The Controversial Use of Heroin-Maintenance Therapy

Heroin maintenance treatment is a controversial method of treating opioid addicted patients, typically those who have failed conventional drug treatments. In a recent edition of BMJ, experts Jurgen Rehm, Benedikt Fischer, and Neil McKeganey debate whether heroin-assisted maintenance treatment should be offered experimentally to reduce health and social harm related to using heroin.

Taking the position that heroin should be prescribed to heroin addicts, chair of the Centre for Addiction and Mental Health in Toronto, Canada, Jurgen Rehm, and professor for the Centre for Addiction and Mental Health in Toronto Canada, Benedict Fischer, argue that three studies support opioid maintenance therapy for people with chronic heroin dependence.

Specifically, a study in Switzerland found that heroin assisted maintenance treatment was effective in a group of long-term users who were more successful in terms of street drug use, mental health, social functioning, and illegal activities than patients in conventional drug treatment. The results of the study are published in Evidence Based Healthcare, "A heroin maintenance program is a clinically effective treatment for heroin users who fail in conventional drug treatment programs." To be clear, however, the patients in the Geneva heroin maintenance program were only a small subgroup of severely addicted patients who were unsuccessful in conventional drug treatments.

Likewise, large clinical trials in the Netherlands and Germany actually compared heroin assisted maintenance treatment to methadone maintenance treatment and found heroin assisted maintenance treatment to yield positive results and to be cost effective.

Rehm and Fischer argue that since heroin dependence is a chronic and relapsing disease, heroin maintenance treatments are justified. However, such treatments should not occur in isolations. They should instead be part of an overall integrated treatment system.

In contrast, Neil McKeganey, professor of drug misuse research at the University of Glasgow, asserts that drug maintenance treatments are merely a strategy "borne of utter frustration at our seeming inability to tackle an escalating drug problem."

According to McKeganey, prescribing heroin to heroin addicts is, at best, "a risky strategy." Prescribing heroin is not so much a treatment as it is a means to reduce social, medical, and behavioral problems that accompany the addiction itself.

In support of his position, McKeganey cites an Australian study that surveyed 429 heroin users 36 months after they started treatment at drug treatment agencies. Of the 429 people, 40 percent had been abstinent for the preceding 12 months. What McKeganey fails to note is that the researchers found that the proportion of those treated who sustained abstinence since over the entire 36 months declined from 14 percent at 12 months to 8 percent at 36 months.

McKeganey's conclusion is that heroin addicts who seek treatment and do so to become drug free should be offered services to support that goal rather than heroin maintenance treatments. Yet, Rehm and Fischer are advocating only for the use of heroin assisted maintenance under specific limited circumstances, such as in the case of treatment resistent users. Consequently, McKeganey does not so much disagree with Rehm and Fischer as he attempts to make the point that users who want to be drug free should be given the opportunity to do so through conventional drug treatment programs in the first instance rather than offered heroin maintenance therapy.

Sources:

Addictive Behaviors, 2007 Sep;32(9):1897-906, "Patterns of sustained heroin abstinence amongst long-term, dependent heroin users: 36 months findings from the Australian Treatment Outcome Study (ATOS)," Darke S, Ross J, Mills KL, Williamson A, Havard A, Teesson M.

BMJ, Volume 336, pp 70-1, "Head to Head: Should heroin be prescribed to heroin misusers?" Jurgen Rehm, Benedikt Fischer, and Neil McKeganey.

Evidence-based Healthcare, Volume 3, Issue 3, Page 64, "A heroin maintenance program is a clinically effective treatment for heroin users who fail in conventional drug treatment programs," Thomas V Perneger, Francisco Giner, Miguel del Rio, and Annie Mino.