Heroin maintenance treatment for chronic heroin-dependent individuals: A Cochrane systematic review of effectiveness

Abstract

The provision of prescribed heroin to chronic heroin-dependent individuals failing other treatments has been supported during the last 70 years on the ground that the first goal of interventions on drug users is to keep them in treatment to protect them from criminal activities and to promote social integration. To assess heroin prescription effectiveness, we conducted a Cochrane systematic review of all relevant randomized controlled trials. We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Library and contacted leading researchers for ongoing studies. We found 19 eligible studies, of which 4 met our inclusion criteria (577 patients). In 1 study, patients in the heroin arm remained in treatment longer than those in the methadone arm ( n = 96, RR = 2.82, 95% CI = 1.70–4.68); in 2 studies, there was no difference; and in 1 study, patients given heroin left the study earlier than those given methadone ( n = 235, RR = 0.79, 95% CI = 0.68–0.90). Heroin was more effective than methadone in refraining people from using street heroin in 2 studies ( n = 96, RR = 1.10, 95% CI = 0.79–1.53; n = 51, RR = 0.33, 95% CI = 0.15–0.72). In 1 study, heroin reduced the risk of being charged (RR = 0.32, 95% CI = 0.14–0.78); 2 studies showed no difference, and another 2 studies adopted a multidomain outcome enclosing criminal offense and social functioning and found improvements with heroin + methadone over methadone only. It is unclear if heroin attracts people in treatment; those in treatment use less street heroin and are likely to have less criminal activities. This review systematizes and compares studies showing some inconsistencies between their aims, their adopted outcomes, and their conclusions drawn from results.