Diamorphine Treatment Research Articles

Soziale Integration nach 4 Jahren Diamorphinbehandlung

Studies from several countries have by now shown the effectiveness of heroin-assisted treatment in comparison to methadone treatment. However, only few long-term results exist, and in particular data with a focus on social integration of the patients are scarce. The study analyzes the course of long-term social integration among the patients of the German diamorphine study. Individual changes in health, drug use and social integration among patients who had participated in a 4-year diamorphine treatment (n=156) were described and statistically tested by means of repeated measures analyses. The criteria used are based on the instruments OTI-HSS and SCL-90-R, on medical findings, urinalyses, and on variables as well as composite scores from the European Addiction Severity Index. In all domains significant improvements were found after long-term treatment. The percentage of patients employed or currently working had increased 3-fold up to 40% after 4 years. Moreover, the living situation and leisure behaviour improved, and criminal activities declined markedly. The main influencing factor for successful social integration after 4 years of treatment is the ability to work. Heroin-assisted treatment is a long-term effective treatment for severely dependent opiate addicts with respect to stabilization of health, reduction of illegal drug use and improvement of social integration. Furthermore, the results show that processes of social (re-)integration of drug users take time.

Switching From Methadone to Diamorphine—2-Year Results of the German Heroin-Assisted Treatment Trial

Background: Several international clinical studies have found diamorphine treatment for opioid-dependent patients to show significantly better effects compared with methadone maintenance treatment. Aims: This analysis of the German trial of heroin-assisted treatment investigates the effects on patients’ health and drug use after switching from 12-month methadone to 12-month diamorphine treatment under similar study conditions. Methods: For a period of 24 months, the state of health was explored using the Opiate Treatment Index (OTI) health scale and the Symptom Checklist-90-R (SCL-90-R), while drug use and social situation by an extended version of the European Addiction Severity Index (EuropASI) every 6 months. Changes in these criteria were tested for significance by repeated measures analyses. Of the 434 patients, who started the 2nd year of study treatment, 90 were methadone–diamorphine switchers, and 344 received diamorphine for 2 years. Results: In the 2nd year, the methadone–diamorphine switchers succeed in catching up with the diamorphine patients. After switching to diamorphine, significant improvements in health and use of street heroin and cocaine were achieved during 1 year of diamorphine treatment. Conclusions: The results of the course of methadone–diamorphine switchers are a methodologically independent contribution toward confirming the positive effects of diamorphine treatment for difficult-to-treat opioid-dependent patients. This study supports the hypothesis that changing from optimized methadone treatment under the conditions of the clinical trial to diamorphine treatment is associated with improvements in health and drug use behavior. The study's limitations are noted.

Is Heroin-Assisted Treatment Effective for Patients with No Previous Maintenance Treatment? Results from a German Randomised Controlled Trial

Background/Aims: Until now, the medical prescription of diamorphine (heroin) has been suggested as suitable for patients who have failed previous maintenance treatments. The aim of this paper is to assess the effects of diamorphine on opioid-dependent patients with no previous maintenance treatment experience (NPME). Methods: The German heroin trial compared diamorphine versus methadone maintenance treatment and included 107 patients with NPME. This paper is a sub-analysis of these patients. Results: When comparing this subsample with the rest of the participants in the study, large baseline differences were found, showing a more severe drug use profile in patients with NPME. However, no differences were found in terms of treatment outcome and treatment retention. In the subsample with NPME, outcome measures on the reduction of illicit drug use were significantly better under diamorphine compared to methadone treatment, while there was no difference in health outcomes. Conclusion: Controlled studies are now necessary to examine whether diamorphine treatment could be considered as one of several options in treating severely opioid-dependent patients, regardless of previous maintenance treatment experience.

Long‐term effects of heroin‐assisted treatment in Germany

Trials in Switzerland, the Netherlands and Spain have found that heroin-assisted treatment (HAT) as maintenance treatment for opioid-dependent patients reduces illicit drug use. A German trial also found diamorphine treatment to be superior to methadone treatment. The present study describes the association between 2 years of heroin treatment and improvements in health and social stabilization, as well as illicit drug use. A prospective cohort study design. A total of 515 patients were assigned to diamorphine treatment; 278 patients remained in the study treatment for the entire period of 24 months (54.8%). The results on physical (Opiate Treatment Index Health Symptoms Scale) and mental (Symptom Checklist 90-Revised Global Severity Index) health and illicit drug use (number of days with drug use within the last month-European Addiction Severity Index) were examined by repeated-measures analyses. Symptoms of physical (Pillai's trace = 0.837, df = 4, P < 0.001) and mental health (Pillai's trace = 0.450, df = 4, P < 0.001) improved during treatment. Street heroin use declined rapidly (Pillai's trace = 0.836, df = 4, P < 0.001), as did cocaine use (Pillai's trace = 0.280, df = 4, P < 0.001). HAT is associated with improvements in mental and physical health in the long term.

Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): evaluating injectable methadone and injectable heroin treatment versus optimised oral methadone treatment in the UK

Whilst unsupervised injectable methadone and diamorphine treatment has been part of the British treatment system for decades, the numbers receiving injectable opioid treatment (IOT) has been steadily diminishing in recent years. In contrast, there has been a recent expansion of supervised injectable diamorphine programs under trial conditions in a number of European and North American cities, although the evidence regarding the safety, efficacy and cost effectiveness of this treatment approach remains equivocal. Recent British clinical guidance indicates that IOT should be a second-line treatment for those patients in high-quality oral methadone treatment who continue to regularly inject heroin, and that treatment be initiated in newly-developed supervised injecting clinics.The Randomised Injectable Opioid Treatment Trial (RIOTT) is a multisite, prospective open-label randomised controlled trial (RCT) examining the role of treatment with injected opioids (methadone and heroin) for the management of heroin dependence in patients not responding to conventional substitution treatment. Specifically, the study examines whether efforts should be made to optimise methadone treatment for such patients (e.g. regular attendance, supervised dosing, high oral doses, access to psychosocial services), or whether such patients should be treated with injected methadone or heroin.Eligible patients (in oral substitution treatment and injecting illicit heroin on a regular basis) are randomised to one of three conditions: (1) optimized oral methadone treatment (Control group); (2) injected methadone treatment; or (3) injected heroin treatment (with access to oral methadone doses). Subjects are followed up for 6-months, with between-group comparisons on an intention-to-treat basis across a range of outcome measures. The primary outcome is the proportion of patients who discontinue regular illicit heroin use (operationalised as providing >50% urine drug screens negative for markers of illicit heroin in months 4 to 6). Secondary outcomes include measures of other drug use, injecting practices, health and psychosocial functioning, criminal activity, patient satisfaction and incremental cost effectiveness. The study aims to recruit 150 subjects, with 50 patients per group, and is to be conducted in supervised injecting clinics across England.

What Are America's Opportunities for Harm Reduction Strategies in Opiate Dependence?

This issue of the American Journal on Addictions has a review of prescribing heroin in Great Britain, where a recent government commission considered its limits. The review is written by one of the commission members who supports its conclusion that ‘‘if diamorphine treatment could be offered to all problematic users who do not successfully access other treatments, we believe it could play a useful part in managing the social problems generated by this group of people.’’ 1 As Dr. Carnwath indicates, this was a controversial conclusion and was based on several studies that have been criticized for their outcome measures (self reports rather than urine toxicologies), lack of blinding in assessments, drug diversion, and incomplete followup. 2–17 A separate concern has been that the cost-benefit of this intervention, particularly if implemented on a larger scale than these small, geographically restricted studies, would be unsupportive. Although prescribing injectable heroin to heroin addicts is unlikely to find community and legal support in the United States, another harm reduction strategy—needle exchange—has broad public health support in the addictions field, and new freedoms are available for buprenorphine prescribing in an office-based setting with significant latitude in take-home medication. Both of these U.S. programs have raised some issues among regulatory agencies and some citizens about the role of these treatment modalities for ‘‘managing the social problems generated by this group of people,’’ as stated in the British Commission report. Medically based harm reduction strategies that do not involve prescribing heroin or decriminalization of all abused substances

New guidelines for prescribing injectable heroin in opiate addiction

Few treatments are more controversial than the prescribing of injectable heroin (diamorphine) to heroin addicts. This practice is still banned in the USA and Australia, despite the serious drug problems in those countries. At present any UK doctor can prescribe injectable methadone for the treatment of heroin addiction; however, the prescribing of heroin requires a special licence from the Home Office. The National Treatment Agency for Substance Misuse is the statutory body currently responsible for advising purchasers (local drug action teams) in regard to specialist services for addictions. They have recently commissioned and published guidelines for the prescription of injectables in opiate addiction (National Treatment Agency for Substance Misuse, 2003). This follows the report of a Government committee, which stated:‘If diamorphine treatment could be offered to all problematic users who do not successfully access other treatments, we believe it could play a useful part in managing the social problems generated by this group of people’ (House of Commons Home Affairs Committee, 2003).

New guidelines for prescribing injectable heroin in opiate addiction

Few treatments are more controversial than the prescribing of injectable heroin (diamorphine) to heroin addicts. This practice is still banned in the USA and Australia, despite the serious drug problems in those countries. At present any UK doctor can prescribe injectable methadone for the treatment of heroin addiction; however, the prescribing of heroin requires a special licence from the Home Office. The National Treatment Agency for Substance Misuse is the statutory body currently responsible for advising purchasers (local drug action teams) in regard to specialist services for addictions. They have recently commissioned and published guidelines for the prescription of injectables in opiate addiction (National Treatment Agency for Substance Misuse, 2003). This follows the report of a Government committee, which stated: ‘If diamorphine treatment could be offered to all problematic users who do not successfully access other treatments, we believe it could play a useful part in managing the social problems generated by this group of people’ (House of Commons Home Affairs Committee, 2003).

Diamorphine treatment for opiate dependence: putative markers of concomitant heroin misuse

The supply of substitute opioid medication as a treatment for heroin dependence is now common practice. There is growing international interest in the prescription of injectable diamorphine for subgroups of patients who are unable to stop injecting opiate drugs; in the United Kingdom it is estimated that there are currently 300 patients prescribed diamorphine for this purpose. The detection of illicit heroin misuse (through urinary diamorphine metabolites) is confounded in subjects prescribed diamorphine. We investigated the potential to distinguish between the use of street heroin and pharmaceutical diamorphine through the detection in urine of various opiate alkaloids originating in the opium poppy, Papaver somniferum. Over a 7-week period, 532 clients of an urban substance misuse service provided a total of 1122 urine samples for clinical purposes. Using a novel mixed-mode solid-phase extraction and gas chromatography/mass spectrometry technique, we screened samples for morphine, 6-monoacetylmorphine, codeine, meconine, papaverine, noscapine, thebaine and their metabolites. All urine samples from diamorphine-treated patients were positive for morphine. Of samples from patients receiving other treatments, 30% (95%CI: 27-33%) were positive for morphine, indicating probable street heroin misuse. Of morphine-positive samples, 61% (95%CI: 55-67%), from the "other treatments" group were positive for at least one of codeine, meconine and putative noscapine or papaverine metabolites. This was reduced to 56% (95%CI: 50-62%) when excluding codeine. Only one sample (0.1%) was positive for any one of these putative markers in the absence of morphine, when excluding codeine. These findings show that the detection of urinary noscapine and papaverine metabolites is useful in distinguishing between use of pharmaceutical diamorphine and street heroin. This may be of benefit to promote safer and more effective prescribing of diamorphine in opiate dependency, and as an outcome measure in trials of diamorphine prescribing.

Provision of Diamorphine (Heroin) by Prescription for Drug Dependency

Existing evidence for the efficacy of diamorphine treatment of heroin dependence is presented, focusing first on ‘gold standard’ randomised controlled trials and then on other forms of evidence. The evidence strongly suggests that diamorphine treatment may be of some value and that further trials are warranted. Nevertheless, there are a range of risks associated with diamorphine trials and these are also discussed. It is recommended that: (i) extensive trialling of the efficacy, safety and cost-effectiveness of diamorphine should be undertaken; (ii) trials should be conducted to the highest scientific standards, but the standards should be realistic; (iii) the risks associated with diamorphine prescribing must be taken seriously and included in trial planning and evaluation; (iv) competing moral positions about diamorphine prescribing should be spelt out and debated; and (v) diamorphine prescription should be viewed as only one of a number of treatment options and should be investigated as part of a pluralist approach to the treatment of heroin dependence.