even mythology. The Swedish prescribing of stimulants in the 1960s was similar in some ways. There appeared to be no prominence of adverse reports from coroners or others at the time but little else can be gleaned from a scientific stand point. There were reports of rapid opiate detoxification (bromides) under sedation from Hong Kong in the British Medical Journal of 1899 and at least one death was reported from that era. The report by van der Brink and colleagues in this week’s British Medical Journal describes 550 methadone patients who were still using illicit heroin in 6 Dutch cities. They were randomised either to remain in methadone treatment or to receive heroin (injectable if they usually injected, inhaled powder if they normally inhaled - making two separate trials). Despite being allowed up to a gram per day in three divided doses, patients chose to take only half that in an average of 2 daily supervised doses. The mean methadone dose was around 70mg daily, with a maximum permitted of 150mg. Although higher than average doses in some areas, this was probably still inadequate, just as occurs with methadone patients in every country. Follow-up rates were as high as 95%. Outcomes of numerous aspects of social, mental and physical integration were examined by independent researchers using a modified Addiction Severity Index (ASI). Improvements were marked in both groups but almost twice as much in the groups permitted heroin as well as methadone (~45% vs. ~25% ‘response’ rate = 40% improvement in ASI). The differences were significant. The rather unfortunate end to the trial was a compulsory 2 months without prescribed heroin, during which the good progress was reversed. Those decrying a heroin trial in Australia are just delaying the inevitable while the consequences of unchecked drug use cause untold damage to the security and prosperity of our community. There has been no report of increased drug addiction or other adverse sequillae of drug use in regions where heroin has been prescribed. Also, in the largest and longest controlled trial in Switzerland, only a small expansion has occurred, disproving any ‘floodgates‘ effect. Politicians should note that a referendum on such policies was resoundingly successful, especially in the older age groups. Comments by Andrew Byrne .. (refs below) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Hartnoll RL, Mitchelson MC, Battersby A, Brown G, Ellis M, Fleming P, Hedley N. Evaluation of Heroin Maintenance in Controlled Trial. Arch Gen Psychiatry 1980 37:877-84. Metrebian N, Shanahan W, Wells B, Stimson GV. Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users: associated health gains and harm reductions. 1998 Med J Aust 168:596-600 Perneger TV, Giner F, del Rio M, Mino A. Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments. BMJ 1998;317:13-18 Ali R, Auriacombe M, Casas M, Cottler L, Farrel M, Kleiber D, et al. Report of the external panel on the evaluation of the swiss scientific studies of medically prescribed narcotics to drug addicts. Sucht 1999;45: 160-70 Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A, Uchtenhagen A. Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet 2001;358: 1417-20 Haemmig RB, Tschacher W. Effects of high-dose heroin versus morphine in intravenous drug users: a randomised double-blind crossover study. J Psychoactive Drugs 2001 Apr-Jun;33(2):105-10 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 MacLeod, N. Cure of morphine, chloral, and cocaine habits by sodium bromide. BMJ (1899) 15/4/1899 p896 Competing interests: None declared |
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Laurence J Reed, Specialist Registrar Bethlem Royal Hospital, South London & Maudsley NHS Trust, Monks Orchard, Beckenham, Kent, BR3 3BX, Cornelis de Wet and Jennifer Bearn
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The study of medical prescription of heroin by van den Brink et al., (1) should be interpreted with caution. Firstly, selection of opiate dependent patients with at least 4 weeks of continuous treatment in the past 5 years does not define methadone treatment resistance, rather early treatment intervention. This may explain the substantial treatment response to longer-term methadone in the control group where the only intervention is randomization into a controlled trial. Secondly it is crucial in such a study to take methadone and heroin dosage levels into account when evaluating clinical outcome; adequate doses of opiate replacement are critical to treatment success (2). Actual doses are only reported in the electronic version of the paper and show that dose of combined heroin/methadone in the heroin treatment groups are about 20% higher in terms of methadone equivalents compared to the control methadone -only treatment group. Furthermore, this latter group received a mean methadone dose of about 75mg/day, which may be sub-optimal. The discrepancy in methadone dosage equivalents between the two groups may account for the apparently favourable effects of additional heroin. Lastly, the deterioration after discontinuing heroin at the end of the study may simply reflect a transition from adequate to inadequate amounts of prescribed opiate-replacement therapy. Heroin treatment needs robust evaluation as it is an intensive and expensive compared other opiate-replacement therapies, including methadone and buprenorphine (3). Clinical studies comparing heroin with other opiate -replacement therapies need to be conducted on a level playing field. 1.Wim van den Brink, Vincent M Hendriks, Peter Blanken, Maarten W J Koeter, Barbara J van Zwieten, Jan M van Ree. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ 2003;327:310 (9 August) 2. Dole V.P. and Nyswander. M. 1967. Successful treatment of 750 criminal addicts. JAMA. 206: 2708-2711 3. Ferri M, Davoli M, Perucci CA. Heroin maintenance for chronic heroin dependents (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software. CD003410 Competing interests: None declared |
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Rebecca A Grant, Pre-Registration House Officer St George's Hospital, Blackshaw Road, Tooting, London SW17 0QT, Dr Ken Checinski, Senior Lecturer in Addictive Behaviour, St George's Hospital Medical School, London
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The recent randomised control study carried out in the Netherlands compared the use of the co-prescription of heroin and methadone to that of methadone alone. It found that co-prescription was significantly more effective in reducing problems, physically, socially and mentally in treatment resistant groups (van den Brink et al, 2003). This supported a previous study by Perneger et al, which also recommended the use of heroin maintenance in those resistant to the use of methadone (Perneger et al, 1998). There is international variation in new developments in the management of heroin addiction, which are focused on different target populations. In Europe the emphasis has been on finding options for those who do not respond well in current management programmes by looking at alternatives to oral methadone. Currently there is an increased interest on prescribing heroin, either injected or inhaled. This would inevitably halt their contact with drug dealers and reduce the financial burden that can lead to crime. Recently in Australia, new approaches have been focused on the development of medicallly supervised injecting centres in high prevalence areas. This attracts injecting drug users that are coming in to contact with services for the first time. It aims to provide a safe and non-judgmental environment that may encourage them to seek further help with their problem. Within the UK the National Treatment Agency have recently issued guidelines on the potential role of both injectable heroin and injectable methadone in patients that are resistant to oral methadone programmes (National Treatment Agency, 2003). It emphasises that this method is not to be used as a firstline treatment but is to be used as alternative to continuing oral methadone when this treatment approach has failed. If these guidelines are to be implemented successfully the nation-wide shortage of doctors holding a Home Office licence for such prescription of injectable heroin will have to be addressed (currently it stands at 94), as well as being distributed more evenly across the country. It is also accepted that this type of approach, especially considering the target population, is a long-term therapy, with a main objective of removing these people from the financial and legal implications of illegal drug use, as well as reducing some of the physical risks. Another key issue made explicit in the NTA guidance is the need for optimal oral methadone treatment to have been offered. It is difficult to see such optimal programmes being offered in many areas, but their development will be applauded. In Australia, heroin is not available via prescription, even for clinical use, making it's use in clinical trials more difficult. This has meant the need to approach the problem from a slightly different angle if they are to continue to develop new ways of managing heroin addiction. Last year they opened their first medically supervised injecting centre, located at 66 Darlinghurst Road, King's Cross, Sydney, an area with a high prevalence of heroin addiction and of IV drug users living on the streets. They have recently completed an 18 month trial at this centre (MSIC Evaluation Committee, 2003), one of the largest completed trials world- wide. It's success is prompting further centres to be opened in other states within Australia (Burton, 2003). The emphasis is on harm reduction with the use of clean needles and a safe environment for injecting, reducing outcomes such as HIV prevalence and overdose morbidity and mortality. It also allows these people to come into contact with other services that may later encourage them to move on into programmes such as oral methadone. Although coming from a slightly different angle, both approaches have the aim of reducing risky behaviour in those heroin addicts that currently choose not to take part in or who consistently fail in methadone treatment programmes. The advantage of this is that alternative methods can by tried and tested in quite similar populations and cultures. When these are successful, it provides a good evidence basis for putting new methods into practice elsewhere, with the end result being a greater international coherence in the management of heroin addiction and the reduction of associated harm world-wide. References: van den Brink W, Hendriks VM, Blanken P, Koeter MWJ, van Zwieten BJ, van Ree JM. (2003) Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. British Medical Journal. 2003; 327: 310-2 Burton, B. Supervised drug injecting room trial considered a success. British Medical Journal. 2003;327:122 (19 July) MSIC Evaluation Committee. Final report of the evaluation of the Sydney Medical Injecting Centre. July 2003 [Online]. Available at http://druginfo.nsw.gov.au/druginfo/reports/msic.pdf (accessed 11 September 2003) National Treatment Agency for Substance Misuse. Injectable heroin (and injectable methadone). Potential roles in drug treatment. Full guidance report. May 2003 Perneger TV, Giner F, del Rio M, Mino A. Randomised trial of heroin maintenance programme who fail in conventional drug treatments. British Medical Journal. 1998; 317: 13-18 Dr Rebecca Grant, Pre-Registration House Officer, St George's Hospital, London Dr Ken Checinski, Senior Lecturer in Addictive Behaviour, St George's Hospital Medical School, London Competing interests: None declared |
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Rebecca A Grant, Pre-Registration House Officer to Dr Hastie, St George's Hospital St George's Hospital, Blackshaw Road, Tooting, London SW17 0QT, Dr Ken Checinski, Senior Lecturer in Addictive Behaviour, St George's Hospital Medical School, London
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The recent randomised control study carried out in the Netherlands compared the use of the co-prescription of heroin and methadone to that of methadone alone. It found that co-prescription was significantly more effective in reducing problems, physically, socially and mentally in treatment resistant groups (van den Brink et al, 2003). This supported a previous study by Perneger et al, which also recommended the use of heroin maintenance in those resistant to the use of methadone (Perneger et al, 1998). There is international variation in new developments in the management of heroin addiction, which are focused on different target populations. In Europe the emphasis has been on finding options for those who do not respond well in current management programmes by looking at alternatives to oral methadone. Currently there is an increased interest on prescribing heroin, either injected or inhaled. This would inevitably halt their contact with drug dealers and reduce the financial burden that can lead to crime. Recently in Australia, new approaches have been focused on the development of medicallly supervised injecting centres in high prevalence areas. This attracts injecting drug users that are coming in to contact with services for the first time. It aims to provide a safe and non-judgmental environment that may encourage them to seek further help with their problem. Within the UK the National Treatment Agency have recently issued guidelines on the potential role of both injectable heroin and injectable methadone in patients that are resistant to oral methadone programmes (National Treatment Agency, 2003). It emphasises that this method is not to be used as a firstline treatment but is to be used as alternative to continuing oral methadone when this treatment approach has failed. If these guidelines are to be implemented successfully the nation-wide shortage of doctors holding a Home Office licence for such prescription of injectable heroin will have to be addressed (currently it stands at 94), as well as being distributed more evenly across the country. It is also accepted that this type of approach, especially considering the target population, is a long-term therapy, with a main objective of removing these people from the financial and legal implications of illegal drug use, as well as reducing some of the physical risks. Another key issue made explicit in the NTA guidance is the need for optimal oral methadone treatment to have been offered. It is difficult to see such optimal programmes being offered in many areas, but their development will be applauded. In Australia, heroin is not available via prescription, even for clinical use, making it's use in clinical trials more difficult. This has meant the need to approach the problem from a slightly different angle if they are to continue to develop new ways of managing heroin addiction. Last year they opened their first medically supervised injecting centre, located at 66 Darlinghurst Road, King's Cross, Sydney, an area with a high prevalence of heroin addiction and of IV drug users living on the streets. They have recently completed an 18 month trial at this centre (MSIC Evaluation Committee, 2003), one of the largest completed trials world- wide. It's success is prompting further centres to be opened in other states within Australia (Burton, 2003). The emphasis is on harm reduction with the use of clean needles and a safe environment for injecting, reducing outcomes such as HIV prevalence and overdose morbidity and mortality. It also allows these people to come into contact with other services that may later encourage them to move on into programmes such as oral methadone. Although coming from a slightly different angle, both approaches have the aim of reducing risky behaviour in those heroin addicts that currently choose not to take part in or who consistently fail in methadone treatment programmes. The advantage of this is that alternative methods can by tried and tested in quite similar populations and cultures. When these are successful, it provides a good evidence basis for putting new methods into practice elsewhere, with the end result being a greater international coherence in the management of heroin addiction and the reduction of associated harm world-wide. References: van den Brink W, Hendriks VM, Blanken P, Koeter MWJ, van Zwieten BJ, van Ree JM. (2003) Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. British Medical Journal. 2003; 327: 310-2 Burton, B. Supervised drug injecting room trial considered a success. British Medical Journal. 2003;327:122 (19 July) MSIC Evaluation Committee. Final report of the evaluation of the Sydney Medical Injecting Centre. July 2003 [Online]. Available at http://druginfo.nsw.gov.au/druginfo/reports/msic.pdf (accessed 11 September 2003) National Treatment Agency for Substance Misuse. Injectable heroin (and injectable methadone). Potential roles in drug treatment. Full guidance report. May 2003 Perneger TV, Giner F, del Rio M, Mino A. Randomised trial of heroin maintenance programme who fail in conventional drug treatments. British Medical Journal. 1998; 317: 13-18 Dr Rebecca Grant, Pre-Registration House Officer, St George's Hospital, London Dr Ken Checinski, Senior Lecturer in Addictive Behaviour, St George's Hospital Medical School, London Competing interests: None declared |
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Eric A Voth, M.D, Chairman, The Institute on Global Drug Policy 600 First Ave Suite 302, St Petersburg FL,, 33701, Ernst Aeschbach, M.D
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To the editors: We wish to question the conclusions of van den Brink et. al. (1) who suggest that the use of heroin is comparable or perhaps better than methadone for resistant addicts. Their measures of efficacy should raise serious questions to the validity of the study. Deterioration of up to 40% in performance measures, or increases of cocaine or amphetamine of up to 20% were deemed successes as long as at least one of three measures improved by at least 40%. To consider deterioration of performance measures of up to 40% as acceptable smacks of manipulating measures of success to fit the data. A 40% deterioration is staggering and should be considered a clear failure. Finally, even the authors concede that 45-88% of the participants did not respond to the heroin handout, yet they consider it a success. We are furthermore not presented with the hard data of actual HIV or hepatitis conversion rates during the heroin handout. We are not given actual criminality or breadth of illegal drugs used. Fundamentally, the medical world needs to understand that heroin handouts are simply keeping addicts addicted. As seen in Switzerland (2), heroin handouts simply further the addiction and enslavement of suffering addicts. Creative approaches such as those employed in Sweden should be examined and implemented to press users more rigorously toward abstinence. Sincerely Eric A. Voth, M.D., FACP
Ernst Aeschbach, M.D.
1. 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: randomised controlled trials. BMJ 2003;327:310-312 2. Satel SL, Aeschbach E, The Swiss Heroin Trials: Scientifically Sound? Journal of Substance Abuse Treatment. 1999;17:331-335. Competing interests: None declared |
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jake lamatta, self employed 78758
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addict would like the resopnd. on 190mg a day methadone, i feel totally helpless. Competing interests: None declared |
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