Reducing Heroin Use Research Articles

Breaking the deadlock over an Australian trial of injectable opioid maintenance.

INJECTABLE HEROIN MAINTENANCE has been advocated as a form of treatment for opioid dependence that would attract, and retain in treatment, addicts who have either not sought treatment or who have failed at other forms of treatment, including methadone maintenance. Advocates of heroin maintenance argue that it would increase the proportion of addicts in treatment and reduce heroin use, drug related crime, and deaths due to overdose.

Does Cigarette Smoking Affect Drug Abuse Treatment?

Does quitting cigarette smoking help or hurt the polydrug user in treatment for drug use? Data were obtained from 407 polydrug users in 15 treatment centers in Los Angeles at baseline and one-year follow-up. Measures: Smoking status, reported drug use, urine test results, SF-36 scores, Hopkins SCL, ASI-alcohol use, -drug use, -psychiatric problems, and ad hoc employment-related problems. Results: Most respondents (95%) reported some lifetime smoking. Over one-year follow-up, 29% reported a change in smoking status. At follow-up, stable former smokers reported fewer psychiatric problems than stable current smokers. Change in smoking status was associated with reduced heroin use, but with increased psychiatric problems and employment-related problems. Stable former smokers consistently reported healthier outcomes than either stable regular smokers or status changers, as reflected in somatization, obsessive/compulsive behavior, depression, and anxiety scores. Conclusions: Long-term but not short-term abstinence from tobacco use in polydrug users undergoing treatment is associated with consistently more favorable health outcomes.

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.

Report of the Council on Scientific Affairs

Extensive evaluation studies show that methadone maintenance therapy (MMT) reduces heroin use and associated problems in a cost-effective manner, without negative public health impact. MMT is limited by inadequate funding and understanding of relevant research, extensive regulation, and limits on the freedom of physicians to provide methadone in a variety of medical settings. Broad-based medical, public health, and scientific support exists for expansion of MMT with greater emphasis on consistency and quality, and provision of ancillary services. Programs for the exchange, free distribution, and legal pharmacy sale of needles and syringes reduce injection drug use and prevent the spread of bloodborne pathogens; drug abuse treatment and other services are important components. Neither strategy increases existing drug use nor leads to drug use initiation. The scientific literature supports assertions that drug abuse issues should be treated primarily as medical and public health rather than criminal justice issues. The effectiveness of both strategies warrants increased support for services, easing of federal and state restrictions governing their availability, and advocacy in their support.

Relationships Between Drug Treatment Careers and Outcomes

A structural equation modeling approach was used to examine the relationships among charac teristics of drug use and treatment careers, length of stay in a current treatment episode, and subsequent drug use among 2,807 clients participating in the Drug Abuse Treatment Outcome Study (DATOS). The model was tested separately for four major modalities. Length of stay in DATOS treatment was significantly related to reduced cocaine use (but not heroin use) during the follow-up period among clients in outpatient drug-free and residential programs and to reduced heroin use (but not cocaine use) among clients in methadone maintenance. Importantly, longer treatment careers were significantly associated with increased length of stay in DATOS outpatient drug-free programs and were associated with reduced heroin use among clients treated in all modalities except for residential programs, demonstrating cumulative treatment effects. These findings support the notion that treatment effects may accumulate across multiple treatment episodes.

The Analysis of Methadone Clinic Data Using Marginal and Conditional Logistic Models with Mixture or Random Effects

The paper develops methods for the statistical analysis of outcomes of methadone maintenance treatment (MMT). Subjects for this study were a cohort of patients entering MMT in Sydney in 1986. Urine drug tests on these subjects were performed weekly during MMT, and were reported as either positive or negative for morphine, the marker of recent heroin use. To allow correlation between the repeated binary measurements, a marginal logistic model was fitted using the generalized estimating equation (GEE) approach and the alternating logistic regression approach. Conditional logistic models are also considered. Results of separate fitting to each patient and score tests suggest that there is substantial between‐patient variation in response to MMT. To account for the population heterogeneity and to facilitate subject‐specific inference, the conditional logistic model is extended by introducing random intercepts. The two, three and four group mixture models are also investigated. The model of best fit is a three group mixture model, in which about a quarter of the subjects have a poor response to MMT, with continued heroin use independent of daily dose of methadone; about a quarter of the subjects have a very good response, with little or no heroin use, again independent of dose; and about half the subjects responded in a dose‐dependent fashion, with reduced heroin use while receiving higher doses of methadone. These findings are consistent with clinical experience. There is also an association between reduced drug use and increased duration in treatment. The mixture model is recommended since it is quite tractable in terms of estimation and model selection as well as being supported by clinical experience.

High dose levomethadyl acetate hydrochloride reduced heroin use in patients dependent on opiates

Eissenberg T, Bigelow GE, Strain EC, et al. Dose-related efficacy of levomethadyl acetate for treatment of opioid dependence. A randomized clinical trial. JAMA 1997 June 25; 277 : 1945 –51...

A Likelihood Approach to Analysing Longitudinal Bivariate Binary Data

AbstractTo study the effect of methadone treatment in reducing multiple drug use, say heroin and benzodiazepines while controlling for their possible interaction, we analyse the results of urine drug screens from patients in treatment at a Sydney clinic in 1986. Weekly tests are either positive or negative for each type of drug and a bivariate binary model was developed to analyse such repeated bivariate binary outcomes. It models simultaneously the logit of each type of drug use and their log odds ratio linearly in some covariates. The serial correlation within subject is accounted for by including the ‘previous outcome’ of both drugs and their interaction as covariates. Our main conclusion is that drug use is reduced over time and the interaction between dose and time effects is not significant. It also suggests that while methadone maintenance is effective in reducing heroin use (CHAN et al., 1995), it does not suppress non‐opioid drug use. Concerning the association between the two drugs, it is found that the present strength of their association depends on the previous outcomes only through a measure of concordance. The proposed model has a tractable likelihood function and so a full likelihood analysis is possible. It can be easily extended to incorporate mixture effects. The EM algorithm is used for the estimation of parameters in the mixture model and model selection can be based on the Akaike Information Criterion.

Evaluation of an AIDS education model for women drug users in jail.

This paper reports outcome evaluation results of an AIDS education program for drug-using women in jail, of whom the majority were current drug injectors, had high-risk sexual partners, and never used condoms for insertive sex. The women participated in four small-group health/HIV education sessions. Education participants and controls were followed-up 7 months after their release from jail; the two groups did not differ significantly on drug- or sex-related HIV risk behaviors at follow-up. However, being in drug dependency treatment (primarily methadone maintenance) at follow-up was associated with reduced heroin use, crack use, drug dealing, and criminal activity. Although improved HIV education in jail is important, better networks of community resources, including more accessible community drug dependency treatment, also must be developed to support drug-dependent women after their release from jail.

The effectiveness of methadone maintenance treatment: an overview

This paper reviews the evidence for the effectiveness of methadone maintenance as used in the treatment of opioid dependence. Findings from randomized controlled trials and observational studies suggest that methadone maintenance reduces heroin use, crime, injection-related risk behaviours and premature mortality among people dependent on opioids. The research further suggests that two aspects of treatment are important in ensuring this effectiveness. Methadone treatment is more effective when higher doses (>50 mg) are employed and, overall, the evidence suggests that a treatment goal of successful maintenance on methadone rather than total abstinence is appropriate. The importance of ancillary services in treatment outcome is less clear and is the subject of current research and debate.

Managing illicit drug use. A practical guide.

Illicit drug use is spreading, especially in the developing world, but has begun to stabilise in most developed countries. The phenomenon of illicit drug use is still poorly understood, with responses in most countries influenced largely by cultural factors. A range of psychosocial and pharmacotherapeutic treatments is available; of these, methadone maintenance treatment for heroin dependence has the most evidence of benefit. A large body of literature--including some well designed studies--indicates that methadone reduces heroin use, mortality, criminal activity and risk of human immunodeficiency virus (HIV) infection. Methadone is more likely to be effective if higher doses, longer durations of treatment and more realistic goals are set. However, research findings which would improve outcomes considerably are often not implemented. Methadone maintenance programmes, which attract and retain more illicit drug users than other treatment modalities, are now being made more available in many countries in recognition of their therapeutic effectiveness and utility in reducing the spread of HIV infection among people injecting heroin. HIV infection is now recognised in many countries to be the most serious complication of illicit drug use for both individual drug injectors and their communities. Levo-alpha-acetylmethadol (LAAM) has similar properties to methadone but a longer half-life. This suggests a number of clinical benefits which would also reduce the cost of treatment. However, LAAM has not been approved by regulatory authorities for routine use despite positive findings in some studies. Buprenorphine has shown some promise in the management of heroin dependence but is still undergoing evaluation. It is, however, unlikely to ever be used widely for the management of illicit drug users. Naltrexone may have some advantages for special populations. Pharmacotherapeutic treatment for cocaine and amphetamine users is still at a developmental stage.

Exposure to Methadone Programs and Heroin Use

The aims of this study were to: (a) assess the effects of various patterns of exposure to methadone programs on heroin use; (b) assess the effects of other patient, program, and treatment variables; and (c) identify variables that promote the type of exposure to methadone programs that is most effective for reducing heroin use. The sample was 526 patients who were admitted from 1979 to 1981 into 17 methadone programs that participated in the Treatment Outcome Prospective Study. The study differs from previous research in that it addresses the time that patients spent in methadone programs during the follow-up period in defining exposure patterns. Heroin use was lowest among patients who were continuously exposed to methadone programs. Retention was highest among patients who attended programs that informed them of their methadone dose levels, were easy to access, and provided them with high quality social services.

Predicting cocaine use among methadone patients: analysis of findings from a national study.

Findings from a large-scale national study of clients admitted to publicly funded drug treatment programs between 1979 and 1981 were used to determine whether cocaine use by current and former methadone patients could be predicted. The sample for this analysis comprised 526 daily or weekly heroin users admitted to 17 methadone maintenance programs. The study found that cocaine use by both current and former methadone patients showed an overall decline during the follow-up year; that patients who stopped using heroin after entering treatment were much more likely to quit using cocaine than were their heroin-using counterparts; and that the odds of initiating cocaine use after admission to a methadone program were much higher among patients who continued using heroin. These findings suggest that methadone programs may be able to reduce cocaine use among some patients by improving their effectiveness in reducing heroin use.

Cocaine Use and HIV Infection in Intravenous Drug Users in San Francisco

We assessed risk factors for human immunodeficiency virus (HIV) infection in 633 heterosexual intravenous drug users. The HIV seroprevalence was 26% in blacks, 10% in Hispanics, and 6% in whites. Intravenous cocaine use significantly increased the risk of HIV infection, with a seroprevalence of 35% in daily cocaine users (odds ratio, 6.4; 95% confidence interval, 3.0 to 13.3). Black subjects were more likely to use cocaine regularly. Drug use in shooting galleries and sharing of drug injection equipment were also associated with HIV infection and were more common in cocaine users. By multivariate analysis, black race, daily cocaine injection by blacks and Hispanics, all other cocaine injection, heavy use prior to entry into methadone treatment by blacks, and use of drugs in shooting galleries were independent predictors of HIV infection. Methadone therapy was associated with substantial reductions in heroin use and some reduction in cocaine use, but 24% of cocaine users receiving methadone began or increased cocaine injection after entry into treatment.

Buprenorphine suppresses heroin use by heroin addicts.

Heroin-dependent men were given buprenorphine (a partial opiate agonist-antagonist) or a placebo under duoble-blind conditions on a clinical research ward where they could acquire heroin (21 to 40.5 milligrams per day, intravenously). Buprenorphine significantly (P less than .001) suppressed the self-administration of heroin over 10 days. Control subjects took between 93 and 100 percent of the available heroin. The effects of buprenorphine were dose-dependent; a dose of 8 milligrams per day reduced heroin use by 69 to 98 percent; a dose of 4 milligrams per day reduced heroin use by 45 percent. Termination of buprenorphie maintenance did not result in opiate withdrawal signs or symptoms. The subjects liked buprenorphine and indicated that it was preferable to methadone or naltrexone. Buprenorphine should be a safe and effective new pharmacotherapy for heroin dependence.

The frequency of narcotic use before and after admission to a methadone maintenance program.

A total of 453 program participants of the Narcotic Abuse Treatment Program, San Diego Country, a methadone maintenance program, were asked to report their use of heroin prior to and after program participation. Results indicated a significant reduction in reported heroin use, suggesting that the program has affected change in the quantity of heroin used by participants and that heroin use of program participants is not sufficient by itself to motivate other criminal involvement. A program may be effecting a reduction in heroin use by clients as well as criminal activity, but the effects may be totally unrelated.

A follow-up of admissions to the California Civil Addict Program.

A follow-up interview study of early admissions to the California Civil Addict Program found that those continuing in the program performed substantially better during the commitment period than did a comparable group discharged shortly after admission. To a lesser extent, the program also appeared to have had some impact subsequent to discharge. Those program discharges defined as successes tended to do relatively well until the time of interview. Comparisons under the strict (pre-1970) and more lenient regimens showed roughly comparable behavior, but the availability of methadone maintenance was also a significant factor in reducing heroin use during the latter period.

California Civil Commitment: A Decade Later

Both the court criteria for commitment and program policies have undergone significant changes in the past several years. The large majority of current commitments follow a felony conviction and typically occur only when the alternative sentencing disposition is more severe. Civil commitments without a criminal conviction are very rare. Program policy changes have resulted in a parole-incarceration time ratio of nearly 3:1 in comparison to 1:1 prior to 1970. A follow-up study of early commitments found that those continuing in the program generally performed better than a comparable sample discharged shortly after admission. Comparisons under the strict (pre-1970) and more lenient regimens showed roughly comparable behavior, but the availability of methadone maintenance was also a significant factor in reducing heroin use during the latter period.

The resurgence of heroin abuse in the District of Columbia.

Prospectively collected drug abuse trend surveillance data suggest that the rate of heroin use in Washington, D.C. is rising following a two year decline in the magnitude of this problem. Supportive data include increased potency of street level heroin, increased numbers of heroin-related deaths, increased detection of heroin positive urine specimens in the D.C. Superior Court arrestee population, increased demand for addiction treatment services and rising property crime rates. Increased prevalence of heroin use has not yet been associated with an increase in incidence, suggesting that former heroin users have begun to use once again following a period of abstinence. Analysis of heroin specimens seized across the United States suggests that cities formerly dependant upon European (white) heroin have now developed a new heroin distribution system which supplies Mexican (brown) heroin. This has offset the reduction in heroin use observed during 1972-1973 concomitant with the East Coast heroin shortage and widespread introduction of addiction treatment services.

Heroin Addiction Trends

Systematic observations made in Washington. D.C., documented the epidemic spread of heroin use and its subsequent decline. Major indicators supporting the contention of reduced heroin use include: 1) a stable year of peak heroin use among all treatment cohorts admitted since January 1971; 2) a marked reduction in deaths due to heroin overdose; 3) a steady decline in the number of urine tests positive for heroin among arrestees tested; 4) a sharp reduction in the annual number of narcotics arrests; 5) a sustained reduction in the demand for heroin addiction treatment; and 6) a significant increase in the mean age of identified heroin users.