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
Competing interests:
No competing interests
18 September 2003
Laurence J Reed
Specialist Registrar
Cornelis de Wet and Jennifer Bearn
Bethlem Royal Hospital, South London & Maudsley NHS Trust, Monks Orchard, Beckenham, Kent, BR3 3BX
Rapid Response:
Not a level playing field
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
Competing interests: No competing interests