Heroin Best Tx for Resistant Opioid Addiction, Expert Says

Liam Davenport

April 22, 2015

Individuals with heroin addiction for whom conventional therapies have failed should be offered heroin-assisted treatment to avoid relapse involving use of illicit heroin, argues a Canadian expert.

Martin T. Schechter, MD, professor, School of Population and Public Health, University of British Columbia, Vancouver, Canada, cites several trials indicating that heroin-assisted therapy is both effective and cost-effective in the most vulnerable patients.

"Conventional therapies such as methadone maintenance should remain the preferred treatment for patients with heroin addiction and should be readily accessible," he writes.

"But heroin assisted therapy should be offered to patients who have not benefited from conventional treatments, provided that the diamorphine is prescribed by physicians at specialized clinics that can assure safety."

The opinion piece was published as a personal view in the BMJ on April 14.

Vulnerable Subset

In an interview with Medscape Medical News, Dr Schechter emphasized that he is talking about a "vulnerable" subset of people with addiction "who have tried the therapies that we currently have available and that has not worked for them."

He believes that these patients compose approximately 15% to 20% of the opioid-addicted population, but that this subgroup "gives rise to a much greater proportion of the activities associated with addiction."

Dr Schechter explains in his article that six randomized, controlled trials of heroin-assisted therapy have been conducted in Europe and Canada and that all the studies have concluded that the treatment is more effective in this subgroup of patients.

Although he notes that heroin-assisted therapy is approximately four times more expensive than conventional therapy, he points to several trials that indicate that, once societal costs are taken into account, it is more cost-effective than methadone therapy.

Describing the argument that therapeutic heroin is too expensive as "false," Dr Schechter says that heroin addicts "cost society a fortune while suffering immeasurably because they have an illness that society does not like."

Dr Schecter explained that moving heroin-assisted treatment up the agenda is "just a question of political will."

"There are several countries in Europe where the trials were conducted, including Germany, the Netherlands, and Switzerland, where this treatment became part of the healthcare system for this subpopulation who benefit from it. Those countries simply had the political will to continue because they saw the evidence," he said.

"In the United States, my colleagues say that it's a very uphill battle. I do know there are a couple of states that have been looking at the possibility of having pilot programs," Dr Schecter added.

"In Canada, we are trying to convince the decision makers that this is worthwhile treatment, and some of this actually has ended up in the courts, because the federal government is clearly opposed to it."

In his article, Dr Schechter explains that Canada's minister of health, Rona Ambrose, attempted to change the regulations to stop the use of heroin-assisted therapy on compassionate grounds.

"That has ended up in the Supreme Court of British Columbia, and we will see what happens at that point," he said. "I think the tendency is to think of it as criminal activity as opposed to an illness, [but] it's a recognized illness, and I think we need to treat it as a medical and public health issue rather than a criminal activity."

Bias, Ideologies Shape Treatment Strategies

Commenting for Medscape Medical News, Maria Sullivan, MD, PhD, associate professor of clinical psychiatry at Columbia University Medical Center, in New York City, agreed that harm reduction, as opposed to abstinence-based treatment, "is a therapeutic modality that is important to consider, particularly for opioid addition."

"I think the evidence is strong that heroin maintenance carries benefits, including improved physical and mental health, reduction in illegal involvement, and, of course, reductions in HIV risk, and these are important considerations for a patient population that is facing high mortality," she added.

However, Dr Sullivan noted that heroin maintenance therapy is only justified when patients have been offered conventional agonist and antagonist treatments. She emphasized that there are effective treatments available for preventing opioid relapse, but these are not yet being effectively implemented.

Specifically, there are two agonist treatments ― methadone and buprenorphine ― as well as a long-acting injectable form of the antagonist naltrexone (Vivitrol, Alkermes, Inc).

"In the opening lines of this article, Dr Schecter refers to the fact that our best available treatments, such as detoxification, access programs, and methadone maintenance, have not been successful," Dr Sullivan said.

"It strikes me that he makes no mention of the only office-based agonist therapy, namely, buprenorphine, nor of antagonist treatment at all, and both have shown retention rates of up to 50% or 60% at 3 to 6 months."

"I think that to compare heroin maintenance to no medication-assisted treatment at all, or only to look at retention in methadone programs, is setting up a bit of straw horse."

Dr Sullivan explained that a major problem is that even if patients with opioid dependence are offered treatment, they are often not given a choice of available pharmacotherapies with proven success in preventing relapse.

"What is all too often the case is that there is, if you will, a silo approach to opioid-dependence treatment, so that the kind of treatment offered to the patient is dependent on where the patient enters into treatment," she said.

Describing the different scenarios in which patients could find themselves, Dr Sullivan stated: "If a patient presents to a maintenance program, he or she is likely to be placed on methadone, and this will likely be continued for years or decades to come."

"When the patient arrives in an emergency room, he or she is, assuming bed availability for a detox, likely to be sent upstairs, given a 6- or 7-day methadone taper, and released on the seventh day with 'no withdrawal'.... Then the patient returns home and within 48 hours is experiencing significant opioid withdrawal and very likely to relapse."

Finally, she said: "It is the rare patient who is fortunate enough to end up in the office of a psychiatrist or internist with addiction training who can lead a discussion about the pros and cons of each of the available therapies."

Dr Sullivan agreed with Dr Schechter, however, that the debate over treatments for opioid addiction is rarely framed in terms of an illness requiring the most appropriate treatment.

"I think that, unfortunately, it continues to be the case that beliefs about addiction treatment are shaped more by ideology than by evidence-based medicine," she said.

"The disapproval that many might express towards even considering heroin-based administration is really an extension of the same debate that waged when methadone was first developed in the early 1960s in this country, with the feeling on the part of many that this was simply giving an addict his drug."

"It is unfortunate that personal bias and ideologies that predated effective medication-assisted treatment continue to shape the discourse in addiction treatment."

"Again, we have newer pharmacotherapies with proven efficacy which are not being allowed to express their therapeutic potential for treating this type of chronic relapsing disease," Dr Sullivan concluded.

Dr Schecter reports no relevant financial relationships. Dr Sullivan was recently appointed medical director of clinical research and development at Alkermes. She remains on the part-time faculty at Columbia in the Division on Substance Abuse.

BMJ. Published online April 14, 2015. Abstract


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