Heroin-Assisted Treatment

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Page last updated June 9, 2020 by Doug McVay, Editor/Senior Policy Analyst.

1. Efficacy of Heroin-Assisted Treatment

"Over the past 15 years, six RCTs [Randomized Controlled Trials] have been conducted involving more than 1,500 patients, and they provide strong evidence, both individually and collectively, in support of the efficacy of treatment with fully supervised self-administered injectable heroin, when compared with oral MMT, for long-term refractory heroin-dependent individuals. These have been conducted in six countries: Switzerland (Perneger et al., 1998); the Netherlands (van den Brink et al., 2003); Spain (March et al., 2006); Germany (Haasen et al., 2007), Canada (Oviedo-Joekes et al., 2009) and England (Strang et al., 2010).

"Across the trials, major reductions in the continued use of ‘street’ heroin occurred in those receiving SIH [Supervised Injectable Heroin] compared with control groups (most often receiving active MMT). These reductions occasionally included complete cessation of ‘street’ heroin use, although more frequently there was continued but reduced irregular use of ‘street’ heroin, at least through the trial period (ranging from 6 to 12 months). Reductions also occurred, but to a lesser extent, with the use of a range of other drugs, such as cocaine and alcohol. However, the difference between reductions in the SIH group and the various control groups was not as great (compared with major reductions in the use of ‘street’ heroin)."

European Monitoring Centre for Drugs and Drug Addiction, "EMCDDA INSIGHTS No. 11: New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond" (Luxembourg: Publications Office of the European Union, April 2012), doi: 10.2810/50141, p. 11.

2. Prescription Heroin and Heroin Maintenance

"Heroin prescription is a form of medical care that involves strictly regulated and controlled prescription of heroin. Offered on its own or as a complement to treatment programs, it is often targeted for use by people for whom opioid substitution treatment and other programs have not succeeded."

"Findings show such programs are feasible and are associated with a number of positive outcomes,12 including:

"Health benefits:
• helping people to stop or reduce their illegal drug use;13
• avoiding illness and death as a result of overdose by ensuring access to a drug of known quality and strength;14
• retention in medical care;15
• facilitating a gradual change from heroin to opioid substitution therapy;16
• reducing the risk of HIV and hepatitis resulting from unsafe injection practices;17 and
• promoting general health and well-being.18

"Social benefits:
• reducing crime related to the acquisition of drugs;19
• reducing the number or visibility of drug markets and public drug use;
• lowering costs associated with health care, social welfare, criminal justice and prisons;20 and
• promoting social integration, including with respect to employment, accommodation and family life.21"

Canadian HIV/AIDS Legal Network, "Legislating on Health and Human Rights: Model Law on Drug Use and HIV/AIDS Module 8: Heroin prescription programs," (Toronto, Ontario: 2006), pp. 7-8.

3. Effectiveness of Heroin-Assisted Treatment

"Heroin prescription represents a contentious approach to treatment. Many would question whether giving users the drug that they are addicted to constitutes 'treatment' in the normal sense of the word. As with any form of substitution therapy, there is also the question of whether users can be moved on from their drug use – perhaps the fact that users are being prescribed their drug of choice (rather than a frequently unpopular alternative) may mean that users will find it even more difficult to move on to abstinence. There is insufficient evidence to answer this latter concern. However, what the evidence base does indicate is that, in the short term, heroin prescription appears to be an effective way to retain users in treatment who have a history of failing in other treatment settings, with consequent benefits in terms of reduced drug use, crime and social reintegration."

Lloyd, Charlie and McKeganey, Neil, "Drugs Research: An overview of evidence and questions for policy," Joseph Rowntree Foundation (London, United Kingdom: June 2010), p. 50.

4. Medication-Based Treatment for Opioid Dependence

"Medication-based treatment for opioid dependence consists of 2 distinct approaches: detoxification and maintenance.4 Detoxification involves the use of medications to bring a patient from an opioid-dependent to an opioid-free state. The medications used are designed to decrease withdrawal-related discomfort and complications. Maintenance therapy involves the substitution of an abused opioid such as heroin or narcotic analgesics, which are often used intravenously or intranasally several times a day, by a medically prescribed opioid such as methadone or buprenorphine that can be taken orally and administered once a day in combination with counseling."

O'Connor, Patrick G., "Methods of Detoxification and Their Role in Treating Patients With Opioid Dependence," Journal of the American Medical Association (Chicago, IL: American Medical Association, August 24, 2005), Vol. 294, No. 8, p. 961.

5. Effectiveness of Heroin-Assisted Treatment Compared With Methadone Maintenance

"Our results on the cost-effectiveness of diacetylmorphine are consistent with those of an economic analysis based on data from two Dutch heroin-assisted treatment trials,21 despite differences in the design of the Dutch trials and the North American Opiate Medication Initiative, and the time horizon and analytic design of the economic analyses.

"The Dutch trials compared methadone maintenance treatment with a combination of methadone and diacetylmorphine (prescribed concurrently), which changed the profiles of health utility and health resource use. Furthermore, participants in the Dutch trials were recruited from methadone maintenance programs, whereas participants in the North American Opiate Medication Initiative had to have been out of treatment for at least six months before trial entry. We considered a range of time horizons, using external parameters where necessary to extrapolate results to longer time horizons. The other economic analysis used trial data exclusively and focused only on a 12-month study period. The consistency in results between our analysis and the analysis of the Dutch trials appears to be due primarily to the advantages diacetylmorphine provides in retaining individuals in treatment.

"We believe a lifetime horizon is the most appropriate period for evaluating treatments of chronic, recurrent diseases such as opioid dependence, because treatment is available indefinitely in practice and will have a long-term impact. The key outcomes, such as progressing to a drug-free state or death, would likely not be realized within the 12-month period of the North American Opiate Medication Initiative."

Bohdan Nosyk PhD., et al., "Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid dependence refractory to treatment," Canadian Medical Association Journal, April 3, 2012, 184(6):E317-E328.