An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research.

This paper examines the changes and advances in research and clinical practice and examines the role of treatment structure and programme characteristics in the delivery of methadone maintenance. Methadone prescribing has become much more available over the past decade, both in countries with a history of its use, such as the United Kingdom and Australia, and in countries around the world which previously had not endorsed substitute prescribing.1 There is a need to examine closely the framework in which this treatment is delivered to ensure that the modes of delivery most effective from both cost and benefit perspectives are utilised. This review focuses entirely on methadone maintenance because this is the most extensively evaluated and most used treatment, with about a quarter of a million drug misusers receiving methadone treatment globally. A small number of experimental diamorphine and buprenorphine substitute programmes are being evaluated in several countries.

Most studies have come from the United States and focus on the long term use of methadone in a specific setting; in contrast, methadone treatment in the United Kingdom has received virtually no formal evaluation to date bar one study.2 There is concern that a considerable amount of the methadone prescribing could be having little impact on illicit drug use or risk taking behaviour,3 a recent study of drug users in police custody echoes this.4 The Advisory Council on the Misuse of Drugs has recommended a shift to a more structured approach for delivery of oral methadone maintenance.

The organisation and regulation of methadone maintenance treatment varies widely, with explicit guidelines for programme operation in the United States and Australia and a virtual absence of structure and regulation in Britain. It is likely that policy analysts and treatment providers in countries with high levels of regulation and structured programmes …

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Fortnightly Review: Methadone maintenance treatment in opiate dependence: a review

Objective: To evaluate an experimental heroin maintenance programme. Design: Randomised trial. Setting: Outpatient clinic in Geneva, Switzerland. Subjects: Heroin addicts recruited from the community who were socially marginalised and in poor health and had failed in at least two previous drug treatments. Intervention: Patients in the experimental programme (n=27) received intravenous heroin and other health and psychosocial services. Control patients (n=24) received any other conventional drug treatment (usually methadone maintenance). Main outcome measures: Self reported drug use, health status (SF-36), and social functioning. Results: 25 experimental patients completed 6 months in the programme, receiving a median of 480 mg of heroin daily. One experimental subject and 10 control subjects still used street heroin daily at follow up (difference 44%; 95% confidence interval 16% to 71%). Health status scores that improved significantly more in experimental subjects were mental health (0.58 SD; 0.07 to 1.10), role limitations due to emotional problems (0.95 SD; 0.11 to 1.79), and social functioning (0.65 SD; 0.03 to 1.26). Experimental subjects also significantly reduced their illegal income and drug expenses and committed fewer drug and property related offences. There were no benefits in terms of work, housing situation, somatic health status, and use of other drugs. Unexpectedly, only nine (38%) control subjects entered the heroin maintenance programme at follow up. Conclusions: A heroin maintenance programme is a feasible and clinically effective treatment for heroin users who fail in conventional drug treatment programmes. Even in this population, however, another attempt at methadone maintenance may be successful and help the patient to stop using injectable opioids.

https://www.bmj.com/content/bmj/317/7150/13.full.pdf

Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments

Data are presented on the 43 people who died over a 22-year follow-up period of a cohort of 128 heroin addicts drawn in 1969 from the newly opened London clinics The main causes of death were drug-related, with 18 deaths specifically determined as due to overdose, of which the great majority were among people being prescribed opiates at the time The mortality rate was a mean of 184% annually, and the excess mortality ratio was 119 This excess was highest at the beginning and varied over the period of study, appearing higher at the opening of the clinics and again in the mid-1980s No sex differences in mortality rates were demonstrated but the excess mortality was concentrated at younger ages No prediction of the 85 survivors could be made on the basis of length of heroin use prior to study intake, nor on age at intake

Death and survival in a cohort of heroin addicts from London clinics: a 22-year follow-up study

"Drug legalization" increasingly merits serious consideration as both an analytical model and a policy option for addressing the "drug problem." Criminal justice approaches to the drug problem have proven limited in their capacity to curtail drug abuse. They also have proven increasingly costly and counterproductive. Drug legalization policies that are wisely implemented can minimize the risks of legalization, dramatically reduce the costs of current policies, and directly address the problems of drug abuse.

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Drug prohibition in the United States: costs, consequences, and alternatives

• Ninety-six confirmed heroin addicts requesting a heroin maintenance prescription were randomly allocated to treatment with injectable heroin or oral methadone. Progress was monitored throughout the next 12 months by research workers operating independently of the clinic. Heroin can be seen as maintaining the status quo, with the majority continuing to inject heroin regularly and to supplement their maintenance prescription from other sources; it was associated with a continuing intermediate level of involvement with the drug subculture and criminal activity. Refusal to prescribe heroin while offering oral methadone constituted a more confrontational response and resulted in a higher abstinence rate, but also a greater dependence on illegal sources of drugs for those who continued to inject. Those offered oral methadone tended to polarize toward high or low categories of illegal drug use and involvement with the drug subculture, and were more likely to be arrested during the 12-month follow-up. There was no difference between the two groups in terms of employment, health, or consumption of nonopiate drugs. Refusal to prescribe heroin resulted in a significantly greater drop out from regular treatment.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=PSYCH&articleId=492369&pdfFileName=archpsyc_37_8_003.pdf

A. Battersby

Papers

Evaluation of Heroin Maintenance in Controlled Trial