AAAP 2008: Heroin-Assisted Treatment Useful as Last-Resort Option

Positive European Experience Suggests Potential Application in the United States

Marlene Busko

December 10, 2008

December 10, 2008 (Boca Raton, Florida) — Heroin-assisted maintenance treatment may be effective for patients with chronic, refractory heroin addiction, researchers say.

Here at the American Academy of Addiction Psychiatry 19th Annual Meeting and Symposium, Wim van den Brink, MD, PhD, from the Academic Medical Center at the University of Amsterdam, in the Netherlands, discussed the European experience and how this treatment might be applied in North America.

"Heroin dependence is a chronic relapsing disease for most patients, and the most effective current therapy is methadone or buprenorphine maintenance treatment, but no one treatment fits all," Dr. van den Brink told Medscape Psychiatry.

"Some patients don’t respond to methadone or buprenorphine, so we need additional options, and heroin-assisted treatment could be one of these," he added.

Dr. van den Brink estimated that heroin-assisted treatment may be an option for 5% to 10% of dependent patients.

Opioid Addiction in Europe

Goals for opioid-dependent patients should be stabilization, harm reduction, and decrease in illicit drug use, he said.

In Europe, opioid addiction ranges from 2 to 3 persons per 1000 population in Latvia, Finland, Czechoslovakia, and the Netherlands to 6 per 1000 in Malta and Italy.

In 2005, it was estimated that of 1.6 million opioid addicts in Europe, 29% were receiving agonist maintenance therapy with methadone, buprenorphine, or another agent.

Methadone and buprenorphine are available in most European countries. Some countries also treat patients with hydrocodeine, slow-release morphine, or naltrexone.

Heroin-assisted treatment is available in Switzerland, Germany, Spain, the United Kingdom, and the Netherlands. Research, including 5 randomized controlled clinical trials in these countries, has shown that supervised heroin-assisted treatment is more effective that methadone maintenance treatment in refractory patients.

Dutch Experience

A 1995 epidemiologic study showed that in the Netherlands, which had a population of 17 million, 24,000 were heroin addicts. Of these, about 70% were either receiving drug-free treatment (4500) or methadone maintenance treatment (12,500). Of the individuals on methadone maintenance treatment, 4500 were integrated into society, but 8000 individuals did not achieve this.

To reach the individuals who were not responsive to existing treatments, the Health Council of the Netherlands decided to continue existing methadone and drug-free treatment programs and add controlled, medically prescribed heroin.

Twelve-month results from a study of 2 open-label, randomized controlled clinical trials in the Netherlands, led by Dr. van den Brink, showed that treatment-resistant heroin addicts randomized to methadone plus heroin-assisted treatment were almost 3 times more likely to respond than those who had been randomized to continue methadone alone (van den Brink W et al. BMJ 2003;327:310).

"This is quite an amazing response in such a treatment-resistant population," said Dr. van den Brink.

Recent, not-yet-published 48-month results from this same study show that the improvements in multiple domains continued, he said.

Promising Canadian Study

Another European study showed that although it is expensive to treat individuals with heroin maintenance, the benefits to society, including reductions in criminal activity, far outweigh the costs.

Recently released 12-month findings from a Canadian study — the North American Opiate Medication Initiative (NAOMI) — showed high retention rates and significant improvements in illicit heroin use, illegal activity, and health for participants who received heroin-injection–assisted therapy or optimized methadone maintenance.

The researchers concluded that heroin-assisted therapy is a safe and effective treatment for individuals with chronic, treatment-resistant heroin addiction.

"Supervised heroin-assisted treatment is a last resort, not a first-line treatment," said. Dr. van den Brink. The treatment is potentially applicable in the United States, but first, methadone and or buprenorphine maintenance therapy would need to be more broadly available and accessible.

"Currently, up to 50% to 60% of opioid-dependent drug users in some European countries are treated with methadone or buprenorphine, whereas in the United States, only about 15% to 20% receive this treatment. So the main goal for the United States should be to have better availability of methadone and buprenorphine. Then heroin-assisted treatment could be added as another treatment option for the estimated 5% to 10% of refractory patients," he said.

Dr. van den Brink has received research grants from Eli Lilly and Merck/Serono and has acted as a consultant for Alkermes, Lundbeck, Merck/Serono, Organon/Schering-Plough, and Solvay. He has been an advisory committee board member for Organon/Schering-Plough.

American Academy of Addiction Psychiatry 19th Annual Meeting and Symposium: Symposium II. December 5, 2008.

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