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Heroin Assisted Treatment/Heroin Maintenance

Published: 01/09/2008 - 17:11

Please use the following links to access these sub-chapters concerning Heroin Maintenance:

Law and policy - " Heroin Maintenance - Law and Policy " information concerning the legal issues surrounding heroin

assisted treatment and heroin maintenance.

Research - " Heroin Maintenance - Research " research studies concerning heroin assisted treatment and heroin

maintenance.

Switzerland - " Heroin Maintenance - Switzerland " research and issues concerning heroin assisted treatment and heroin

maintenance in Switzerland.

Canada - " Heroin Maintenance - Canada " research and issues concerning heroin assisted treatment and heroin

maintenance in Canada including the NAOMI and SALOME clinical trials.

__________________________________________________

1.

(heroin maintenance definition and benefits) "Heroin prescription is a form of medical care that involves strictly regulated

and controlled prescription of heroin. Offered on its own or as a complement to treatment programs, it is often targeted for use

by people for whom opioid substitution treatment and other programs have not succeeded."

"Findings show such programs are feasible and are associated with a number of positive outcomes, 12 including:

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Health benefits:

helping people to stop or reduce their illegal drug use; 13

avoiding illness and death as a result of overdose by ensuring access to a drug of known quality and strength; 14

retention in medical care; 15

facilitating a gradual change from heroin to opioid substitution therapy; 16

reducing the risk of HIV and hepatitis resulting from unsafe injection practices; 17 and

promoting general health and well-being. 18

Social benefits:

reducing crime related to the acquisition of drugs; 19

reducing the number or visibility of drug markets and public drug use;

lowering costs associated with health care, social welfare, criminal justice and prisons; 20 and

promoting social integration, including with respect to employment, accommodation and family life. 21 "

Source:

Canadian HIV/AIDS Legal Network, "Legislating on Health and Human Rights: Model Law on Drug Use and HIV/AIDS

Module 8: Heroin prescription programs," (Tornoto, Ontario: 2006), pp. 7-8.

http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=875

2.

(heroin maintenance - benefits) "Heroin prescription represents a contentious approach to treatment. Many would question

whether giving users the drug that they are addicted to constitutes treatment in the normal sense of the word. As with any

form of substitution therapy, there is also the question of whether users can be moved on from their drug use perhaps the

fact that users are being prescribed their drug of choice (rather than a frequently unpopular alternative) may mean that users

will find it even more difficult to move on to abstinence. There is insufficient evidence to answer this latter concern. However,

what the evidence base does indicate is that, in the short term, heroin prescription appears to be an effective way to retain users

in treatment who have a history of failing in other treatment settings, with consequent benefits in terms of reduced drug use,

crime and social reintegration."

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Source:

Lloyd, Charlie and McKeganey, Neil, "Drugs Research: An overview of evidence and questions for policy," Joseph Rowntree

Foundation (London, United Kingdom: June 2010), p. 50.

http://www.jrf.org.uk/sites/files/jrf/drugs-research-overview-full.pdf

3.

(heroin maintenance and crime reduction) "Overall, results indicate that heroin prescription is a very promising approach in

reducing any type of drug related crime across all relevant groups analyzed. It affects property crime as well as drug dealing

and even use/possession of drugs other than heroin. These results suggest that heroin maintenance does not only have animpact by reducing the acquisitive pressure of treated patients, but also seems to have a broader effect on their entire life-style

by stabilizing their daily routine through the commitment to attend the prescription center twice or three times a day, by giving

them the opportunity for psychosocial support, and by keeping them away from open drug scenes."

Source:

Ribeaud, Denis, "Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of Treated Heroin Users," Journal of

Drug Issues (Talahassee, FL: University of Florida, Winter 2004), p. 188.

http://www.esrnexus.com/displayArticle.aspx?codedarticleid=394110

4.

(medication-based treatment to opioid dependence) "Medication-based treatment for opioid dependence consists of 2 distinct

approaches: detoxification and maintenance. 4 Detoxification involves the use of medications to bring a patient from an

opioid-dependent to an opioid-free state. The medications used are designed to decrease withdrawal-related discomfort andcomplications. Maintenance therapy involves the substitution of an abused opioid such as heroin or narcotic analgesics, which

are often used intravenously or intranasally several times a day, by a medically prescribed opioid such as methadone or

buprenorphine that can be taken orally and administered once a day in combination with counseling."

Source:

O'Connor, Patrick G., "Methods of Detoxification and Their Role in Treating Patients With Opioid Dependence," Journal of

the American Medical Association (Chicago, IL: American Medical Association, August 24, 2005), Vol. 294, No. 8, p. 961.

http://www.doctordeluca.com/Library/DetoxEngage/MethodsRoleOpioidDetox05...

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5.

(history of heroin maintenance) "Historically ... heroin was the main drug of choice for treatment. In the 1920s and earlier

in Britain, it was the treatment or maintenance drug for compliant middle-class addicts, those who accepted the authority of

the doctor to prescribe to them. The prescription of heroin was the basis of the so-called British system, which operated until

the 1960s. 6 This was not the case in the United States. The inability to conduct the NAOMI trial in the United States

reflects a historically different attitude toward the medical prescription of heroin to addicts; this prohibition dates back to the

implementation of the 1914 Harrison Narcotics Act before World War I. Doctors were prosecuted thereafter if they prescribed

heroin for addicts."

Source:

Berridge, Virginia, "Heroin Prescription and History," New England Journal of Medicine (Boston, MA: Massachusetts

Medical Society, August 20, 2009) Volu. 361, Issue 8, p. 820.

http://www.innerchangefoundation.org/pdf/NEJM2009.pdf

6.

(treatment with prescription injectable opiates) "Prescribing injectable opiates is one of many options in a range of

treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug

users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health

and social status, our findings endorse the view that it is a feasible option."

Source:

Metrebian, Nicky, Shanahan, William, Wells, Brian, and Stimson, Gerry, "Feasibility of prescribing injectable heroin and

methadone to opiate-dependent drug users; associated health gains and harm reductions," The Medical Journal of Australia

(MJA 1998; 168: 596-600).

http://mja.com.au/public/issues/jun15/mtrebn/mtrebn.html

7.

(1975-2002 - incidence of heroin use in Switzerland ) "The incidence of regular heroin use in the canton of Zurich started

with about 80 new users in 1975, increased to 850 in 1990, and declined to 150 in 2002, and was thus reduced by 82%.

Incidence peaked in 1990 at a similar high level to that ever reported in New South Wales, Australia, or in Italy. But only in

Zurich has a decline by a factor of four in the number of new users of heroin been observed within a decade. This decline in

incidence probably pertains to the whole of Switzerland because the number of patients in substitution treatment is stable, the

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age of the substituted population is rising, the mortality caused by drugs is declining, and confiscation of heroin is falling.

Furthermore, incidence trends did not differ between urban and rural regions of Zurich. This finding is suggestive of a more

similar spatial dynamic of heroin use for Switzerland than for other countries."

Source:

Nordt, Carlos, and Rudolf Stohler, "Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis,"

The Lancet, Vol. 367, June 3, 2006, p. 1833.

http://www.cesda.net/downloads/lancet1.pdf

8. Heroin Maintenance - Law and Policy

(law - heroin maintenance) "Many countries believe (erroneously) that the international drug conventions prohibit the use of

heroin in medical treatment. Furthermore, the International Narcotics Control Board (INCB) has exerted great pressure on

countries to cease prescribing heroin for any medical purpose. Nevertheless, a few countries, including the UK, Belgium, the

Netherlands, Iceland, Malta, Canada and Switzerland, continue to use heroin (diamorphine) for general medical purposes,

mostly in hospital settings (usually for severe pain relief). Until recently, however, Britain was the only country that allowed

doctors to prescribe heroin for the treatment of drug dependence."

Source:

Stimson, Gerry V., and Nicky Metrebian, Centre for Research on Drugs and Health Behavior, "Prescribing Heroin: What is the

Evidence?" (London, England: Rowntree Foundation, 2003), p. 4.

http://www.jrf.org.uk/sites/files/jrf/1859350836.pdf

9.

(safe injection - international treaties) "23. It might be claimed that this approach [drug injection rooms] is incompatible with

the obligations to prevent the abuse of drugs, derived from article 38 of the 1961 Convention and article 20 of the 1971

Convention. It should not be forgotten, however, that the same provisions create an obligation to treat, rehabilitate and

reintegrate drug addicts, whose implementation depends largely on the interpretation by the Parties of the terms in question.

If, for example, the purpose of treatment is not only to cure a pathology, but also to reduce the suffering associated with it

(like in severe-pain management), then reducing IV drug abusers exposure to pathogen agents often associated with their

abuse patterns (like those causing HIV-AIDS, or hepatitis B) should perhaps be considered as treatment. In this light, even

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supplying a drug addict with the drug he depends on could be seen as a sort of rehabilitation and social reintegration, assuming

that once his drug requirements are taken care of, he will not need to involve himself in criminal activities to finance his

dependence."

Source:

"Flexibility of Treaty Provisions as Regards Harm Reduction Approaches," Legal Affairs Section UNDCP (Vienna, Austria:

International Narcotics Control Board, September 30, 2002), p. 5.

http://www.communityinsite.ca/INCB-HarmReduction.pdf

10.

(heroin maintenance and research ethics) "The most widely accepted document outlining ethical standards for research at the

international level is the Declaration of Helsinki [36]. There is a crucial section, paragraph 30, of the document that is

pertinent to research on heroin treatment for addiction. It reads:

"'At the conclusion of the study, every patient entered into the study should be assured of access to the best proven

prophylactic, diagnostic and therapeutic methods identified by the study'[37]

"The main motive for this portion of the international research guidelines is to prevent the sponsors of research trials

(government, university, hospital or private) and physician collaborators from initiating research on subjects who would

otherwise be unable to access the treatment offered in the research and then taking away the treatment when the research

schedule is complete [36]."

Source:

Small, Dan, and Drucker, Ernest, "Policy Makers Ignoring Science Scientists Ignoring Policy: The Medical Ethical Challenges

of Heroin Treatment," Harm Reduction Journal (London, United Kingdom: May 2006), Vol. 3, p. 13.

http://www.harmreductionjournal.com/content/pdf/1477-7517-3-16.pdf

http://www.harmreductionjournal.com/content/3/1/16

11.

(heroin maintenance and human rights) "Heroin prescription is consistent with a number of state responsibilities under

international human rights instruments. The Universal Declaration of Human Rights states that 'everyone has the right to astandard of living adequate for the health and wellbeing of himself including medical care and necessary social

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services.' 24 Similarly, the International Convention on Economic, Social and Cultural Rights (ICESCR) recognizes the

'right of everyone to the highest attainable standard of physical and mental health.' 25 The UNAIDS/OHCHR International

Guidelines on HIV/AIDS and Human Rights recommend that states ensure the 'widespread availability of qualitative

prevention measures and services, adequate HIV prevention and care information' in order to protect the human rights of

people living with HIV/AIDS and stem the spread of the virus."

Source:

Canadian HIV/AIDS Legal Network, "Legislating on Health and Human Rights: Model Law on Drug Use and HIV/AIDS

Module 8: Heroin prescription programs," (Tornoto, Ontario: 2006), p. 9.

http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=875

12.

(heroin maintenance and political opposition) "The existing interference and non-evidence-based opposition from politicians

and care providers, who refuse to acknowledge the limitations of methadone maintenance and the superiority of prescribed

heroin in selected populations, is arguably unethical. Denying effective second-line therapy to those in need ultimately serves

to condemn many users of illicit heroin to the all too common outcomes of untreated heroin addiction, including HIV infection

or death from overdose."

Source:

Kerr, Thomas; Montaner, Julio SG; and Wood, Evan, "Science and politics of heroin prescription," The Lancet (London,United Kingdom:May 29, 2010) Vol. 375, Issue 9729, p. 1850.

http://www.thelancet.com/journals/lancet/article/PIIS0140673610605442/fu...

13. Heroin Maintenance - Research

(heroin vs. methadone maintenance) "The central result of the German model project shows a significant superiority of

heroin over methadone treatment for both primary outcome measures. Heroin treatment has significantly higher response rates

both in the field of health and the reduction of illicit drug use. According to the study protocol, evidence of the greater efficacy

of heroin treatment compared to methadone maintenance treatment has thus been produced. Heroin treatment is also clearly

superior to methadone treatment when focusing on patients, who fulfill the two primary outcome measures."

Source:

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Naber, Dieter, and Haasen, Christian, Centre for Interdisciplinary Addiction Research of Hamburg University, "The German

Model Project for Heroin Assisted Treatment of Opioid Dependent Patients -- A Multi-Centre, Randomised, Controlled

Treatment Study: Clinical Study Report of the First Study Phase," January 2006, p. 117.

http://www.heroinstudie.de/H-Report_P1_engl.pdf

14.

(heroin vs methadone maintenance) "To conclude, it must be stated that heroin treatment involves a somewhat higher safety

risk than methadone treatment. This is mainly due to the intravenous form of application. The rather frequently occurring

respiratory depressions and cerebral convulsions are not unexpected and can easily be clinically controlled. Overall, the

mortality rate was low during the first study phase, and no death occurred with a causal relationship with the study

medication. Compared to much higher health risks related to the i.v. application of street heroin, the safety risk of medically

controlled heroin prescription has to be considered as low."

Source:





15.

(heroin vs. methadone maintenance) "The German model project for heroin-assisted treatment of opioid dependent patients

is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends

particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For

the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone

maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In

accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can

be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

Source:





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16.

(heroin maintenance in the United Kingdom) "The UK is exceptional internationally because heroin is included in the range

of legally sanctioned treatments for opiate dependence. In practice, this treatment option is rarely utilised: only about 448

heroin users receive heroin on prescription."`

Source:

Stimson, Gerry V., and Nicky Metrebian, Centre for Research on Drugs and Health Behavior, "Prescribing Heroin: What is the

Evidence?" (London, England: Rowntree Foundation, 2003), p. 1.

http://www.jrf.org.uk/sites/files/jrf/1859350836.pdf

17.

(heroin maintenance and street heroin) "We have shown that treatment with supervised injectable heroin leads to

significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone. Furthermore,

this difference was evident within the first 6 weeks of treatment.

"This randomised controlled trial of treatment with supervised injectable opiates builds on the findings of five randomised

trials of supervised injectable heroin versus oral methadone."

Source:

Strang, John; Metrebian, Nicola; Lintzeris, Nicholas; Potts, Laura; Carnwath, Tom; Mayet, Soraya; Williams, Hugh; Zador,

Deborah; Evers, Richard; Groshkova, Teodor; Charles, Vikki; Martin, Anthea; and Forzisi, Luciana, "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," The Lancet (London, United Kingdom: May 29, 2010)

Vol. 375, Issue 9729, p.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960...

18.

(candidates for heroin maintenance) "These pilot study findings showed that opiate-dependent injecting drug users with long

injecting careers (most started between 1970 and 1982) and for whom opiate treatment had failed multiple times previously

were attracted into and retained by therapy with injectable opiates."

Source:

Metrebian, Nicky, Shanahan, William, Wells, Brian, and Stimson, Gerry, "Feasibility of prescribing injectable heroin and

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methadone to opiate-dependent drug users; associated health gains and harm reductions," The Medical Journal of Australia

(MJA 1998; 168: 596-600).

http://mja.com.au/public/issues/jun15/mtrebn/mtrebn.html

19.

(medicalization of heroin) "The harm reduction policy of Switzerland and its emphasis on the medicalisation of the heroin

problem seems to have contributed to the image of heroin as unattractive for young people."

Source:

Nordt, Carlos, and Rudolf Stohler, "Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis,"The Lancet, Vol. 367, June 3, 2006, p. 1830.


20. Switzerland - Heroin Maintenance

(heroin assisted trials in Switzerland) "... hundreds of peer-reviewed journal articles on the trials, as well as a book produced

by FOPH (Rihs-Middel et al. 2005), attest to the care taken to document a wide range of health and social outcomes from the

HAT experience. In brief, some of these results are as follows (See esp. Uchtenhagen 2009, 34 and Bammer et al. 2003, 365):

" It was possible to stabilize dosages of heroin, usually in two or three months, without a continuing increase of dosages,

which some had feared.

" There was significant and measurable improvement in health outcomes for patients, including significantly reduced

consumption of illicit heroin and even illicit cocaine.

" There was a significant reduction in criminal acts among the patients, to the point where the estimated benefits of this effect

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well exceeded the cost of the treatment (See also Killias et al. 2005).

" Heroin from the trials did not find its way into illicit markets.

" Initiation of new heroin use did not increase.

" Utilization of treatments other than HAT, especially methadone, increased after the advent of HAT rather than declining as

some had feared.

In short, the fears of opponents of HAT were largely refuted by solid evidence, though, of course, political debate would

continue."

Source:

Csete, Joanne, "From the Mountaintops: What the World Can Learn from Drug Policy Change in Switzerland," Global Drug

Policy Program (New York, NY: Open Society Foundations, May 2010), p. 19.

http://www.soros.org/initiatives/drugpolicy/articles_publications/public...

21.

(heroin maintenance in Switzerland) "Despite the availability of a wide range of treatment programs, including methadone

substitution, not all drug addicts with serious health and social problems could be motivated to enter treatment. A core group

remained, which was characterized by numerous social and physical deficiencies. In an attempt to reach this group, Heroin on

prescription was launched in 1994 as part of a nationally-based research project. Admission criteria were a minimum age of 20years, at least a two-year duration of daily intravenous heroin consumption, a negative outcome of at least two previous

treatments, and documented social and health deficits as a consequence of their heroin dependence. The treatment consisted of

between one to three injections of heroin a day, and medical, psychiatric, and social monitoring.

"After three years, the results showed, amongst numerous other findings, that:

" The program is able, to a greater extent than other treatments, to reach its designated target group.

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" The improvements in physical health proved to be stable over the whole period.

" Illicit heroin and cocaine use regressed rapidly and markedly, whereas benzodiazepine use decreased only slowly andalcohol and cannabis consumption hardly declined at all.

" The participants' housing situation and fitness for work improved considerably.

" The income from illegal and semi-illegal activities decreased dramatically (10% as opposed to 69% originally).

" Both the number of offenders and the number of criminal offenses decreased by about 60% during the first six months of

treatment.

Source:

van der Linde, Francois, "Moving Beyond the 'War on Drugs': The Swiss Drug Policy," James A. Baker III Institute for Public

Policy (Houston, Texas: Rice University, April 11, 2002), p. 4

http://www.bakerinstitute.org/publications/wp_dp_vanderlinde.pdf

22.

(heroin maintenance in Switzerland) "The harm reduction policy of Switzerland and its emphasis on the medicalisation of the

heroin problem seems to have contributed to the image of heroin as unattractive for young people."

Source:




23.

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(heroin maintenance in Switzerland) "Heroin misuse in Switzerland was characterised by a substantial decline in heroin

incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are

different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a

steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared

to become users in friendship chains. Musto's generational theory regards the decline in incidence more as a social learning

effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant earlyexperiences to devastating circumstances for addicts, families, and communities later on."

Source:




24.

(Swiss heroin prescription program) "With respect to the group of those treated uninterruptedly during four years, a strong

decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was

found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of

drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported

and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police

records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program

participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and

were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard toheroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also

remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the

drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers

towards program participants.

"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences

were found with regard to in-treatment rates. Taken as a whole, this suggests that the treatment had a somewhat more

beneficial effect on men than women. This result is corroborated by self-report data (Killias et al., 2002). With respect to age

and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter ofthe patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated

addicts, this retention rate is, at least, promising."

Source:




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25.

(Swiss heroin prescription program) "Finally, the analysis of the reasons for interrupting treatment revealed that, even in the

group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type

of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment

and a fortiori abstinence treatment is able to substantially reduce acquisitive crime, the redirection of heroin maintenancepatients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal

involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance

seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back 'on the

street'."

Source:




26.

(Swiss heroin prescription program) "With respect to the group of those treated uninterruptedly during four years, a strong

decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was

found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of

drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported

and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of policerecords suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program

participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and

were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to

heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also

remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the

drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers

towards program participants.

"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differenceswere found with regard to intreatment rates. Taken as a whole, this suggests that the treatment had a somewhat more

beneficial effect on men than women. This result is corroborated by selfreport data (Killias et al., 2002). With respect to age

and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of

the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated

addicts, this retention rate is, at least, promising."

Source:




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27.

(Swiss heroin prescription program) "Overall, results indicate that heroin prescription is a very promising approach in

reducing any type of drug related crime across all relevant groups analyzed. It affects property crime as well as drug dealing

and even use/possession of drugs other than heroin. These results suggest that heroin maintenance does not only have an

impact by reducing the acquisitive pressure of treated patients, but also seems to have a broader effect on their entire life-styleby stabilizing their daily routine through the commitment to attend the prescription center twice or three times a day, by giving

them the opportunity for psychosocial support, and by keeping them away from open drug scenes."

Source:




28.

(Swiss heroin prescription program) "As one of the responses to dramatically increasing drug scenes, heroin maintenance

trials were implemented in Switzerland from 1994 onwards. The target population for this new treatment consists of heroin

users who did not comply with other forms of treatment and who presented serious health and/or social problems."

Source:


Drug Issues (Talahassee, FL: University of Florida, Winter 2004), pp. 186-187.


29.

(Swiss heroin prescription program) "Finally, the analysis of the reasons for interrupting treatment revealed that, even in thegroup of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type

of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment

and a fortiori abstinence treatment is able to substantially reduce acquisitive crime, the redirection of heroin maintenance

patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal

involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance

seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back on the

street ."

Source:

Ribeaud, Denis, "Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of Treated Heroin Users," Journal ofDrug Issues (Talahassee, FL: University of Florida, Winter 2004), p. 188.

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30.

(2000 - heroin-assisted treatment in Switzerland ) "It has emerged that heroin-assisted treatment is a suitable option only for

a small proportion (currently 4%) of the 30,000 severely dependent injecting drug users. Heroin-assisted treatment is not a

replacement for other substitution or abstinence-based therapies, but an important addition for those drug users that have so far

fallen through the therapeutic net. This is confirmed by the relatively modest increase in patient numbers since the bar on the

legally permitted maximum number was lifted."

Source:

"Heroin-Assisted Treatment (HeGeBe) in 2000," Swiss Federal Office of Public Health (Bern, Switzerland: SFOPH, August28, 2001), p. 2.

31. Canada - Heroin Maintenance

(heroin maintenance vs. methadone) "The North American Opiate Medication Initiative (NAOMI) is a carefully controlled

(clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who

have not benefited from previous repeated attempts at methadone maintenance and abstinence programs.

"The NAOMI study will enrol 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal

sites are expected to begin recruitment this spring. "Each site will enroll about 157 participants. About half of these volunteers

will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control

group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic.

Those in the heroin group will be treated for 12 months then transitioned, over three months, into either

methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that

the total time to complete the study will be 21 to 24 months."

Source:

Health Canada News Release, "North America's First Clinical Trial Of Prescribed Heroin Begins Today," (Vancouver:

February. 9, 2005).

http://dev.cihr.ca/e/26516.html

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32.

(heroin maintenance clinical trials in Canada)

What is the NAOMI clinical trial?

"The North American Opiate Medication Initiative (NAOMI) was a randomized trial aimed at testing whether medically

prescribed diacetylmorphine, the active ingredient in heroin, offered benefits over and above optimized methadone therapy in

the treatment of individuals with chronic opioid dependence who were not benefiting from other available treatments. Patients

allocated to injectable diacetylmorphine were more likely to stay in treatment and more likely to reduce their use of illegal

drugs and other illegal activities than patients allocated to oral methadone.

If the NAOMI trial was a success, why the treatment did not continue?

"The NAOMI investigators requested permission to prescribe diacetylmorphine under compassionate use through HealthCanada's Special Access Programme. However, the requests were denied. Also, the funding for both clinics (Vancouver and

Montreal) was part of a CIHR grant that ended with the study period. The investigators are working on other options, such as

the SALOME study. Canada is the only country where diacetylmorphine has been tested for addiction treatment and has been

denied compassionate use."

Source:

"SALOME Clinical Trial Questions and Answers," InnerChange Foundation (Vancouver, British Columbia: 2010), p. 1.

http://www.innerchangefoundation.org/pdf/SALOME_FAQs_v4.pdf

33.


"What is the SALOME clinical trial?

"The Study to Assess Longer-term Opioid Medication Effectiveness [SALOME] is a clinical trial that will test whether

diacetylmorphine, the active ingredient of heroin, is as good as hydromorphone (Dilaudid), a licensed medication, in

benefiting people suffering from chronic opioid addiction who are not benefiting sufficiently from other treatments. Also, this

study will test if those effectively treated with injectable diacetylmorphine or hydromorphone can be successfully switched and

retained to the oral formulations of the medications."

Source:



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34.


"How are SALOME and NAOMI trials related?

"In the NAOMI study, a small group of patients received hydromorphone (Dilaudid) instead of diacetylmorphine in a

double-blind basis (nor the patients or staff knew which drug they were receiving), for the purpose of validation of

self-reported use of street heroin in urine toxicological tests. An unexpected finding was that injection patients could not

accurately discriminate whether they were receiving diacetylmorphine or hydromorphone."

Source:



35.

(NAOMI heroin maintenance clinical trials in Canada) "The North American Opiate Medication Initiative (NAOMI) is a

two-centre, parallel, open-label randomized controlled trial (RCT) aimed at testing whether heroin assisted treatment (HAT)

offers benefits over and above optimized methadone therapy in the treatment of individuals with chronic addiction whocontinue to use heroin despite having tried conventional treatments in the past."

CONCLUSIONS

"1. Heroin-assisted therapy proved to be a safe and highly effective treatment for people with chronic, treatment-refractory

heroin addiction. Marked improvements were observed including decreased use of illicit street heroin, decreased criminal

activity, decreased money spent on drugs, and improved physical and psychological health.

"2. The NAOMI trial attracted the most chronic and marginalized heroin users who were outside the treatment system and

continued to use heroin despite numerous previous treatment attempts. Both heroin-assisted therapy and optimized methadone

maintenance treatment achieved high retention rates and remarkable response rates in this difficult-to-treat group.

"3. Contrary to pre-existing concerns, the treatment clinics appeared to have no negative impacts on the surrounding

neighbourhoods.

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"4. Participants on hydromorphone did not distinguish this drug from heroin. Moreover, hydromorphone appeared to be

equally effective as heroin although the study was not designed to test this conclusively. If this were proven to be true,

hydromorphoneassisted therapy could offer legal, political and logistical advantages over heroin and could be made more

widely available."

Source:

"Reaching the Hardest to ReachTreating the Hardest-to-Treat," The NAOMI Study Team (Ottawa, Ontario: Canadian

Institutes of Health, October 17, 2008), pp. 2 and 18.

http://vancouver.ca/fourpillars/documents/NAOMIResultsSummary-Oct172008....

36.

(NAOMI heroin maintenance clinical trial and motivation) "Our study had two primary findings. First, we found that most

study participants were motivated for treatment, despite not accessing it in at least the past 6 months (as per trial entry

criteria). This may be the result of a lack of accessible or attractive treatment options available to them. Second, we found that

baseline motivation for treatment did not predict retention in either HAT [heroin assisted treatment] or MMT [methadone

maintenance treatment], however motivated patients receiving HAT were more likely to achieve response than unmotivated

patients. While HAT is likely to retain patients regardless of motivational status, success in treatment, in terms of decreases in

illicit drug use and crime, is more likely among motivated patients, as measured in our study. Further, HAT was statistically

significantly more effective than MMT on each of the outcomes assessed."

Source:

Nosyka, Bohdan; Geller, Josie; Guh, Daphne P.; Oviedo-Joekes, Eugenia; Brissette, Suzanne; Marsh, David C.; Schechter,

Martin T.; Anis, Aslam H., "The effect of motivational status on treatment outcome in the North American Opiate Medication

Initiative (NAOMI) study," Drug and Alcohol Dependence (Philadelphia, PA: College on Problems of Drug Dependence,

September 2010), p.

37.

(NAOMI heroin maintenance clinical trial) "The present study investigated treatment response and retention by gender in

North Americas first randomized controlled trial of injectable diacetylmorphine. DAM showed greater effectiveness than

MMT with respect to treatment retention and response at 12 months for both men and women, although there were significant

treatment differences in more sub-scores for men than women. There were no gender differences in overall clinical response

and retention at 12 months in the DAM and MMT groups."

Source:

Oviedo-Joekesa, Eugenia; Guh, Daphne; Brissette, Suzanne; Marchand, Kirsten; Marsh, David; Chettiarb, Jill; Nosyk,

Bohdan; Krausz, Michael; Anisa, Aslam; Schechtera, Martin T., "Effectiveness of diacetylmorphine versus methadone for the

treatment of opioid dependence in women," Drug and Alcohol Dependence, (Philadelphia, PA: College on Problems of DrugDependence, September 2010), p. 4.

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http://www.ncbi.nlm.nih.gov/pubmed/20510551

Related Chapters:

- Hepatitis C

- Heroin

- HIV/AIDS

- Methadone & Buprenorphine
http://www.ncbi.nlm.nih.gov/pubmed/20510551http://cms/Hepatitis_Chttp://cms/Heroinhttp://cms/HIV-AIDShttp://cms/Methadonehttp://cms/Methadonehttp://cms/HIV-AIDShttp://cms/Heroinhttp://cms/Hepatitis_Chttp://www.ncbi.nlm.nih.gov/pubmed/20510551

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