Heroin-assisted Treatment Research Articles

Heroin maintenance for chronic heroin-dependent individuals.

Several types of medications have been used for stabilizing heroin users: Methadone, Buprenorphine and levo-alpha-acetyl-methadol (LAAM.) The present review focuses on the prescription of heroin to heroin-dependent individuals. To compare heroin maintenance to methadone or other substitution treatments for opioid dependence regarding: efficacy and acceptability, retaining patients in treatment, reducing the use of illicit substances, and improving health and social functioning. A review of the Cochrane Central Register of Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to november 2009), EMBASE (1980 to 2005) and CINAHL until 2005 (on OVID) was conducted. Personal communications with researchers in the field of heroin prescription identified ongoing trials. Randomised controlled trials of heroin maintenance treatment (alone or combined with methadone) compared with any other pharmacological treatment for heroin-dependent individuals. Two reviewers independently assessed trial quality and extracted data. Eight studies involving 2007 patients met the inclusion criteria. Five studies compared supervised injected heroin plus flexible dosages of methadone treatment to oral methadone only and showed that heroin helps patients to remain in treatment (valid data from 4 studies, N=1388 Risk Ratio 1.44 (95%CI 1.19-1.75) heterogeneity P=0.03), and to reduce use of illicit drugs. Maintenance with supervised injected heroin has a not statistically significant protective effect on mortality (4 studies, N=1477 Risk Ratio 0.65 (95% CI 0.25-1.69) heterogeneity P=0.89), but it exposes at a greater risk of adverse events related to study medication (3 studies N=373 Risk Ratio 13.50 (95% CI 2.55-71.53) heterogeneity P=0.52). Results on criminal activity and incarceration were not possible to be pooled but where the outcome were measured results of single studies do provide evidence that heroin provision can reduce criminal activity and incarceration/imprisonment. Social functioning improved in all the intervention groups with heroin groups having slightly better results. If all the studies comparing heroin provision in any conditions vs any other treatment are pooled the direction of effect remain in favour of heroin. The available evidence suggests an added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment refractory, opioid users, to reach a decrease in the use of illicit substances, involvement in criminal activity and incarceration, a possible reduction in mortaliity; and an increase in retention in treatment. Due to the higher rate of serious adverse events, heroin prescription should remain a treatment for people who are currently or have in the past failed maintenance treatment, and it should be provided in clinical settings where proper follow-up is ensured.

Staff concerns in heroin‐assisted treatment centres

Heroin-assisted treatment (HAT) is a solution for improving the condition of treatment-resistant heroin addicts. Since 1994, six randomized controlled trials have concluded that HAT is more efficacious than oral methadone for severe heroin addicts. We visited seven HAT treatment centres in four countries in order to observe diacetylmorphine (DAM) administration and to study the main concerns of the staff. Nurses were concerned by the risk taken if a previously intoxicated patient received his dose of DAM. Another concern was the smuggling of DAM doses. The HAT centres face a dilemma: treating patients while at the same time allowing their risky street habits in the centre.

A Comparison of Cognitive Function in Patients under Maintenance Treatment with Heroin, Methadone, or Buprenorphine and Healthy Controls: An Open Pilot Study

Introduction: Cognitive impairment has been reported in drug-dependent patients under opioid maintenance treatment. Objectives: To compare cognitive functioning in healthy controls and in opioid-dependent patients treated with Buprenorphine, Heroin, or methadone maintenance. Methods: We used the standardized test battery ART-90 to study cognitive function in patients under long-term heroin treatment (n = 20), Bup (n = 22), or Met (n = 24) maintenance treatment and healthy controls (n = 25). Results: Patients receiving heroin performed significantly worse than healthy controls in most domains. Heroin patients performed worse than patients in the other two treatment groups in subtests measuring psychomotor performance under stress conditions and monotony. Conclusions and Scientific Significance: Although a number of limitations must be taken into account, this study provides some preliminary evidence that cognitive function may be more impaired in patients under heroin maintenance treatment than in patients receiving Bup or Met and in healthy controls.

Briefing Paper- Heroin Assisted Treatment: The State of Play

The United Nations Office on Drugs and Crime (UNODC) estimates that there are presently between 15.5 and 21.1 million opiate users in the world, the majority of whom are heroin users.1 There has been a growing awareness of the importance of treatment for this population in recent decades, with Opiate Substitution Therapy (OST) prominent amongst the range of treatment modalities. While methadone remains the most widely used substitute, clinicians and researchers recognize that there is a significant number of users for whom methadone has proved ineffective. This recognition has driven an expansion in the range of substitution modalities, and, in some parts of the world, clinicians have employed heroin (or, more precisely, diacetylmorphine or diamorphine, its licit, unadulterated pharmaceutical form) in the treatment of opiate addiction.This briefing paper explores the question of Heroin Assisted Treatment (HAT), examines the growing body of evidence emerging from its clinical use in addiction therapies, and makes recommendations for policy makers.

Craving and illicit heroin use among patients in heroin-assisted treatment

Aims To investigate in heroin-assisted treatment (HAT) compared to methadone maintenance treatment (MMT): the course of heroin craving and illicit heroin use, their mutual association, and their association with multi-domain treatment response. Design RCTs on the efficacy of 12 months co-prescribed injectable or inhalable HAT compared to 12 months continued oral MMT. Setting Outpatient treatment in MMT- or specialized HAT-centers in the Netherlands. Participants Chronic, treatment-refractory heroin dependent patients ( n = 73). Study parameters General craving for heroin (Obsessive Compulsive Drug Use Scale); self-reported illicit heroin use; multi-domain treatment response in physical, mental and social health and illicit drug use. Findings The course of heroin craving and illicit heroin use differed significantly, with strong reductions in HAT but not in MMT. General heroin craving was significantly related to illicit heroin use. Heroin craving was not and illicit heroin use was marginally related to multi-domain treatment response, but only in MMT and not in HAT. Conclusions Heroin craving and illicit heroin use were significantly associated and both strongly decreased in HAT but not in MMT. Craving was not related to multi-domain treatment response and illicit heroin use was marginally related to treatment response in MMT, but not in HAT. The latter was probably due to the strong reduction in illicit heroin use in most patients in HAT and the small sample size of the sub-study. It is hypothesized that the strong reductions in craving for heroin in HAT are related to the stable availability of prescribed, pharmaceutical grade heroin.

Physical and mental health in severe opioid‐dependent patients within a randomized controlled maintenance treatment trial

To evaluate physical and mental health and compare treatment outcomes in opiate-dependent patients substituted either with heroin or methadone. Twelve-month open-label randomized controlled trial. Out-patient substitution clinics in seven German cities. A total of 1015 opiate-dependent individuals. Opiate Treatment Index-Health Scale Score (OTI), Body Mass Index (BMI), serology for infectious diseases such as hepatitis B, C and human immunodeficiency virus as well as tuberculosis, Karnofsky Performance Scale (KPS), electrocardiogram (ECG), echocardiogram, Symptom Checklist 90-R (SCL-90-R), Global Assessment of Functioning (GAF), Modular System for Quality of Life and study medication-related serious adverse events (SAE). Improvements were found in both heroin and methadone substituted patients regarding OTI, BMI, KPS, SCL-90-R, and GAF, but they were more pronounced for the heroin group (analysis of variance, all P = 0.000). The frequency of pathological echocardiograms decreased in the heroin group and increased in the methadone group (χ(2) test, <0.05). Markers for infectious diseases and frequencies of pathological ECGs did not differ between baseline and 12 months, or between treatment groups. Study medication-related serious adverse events, all of which were treated successfully, occurred 2.5 times more often in the heroin group. The majority of heroin-related SAEs (41 of 58) occurred within a few minutes of the injections. The integration of severe injection drug users either in methadone or heroin-assisted maintenance treatment has positive effects on most physical and mental change-sensitive variables, with heroin showing superior results. Due to medication-related adverse events, patients should be observed for 15 minutes after a heroin injection.

Effet de l’implantation d’une clinique de prescription médicale d’héroïne sur l’environnement communautaire

Heroin-assisted treatment clinics are currently the focus of a social debate. In spite of the clinics' effectiveness in reducing illicit opiate use, some decision-makers refuse to set them up because of their possible negative impact. These clinics could attract new drug users into the neighbourhood which could lead to an accumulation of injection debris and to a decrease in the sense of security in the community. This study assesses the impact on some elements observed in the surrounding community following the opening of the Montreal heroin-assisted treatment clinic. Ethnographical walks were taken in order to collect data on the amount of injection debris, street debris and deviant activities. Data were then aggregated on a daily basis and our interrupted time series were analyzed using the segmented regression methodology. Results show that the opening of the clinic was followed by a significant drop in the amount of injection and street debris. This reduction appears proportional to the number of clinic participants. The Montreal heroin-assisted treatment clinic did not produce any negative impact on the surrounding community. In fact, implementation of this kind of clinic was followed by a positive effect on the neighbourhood. In addition to the ethnographical walks, further studies should include surveys in order to estimate the impact of heroin-assisted treatment clinics on residents' sense of security. Even if there appears to be a positive impact, it is possible that the mere presence of these clinics negatively affects community members' sense of security.

Effet de l’implantation d’une clinique de prescription médicale d’héroïne sur l’environnement communautaire

Objectives Heroin-assisted treatment clinics are currently the focus of a social debate. In spite of the clinics’ effectiveness in reducing illicit opiate use, some decision-makers refuse to set them up because of their possible negative impact. These clinics could attract new drug users into the neighbourhood which could lead to an accumulation of injection debris and to a decrease in the sense of security in the community. This study assesses the impact on some elements observed in the surrounding community following the opening of the Montreal heroin-assisted treatment clinic. Methods Ethnographical walks were taken in order to collect data on the amount of injection debris, street debris and deviant activities. Data were then aggregated on a daily basis and our interrupted time series were analyzed using the segmented regression methodology. Results Results show that the opening of the clinic was followed by a significant drop in the amount of injection and street debris. This reduction appears proportional to the number of clinic participants. Conclusion The Montreal heroin-assisted treatment clinic did not produce any negative impact on the surrounding community. In fact, implementation of this kind of clinic was followed by a positive effect on the neighbourhood. In addition to the ethnographical walks, further studies should include surveys in order to estimate the impact of heroinassisted treatment clinics on residents’ sense of security. Even if there appears to be a positive impact, it is possible that the mere presence of these clinics negatively affects community members’ sense of security.

Heroin maintenance treatment: From idea to research to practice

Maintaining opiate addicts on opiates has a long history. The idea to prescribe pharmaceutical morphine as a substitute for street heroin started in USA and was abolished on the basis of prohibitionist legislation. A new approach to maintain opiate addicts on substitution therapy was initiated in USA in 1963, with the prescription of methadone. This approach found, although slowly, increasing acceptance, and is nowadays considered to be a cornerstone in the management of opiate dependence and for the prevention of HIV/AIDS in opiate injectors. Since 1975, the concept of heroin maintenance treatment was re-activated in order to reach out to treatment-resistant heroin addicts. Research projects were performed in Switzerland, the Netherlands, Germany, Spain, Canada and in England, another one is planned in Belgium. Based on the unanimously positive outcomes, heroin maintenance has become routine treatment for otherwise untreatable heroin addicts in Switzerland, the Netherlands, Germany and England, and Denmark has set up heroin maintenance without new research trials.

Is There a Need for Heroin Substitution Treatment in Vancouver’s Downtown Eastside? Yes There Is, and in Many Other Places Too

The prescription of medically-supervised diacetylmorphine, the active ingredient in heroin, to individuals with treatment-refractory opioid dependence is a controversial and often politically charged subject. Just as methadone maintenance was opposed in the 1960s by some treatment providers who preferred abstinence-based therapies, heroin-assisted therapy is now being opposed by some methadone treatment providers--this despite the fact that the effectiveness of heroin-assisted treatment has been demonstrated in no less than six randomized trials in Switzerland, the Netherlands, Spain, Germany, Canada and the UK. The North American Opiate Medication Initiative (NAOMI) trial in Canada clearly showed heroin-assisted therapy to be superior to methadone in individuals with chronic, treatment-refractory heroin addiction both in terms of retention in addiction treatment and clinical response. An international internal review panel, three Research Ethics Boards, the CIHR RCT review panel, the Therapeutic Products Directorate of Health Canada, and several journal peer-reviewers reviewed the NAOMI trial. Nevertheless, authors of a commentary in this issue of CJPH find fault with the trial in terms of methadone prescribing, use of intention-to-treat analysis, safety and cost. We take this opportunity to respond to the numerous misconceptions and errors in their commentary.

Alpha‐synuclein and heroin craving in opiate‐dependent patients on injectable heroin maintenance

Research suggests that alpha-synuclein (SNCA) and NACP-Rep1, a polymorphic complex microsatellite repeat ~10 kb upstream of the SNCA gene translational start, may be involved in substance-use behaviors and craving. This study was the first to examine the effects of diacetylmorphine (DAM) on peripheral SNCA protein expression along with craving in opiate-dependent patients and to compare their NACP-Rep1 allele lengths with those of healthy controls. Using an experimental design, opiate-dependent patients on injectable heroin maintenance were investigated at four time points, twice pre- and post-injection of DAM. SNCA protein levels of 30 DAM-maintained patients were measured using enzyme-linked immunosorbent assay. Participant-rated effects were assessed in 42 patients by Tiffany's Heroin Craving Questionnaire (HCQ), Gossop's Short Opiate Withdrawal Scale and Visual Analogs. NACP-Rep1 alleles of 42 patients and 101 controls were analyzed. One-way repeated-measures ANOVAs provided significant overall effects for SNCA protein content (P = 0.028), craving (P < 0.001), withdrawal symptomatology (P < 0.001) and mood (P < 0.001), indicating that DAM injections may not only reduce craving but also SNCA protein expression. However, there was no association between protein expression and craving. Relative to controls, patients had significantly longer NACP-Rep1 alleles (P < 0.001). NACP-Rep1 allele lengths correlated positively with HCQ total scores averaged across all time points (r = 0.420; P = 0.006) as well as with post-DAM HCQ total scores in the morning (r = 0.488, P = 0.001) and afternoon (r = 0.423, P = 0.005). The findings provide evidence of a contributory role of SNCA and NACP-Rep1 for opiate dependence.

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.

Optimizing heroin-assisted treatment (HAT): Assessment of the contribution of direct ethanol metabolites in identifying hazardous and harmful alcohol use

Heavy alcohol consumption may accelerate the progression of hepatitis C-related liver disease and/or limit efforts at antiviral treatment in opioid-dependent patients receiving heroin-assisted treatment (HAT). Our study aims to assess alcohol intake among HAT patients by self-reports compared to direct ethanol metabolites. Fifty-four patients in HAT were recruited from the centre for HAT at the University of Basel, Switzerland. The patients completed the Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire on past-week ethanol intake and provided samples for the determination of ethyl glucuronide (UEtG) and ethyl sulphate (UEtS) in urine and of ethyl glucuronide (HEtG) in hair. Eighteen patients scored above the AUDIT cut-off levels. Twenty-six patients tested positive for UEtG and 29 for UEtS. HEtG identified ethanol intake of more than 20 g/d in 20 additional cases that did not appear in the AUDIT. Using the total score of the AUDIT, HEtG detected 14 additional cases of relevant alcohol intake. The findings of this study, which is the first assessing alcohol intake in HAT patients using direct ethanol metabolites and self reports, suggest the complementary use of both. Improved detection of hazardous or harmful alcohol consumption in the context of HCV and heroin dependence will allow for earlier intervention in this population. This ultimately will contribute to an improvement in quality of life of patients in HAT. Furthermore, a significant reduction of costs can be achieved through a reduction of complications caused by alcohol intake.

Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence

Background There is increasing evidence that health-related quality of life (HRQOL) is associated with a successful treatment and better outcome in opioid addiction. The aim of the present study was the longitudinal investigation of HRQOL in patients with severe opioid dependence, who were randomly assigned to four groups of medical and psychosocial treatment: heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively. Methods HRQOL (MSQoL) and physical health (OTI) were investigated in 938 subjects, who participated in the German multi-centre study examining the effects of heroin-assisted treatment in patients with severe opioid dependence. Data for the present analysis were taken from baseline and 12-month follow up. Results Under both forms of maintenance and psychosocial treatment HRQOL improved significantly during the observation period. HRQOL improvement under maintenance with heroin exceeded improvement under methadone, especially with regard to subjective physical health. HRQOL improvement was significantly associated with better expert-rated physical health. Further analyses showed significant better improvement of HRQOL in subjects treated with PSE compared with CM. Conclusions The advantage of heroin with regard to the improvement of HRQOL may be partially explained by a better improvement of physical health under maintenance with heroin compared with methadone, which highlights the importance of a comprehensive model of health care for patients with severe opioid dependence. Future studies need to investigate the benefits of PSE for patients in maintenance therapy.

Benzodiazepine use among patients in heroin-assisted vs. methadone maintenance treatment: Findings of the German randomized controlled trial

Benzodiazepine (BZD) use has been found to be associated with poorer psychosocial adjustment, higher levels of polydrug use and more risk-taking behaviors among opioid dependent patients. The aim of this paper is to analyze the correlation between BZD use, BZD prescription and treatment outcome among participants in the German trial on heroin-assisted treatment. 1015 patients who participated in the study comparing heroin-assisted and methadone maintenance treatment (HAT & MMT) for 12 months were included in the analysis. Analyses were carried out to assess the association of treatment outcome with baseline BZD use, with ongoing BZD use and with different patterns of BZD prescription. Baseline BZD use correlated with lower retention rates but not with poorer outcome. Ongoing BZD use correlated with poorer outcomes. Significantly better outcomes were found in the course of phobic anxiety symptomatology for those with regular prescription of BZD. The percentage of BZD positive urine tests decreased more in HAT than in MMT. Poorer outcome for benzodiazepine users may be mediated by a higher severity of addiction. Cautious prescribing of benzodiazepines may be beneficial due to the reduction of overall illicit use.

Implication of Gender Differences in Heroin‐Assisted Treatment: Results from the German Randomized Controlled Trial

Despite a lower prevalence of opioid dependence among females, drug-related problems and risk factors such as prostitution have a negative effect for women in treatment. This study was conducted with the purpose of analyzing gender differences in the German trial on heroin-assisted treatment (HAT), which compared HAT with methadone maintenance treatment (MMT). Significant baseline gender differences were found, with females showing a greater extent of mental distress. Differences in retention and outcome were significant for male patients, but no differences between treatment options were found for female patients. Ongoing prostitution was found to influence drug use outcomes. Other outcome criteria may need to be stressed when assessing the effect of HAT for women.

The effect of motivational status on treatment outcome in the North American Opiate Medication Initiative (NAOMI) study

Dropout and recidivism from addiction treatment has been found to be associated with individuals’ readiness for change. Motivation for treatment among participants entering the North American Opiate Medication Initiative (NAOMI) randomized controlled trial, which compared heroin assisted treatment (HAT) to optimized methadone maintenance treatment (MMT), was assessed. Through multivariate regression, we aimed to determine whether baseline motivational status was predictive of four treatment outcomes: early dropout, 12-month retention, 12-month response to treatment, and time to discontinuation of treatment. Among the 251 out-of-treatment chronic opioid dependent patients recruited in Montreal, Quebec and Vancouver, British Columbia, 52% reported having a high level of motivation for treatment. HAT was statistically significantly more effective than MMT on each of the outcomes assessed. Baseline motivational status did not predict retention or time to discontinuation in either HAT or MMT. However, while patients were retained in HAT regardless of motivational status, motivated patients showed a more favourable response to treatment in terms of decreases in crime and illicit drug use. These results suggest that HAT successfully retains opioid dependent patients who otherwise may not have been attracted into existing treatment options, and may enhance the odds of successful rehabilitation among patients motivated for treatment.

Characteristics and Response to Treatment among Aboriginal People Receiving Heroin-assisted Treatment

Background: Medically prescribed diacetylmorphine, the active ingredient of heroin, has been shown to be effective for the treatment of severe opioid addiction. However, there are no data regarding its effectiveness among Aboriginal heroin injectors. Methods: The present analyses were performed using data from the NAOMI study (North American Opiate Maintenance Initiative), an open-label randomized controlled trial that compared the effectiveness of injectable diacetylmorphine (45.8%) and hydromorphone (10%) vs. oral methadone (44.2%) among long-term treatment-refractory opioid-dependent individuals. Rates of retention and response to treatment were analyzed among participants from the Vancouver site (n=192). Results: Baseline profiles were similar among Aboriginal (n=60) and non-Aboriginal (n=132) participants except for higher HIV positive rates among Aboriginal people (23.3% vs. 8.3%). Among Aboriginal participants in the injection and methadone groups, retention rates at 12 months were 84.4% vs. 57.1% and response rates were 68.8% vs. 53.4%, respectively. Aboriginal and non-Aboriginal rates were not significantly different. Discussion: Offering treatment assisted with medically prescribed diacetylmorphine or hydromorphone to long-term treatment-refractory opioid-dependent Aboriginal people could be an effective way to attract them into and retain them in treatment as well as dramatically reduce the risk of HIV infection. Key words: Aboriginal, Canada; opioid-dependence; substitution treatment; diacetylmorphine, injectable; hydromorphone, injectable; methadone, oral

Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial

Some heroin addicts persistently fail to benefit from conventional treatments. We aimed to compare the effectiveness of supervised injectable treatment with medicinal heroin (diamorphine or diacetylmorphine) or supervised injectable methadone versus optimised oral methadone for chronic heroin addiction. In this multisite, open-label, randomised controlled trial, we enrolled chronic heroin addicts who were receiving conventional oral treatment (>or=6 months), but continued to inject street heroin regularly (>or=50% of days in preceding 3 months). Randomisation by minimisation was used to assign patients to receive supervised injectable methadone, supervised injectable heroin, or optimised oral methadone. Treatment was provided for 26 weeks in three supervised injecting clinics in England. Primary outcome was 50% or more of negative specimens for street heroin on weekly urinalysis during weeks 14-26. Primary analysis was by intention to treat; data were adjusted for centre, regular crack use at baseline, and treatment with optimised oral methadone at baseline. Percentages were calculated with Rubin's rules and were then used to estimate numbers of patients in the multiple imputed samples. This study is registered, ISRCTN01338071. Of 301 patients screened, 127 were enrolled and randomly allocated to receive injectable methadone (n=42 patients), injectable heroin (n=43), or oral methadone (n=42); all patients were included in the primary analysis. At 26 weeks, 80% (n=101) patients remained in assigned treatment: 81% (n=34) on injectable methadone, 88% (n=38) on injectable heroin, and 69% (n=29) on oral methadone. Patients on injectable heroin were significantly more likely to have achieved the primary outcome (72% [n=31]) than were those on oral methadone (27% [n=11], OR 7.42, 95% CI 2.69-20.46, p<0.0001; adjusted: 66% [n=28] vs 19% [n=8], 8.17, 2.88-23.16, p<0.0001), with number needed to treat of 2.17 (95% CI 1.60-3.97). For injectable methadone (39% [n=16]; adjusted: 30% [n=14]) versus oral methadone, the difference was not significant (OR 1.74, 95% CI 0.66-4.60, p=0.264; adjusted: 1.79, 0.67-4.82, p=0.249). For injectable heroin versus injectable methadone, a significant difference was recorded (4.26, 1.63-11.14, p=0.003; adjusted: 4.57, 1.71-12.19, p=0.002), but the study was not powered for this comparison. Differences were evident within the first 6 weeks of treatment. Treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone. UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts. Community Fund (Big Lottery) Research section, through Action on Addiction.

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.