Methadone & Other Opiate Maintenance

Feature: Heroin More Effective Than Methadone for Some Addicts, NAOMI Study Reports

by psmith, August 20, 2009, 11:00pm, (Issue #598)

In a report that was actually completed last October but not published until this week in the New England Journal of Medicine, researchers from the North American Opiate Medication Initiative (NAOMI) found that giving heroin under supervision to some hard-core drug addicts was more effective than giving them methadone. The study's publication in the prestigious peer-reviewed journal is already leading to calls for experiments with heroin maintenance in the US. To qualify for the study, participants had to have been addicted to heroin, Dilaudid, or another opiate for at least five years, have been injecting for at least the past year, have tried addiction treatment, including methadone maintenance, at least twice, and be at least 25 years of age. While researchers were loathe to generalize their findings, they described heroin maintenance as "a safe and effective treatment" for chronic addicts who have not taken to other forms of treatment.

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Hastings St., downtown Vancouver (from vandu.org)

In the NAOMI project, researchers monitored 251 heroin addicts in Vancouver and Montreal and provided them with maintenance drugs for a year under the supervision of nurses, doctors, social workers, and psychiatrists. One hundred fifteen received pharmaceutical heroin (diacetylmorphine), 111 received methadone, and 25 received Dilaudid (hydromorphone).

Among participants who received heroin by injection, 88% completed the program compared to 54% of those receiving oral methadone. Similarly, illicit drug use rates dropped by 67% among those receiving heroin, compared to 48% among those receiving methadone.

"Our data show remarkable retention rates and significant improvements in illicit heroin use, illegal activity and health for participants receiving injection assisted therapy, as well as those assigned to optimized methadone maintenance," said Dr. Martin Schechter, principal investigator for the Center for Health Evaluation and Outcome Sciences at the University of British Columbia School of Population and Public Health and NAOMI's lead researcher. "Prior to NAOMI, all of the study participants had not benefited from repeated standard addiction treatments. Society had basically written them off as impossible to treat," he said.

"We now have evidence to show that heroin-assisted therapy is a safe and effective treatment for people with chronic heroin addiction who have not benefited from previous treatments. A combination of optimal therapies -- as delivered in the NAOMI clinics -- can attract those most severely addicted to heroin, keep them in treatment and more importantly, help to improve their social and medical conditions," explained Schechter.

The NAOMI research results mirror similar findings from a number of European countries, a fact noted in a Journal editorial by Virginia Berridge. "The results of this trial may be added to those from Germany, the Netherlands, Spain and Switzerland," Berridge wrote. "Switzerland has 10 years of experience in the prescription of heroin, and in a November 2008 referendum, 68% of voters were in favor of its continued prescription."

The NAOMI findings, along with earlier work from Europe, are relevant to the United States. According to government figures, nearly 700,000 Americans are heroin users, and 15% to 25% of them are heavy users who could benefit from prescription heroin.

But heroin is a Schedule I drug under the US Controlled Substances Act, which means it cannot legally be prescribed. That is unlikely to change anytime soon. Even allowing for a pilot program would require political decisions that are unlikely to be made in the foreseeable future.

That needs to change, said advocates of evidence-based drug policies. "The NAOMI results are clear that prescription heroin reduces crime, and overdose deaths," said Laura Thomas, deputy state director of the Drug Policy Alliance. "The reason this effective treatment isn't available in the United States right now is politics. The science is there."

"The success of NAOMI, combined with similar results in other countries, leaves little question that heroin prescription would reduce crime, and overdose fatalities in the United States as well," added DPA executive director Ethan Nadelmann. "Recent votes in Germany and Switzerland, combined with similar evidence of public support in other countries, show that the public will support even controversial drug policies when they have proven results. There is no question that heroin prescription programs are needed and long overdue in this country. All that stands in the way is ideology and the backward assumption that it can never happen in the United States."

It wasn't just DPA wondering about more effective forms of drug treatment. In a blog post titled Prescription Heroin?, New York Times science columnist John Tierney asked just that: Is it time for prescription heroin in the US? He didn't provide an answer, but the fact that the question is being asked by someone like Tierney is suggestive.

And if not prescription heroin, what about Dilaudid? It is Schedule II and can be prescribed, although not, under current law, for maintenance purposes. Schecter and his fellow researchers found that NAOMI participants could not distinguish it from heroin and that it appeared to be equally effective.

Glorious Kyrgyzstan -- the Best Harm Reduction Program in Central Asia

by borden, July 26, 2009, 03:22pm

The Central Asian Republic of Kyrgyzstan sits along a drug trafficking route, and has an estimated 80,000-100,000 drug users, more than half of whom inject drugs. Unlike some countries in the region, Kyrgyzstan has embraced harm reduction strategies such as needle exchange and methadone maintenance. Even prisoners in Kyrgyzstan have access to these programs. By going this route, they have been able to curb the country's HIV epidemic. A new video from the Hungarian Civil Liberties Union -- in Russian, with English subtitles -- tells the story. Check it out:

Europe: British Prisons Install Methadone Vending Machines

by psmith, July 23, 2009, 11:00pm, (Issue #595)

In a bid to promote opiate maintenance therapy behind bars, the British government has begun installing methadone vending machines in the country's prisons. Justice Minister Phil Hope told parliament last week that 57 vending machines have been installed so far.

The machines allow prisoners to receive an individualized dose of methadone by giving a fingerprint or an iris scan. The machines are paid for by the Department of Health and will cost about $6.5 million dollars, about 10% of the department's prison drug treatment budget. The target is to have the machines in half of Britain's 140 prisons.

According to the latest available prison population statistics, in 2007, nearly 6,400 of Britain's 81,000 prisoners were there on drug charges, with slightly more than half of them charged with simple drug possession or possession with intent to distribute. The official statistics provide no breakdown of which drugs were involved.

"Methadone dispensers are a safe and secure method for providing a prescribed treatment," said a health department spokesman. "They can only be accessed by the person who has been clinically assessed as needing methadone and that person is recognized by a biometric marker, such as their iris."

Providing methadone to addicted prisoners allows them to manage their habits without resorting to illicit heroin supplies within the prisons. But the opposition Conservatives were quick to try to score political points, claiming that the Labor government would rather "manage offenders' addiction" than end it.

"The public will be shocked that Ministers are spending more on methadone vending machines than the entire budget for abstinence based treatments," said Dominic Grieve, the Conservative shadow justice secretary. "Getting prisoners clean of drugs is one of the keys to getting them to go straight. We need to get prisoners off all drug addiction -- not substitute one dependency for another. The government's approach of trying to 'manage' addiction is an admission of failure."

The Conservatives are hammering away at Labor any way they can as they prepare for national elections sometime in the coming months. Attacking enlightened approaches to inmate drug addiction is just another arrow in their "tough on crime" quiver.

Canada: New Heroin Maintenance Pilot Program to Get Underway Later This Year

by psmith, June 04, 2009, 11:00pm, (Issue #588)

Despite fighting in the courts to shut down Insite, Canada's only safe injection site, Canada's conservative federal government is providing funding for a heroin prescription pilot program in Vancouver and Montreal. The program will begin providing heroin to some 200 hard-core users later this year.

Known as SALOME (the Study to Assess Longer-term Opioid Medication Effectiveness), the program builds on a similar multi-year program in Vancouver that ended last summer. That program, NAOMI (the North American Opiate Medication Initiative), was funded with $8 million from the Canadian Institutes of Health Research with the approval of Health Canada, but the government of Prime Minister Steven Harper has refused to publicly acknowledge research findings that participants' physical and mental health improved and that they committed fewer crimes.

Still, the Institutes of Health Research are quietly throwing in $1 million for SALOME. Josee Bellemare, press secretary to Health Minister Leona Aglukkaq, told the Toronto Globe & Mail: "Our government recognizes that injection drug users need assistance. That's why we are investing in prevention and treatment, to help people recover from their drug addictions."

The three-year trial will offer heroin in both pill and injectable forms, and will also offer hydromorphone to see if it could be used as a substitute. The trial will seek to assess whether prescription heroin is a safe and effective treatment and whether users will accept the drug in pill form. Researchers are currently recruiting hard-core users who have not responded to conventional treatments and say they expect to have clinics operating in the two cities by this fall.

Canada joins Britain, Denmark, the Netherlands, Spain, and Switzerland as countries where heroin prescription programs are in place either permanently or on a trial basis. The German parliament voted last week to join the club, too.

Europe: German Parliament Approves Heroin Maintenance

by psmith, June 04, 2009, 11:00pm, (Issue #588)

The German parliament has voted to allow the prescription of heroin to addicts who have not responded to other treatments. The lower house of parliament approved the measure May 28.

Under the new law, heroin users who have been using for at least five years, are at least 23 years old, and who have failed to stop in other treatment programs will be able to receive pharmaceutical heroin in designated treatment centers. The law follows a German pilot program conducted in seven cities between 2002 and 2006 that showed impressive results in reducing crime, overdose fatalities, and HIV among hard-core users.

Similar results have been reported in Britain, Canada, the Netherlands, Spain, and Switzerland. Last year, Swiss voters legalized prescription heroin in a public referendum.

The news was welcomed by drug reformers around the planet. "The success of the German heroin prescription projects, combined with similar results in other countries, leaves little question that heroin prescription could reduce crime, HIV and overdose fatalities in the United States as well," said Ethan Nadelmann, executive director of the Drug Policy Alliance. "And [the May 28] vote in Germany, combined with similar evidence of public support in other countries shows that the public will support even controversial drug policies when they are given a chance to prove themselves. There is no question that heroin prescription programs are needed and long overdue in this country. All that stands in the way is politics and the backward assumption that it can never happen in the United States."

The Australian group Families and Friends for Drug Law Reform likewise used the German vote to agitate for similar policies Down Under. "The German decision challenges Australia to remove John Howard's veto of this medical treatment and put humanity and social well-being first," said Brian McConnell, President of Families and Friends for Drug Law Reform. "The veto of the decision of the Australian Health Ministers in 1997 for a heroin trial must be reviewed in the light of the rising number of overdose deaths and the threat of a renewed flood of Afghan heroin," he said

"Excuses for not introducing it have become baseless given the overwhelming evidence that now exists in support of the measures," McConnell added. "Attracting the severely addicted into treatment, away from recruiting and selling to new users to support their habit, will surely allay parents' and governments' concerns about the provision of this treatment. It can undermine organized crime's profit from heroin, which is critical at a time when world production of heroin is increasing. Much is to be gained with this common sense measure: there are lives to be saved, individuals' health to improve and a huge potential for reduced crime and trafficking in illegal heroin."

Heroin Maintenance: Study Suggests Baltimore Could Be Ripe for a Pilot Program

by psmith, February 26, 2009, 11:00pm, (Issue #574)

Baltimore is home to one of the nation's most intractable heroin-using populations, and now a study done for the city's Abell Foundation is suggesting it could be time to try something new, at least in this country: heroin maintenance. The idea is not so much to push for such a program now, but to open the door for discussion -- a worthy idea given that decades of repression and, more recently, conventional drug treatment have done little to stem the tide of addicts.

Authored by University of Maryland drug policy expert Peter Reuter, the study, Can Heroin Maintenance Help Baltimore?, examined existing heroin maintenance programs in Switzerland and Germany as well as the now-ended North American Opiate Maintenance Initiative (NAOMI) program in Vancouver, and examined the Baltimore heroin scene. His review of results so far found decreases in criminality, increases in employment, and health improvements for participants.

But Reuter also noted that those existing programs are expensive (more expensive than methadone treatment), serve relatively small numbers, and would be politically controversial in the US setting. In fact, the US National Institute on Drug Abuse, offered a chance to participate in the NAOMI program, declined. In addition, Reuter wrote that significant differences between hard core heroin users in Baltimore and in European cities made predictions of success difficult.

Can heroin maintenance help Baltimore? Here's how Reuter answered his own question:

At best there is a case only for an experiment. There are too many potential differences between Baltimore City and the other sites in which HAT [heroin-assisted therapy] has been tried to allow confident predictions of the outcomes. Visits to facilities in other countries hardly provide an inspiring model. The client population in Baltimore City is highly troubled so even if HAT leads to better outcomes for the group as a whole, many of the clients will remain unemployed, marginalized, and in poor health conditions. There will be some poster children but not many.

The potential for gain, however, is substantial. Even in the aging heroin-addict population, there are many who are heavily involved in crime and return frequently to the criminal justice system. Their continued involvement in street markets imposes a large burden on the community in the form of civil disorder that helps keep investment and jobs out. If heroin maintenance could remove 10 percent of Baltimore's most troubled heroin addicts from the streets, the result could be substantial reductions in crime and various other problems that greatly trouble the city. That is enough to make a debate on the matter worthwhile.

"It is a sensible innovation to consider," Reuter told the Baltimore Sun. "I am not a passionate advocate for it, but I do think someone should try it in the US. It has enough plausibility that it's worth trying."

But Baltimore officials are not convinced. "I think it would be a mistake to pursue an expensive and unproven idea when we need more resources for effective drug treatment," said Dr. Joshua Sharfstein, the city health commissioner, who apparently did not actually read the report. "There's nothing that persuades me to invest in something that is so expensive and without evidence."

Former Baltimore health commissioner Dr. Peter Beilenson worried that the notion was too radical to fly in the US and could undercut more plausible reforms. "It's not like everything has been tried and everything has failed and you just throw up your hands," said Beilenson, who is now Howard County's top health official. "The problem is if you are going to do any reasonable drug policy reform, this heroin thing is such a red flag that it takes all the attention away. It makes it look like anyone who is interested in drug policy reform is crazy." [Ed: Beilenson should know -- he tried it in 1998.]

But some addiction specialists said there should at least be a clinical trial. "Do I think it would be interesting? In a controlled clinical trial setting, yes," said Susan Sherman, an epidemiologist with the Johns Hopkins Bloomberg School of Public Health "To me, it's also important to have a public dialogue, regardless of the outcome. It forces people to deal with really hard issues about drug use and drug users."

"Most studies clearly show they help," said Dr. Christopher Welsh, assistant professor of psychiatry at the University of Maryland medical school. "But using public funds to fund something like this would be a whole other level of politics, especially in this economy."

Europe: Danish Heroin Maintenance Program to Commence Next Month

by psmith, February 12, 2009, 11:00pm, (Issue #572)

Beginning sometime next month, hard core heroin users in Denmark will be able to receive two doses of heroin a day, courtesy of the Danish health system. They will have to go to one of five drug clinics established around the country, where they will be able to inject pharmaceutical grade heroin under a doctor's supervision.

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downtown Copenhagen

The heroin maintenance initiative was approved a year ago by an overwhelming consensus in the Danish parliament. Only one small far-left party opposed it, and not on principle, but because of funding issues. It even won the support of the rightist Danish People's Party, not normally a bastion of progressive ideas.

Denmark thus joins a small but growing number of European countries, including Switzerland, the Netherlands, and Great Britain that have heroin maintenance programs. The goal is harm reduction.

"The aim is to improve their state of health, help them avoid committing crimes and stabilize their lives," Dr. Anne Mette Doms of the Danish Board of Health told the British newspaperThe Guardian. "Quitting altogether is not a realistic option for most of these patients. For them, this will be a chronic treatment, as if you were treating a chronic disease."

Support for such programs is a welcome change, said Preben Brandt, chairman of the Council for Socially Marginalized People. "Five years ago I decided I would not participate in yet another debate on drugs," he told the Guardian. "It was too emotional, with different groups being very aggressive. The counter-argument was always 'you kill people by giving heroin' or 'with this initiative, you are telling people that taking heroin is OK'," he said. "It is very difficult to have a rational debate when you are arguing against beliefs."

But successes in other European countries experimenting with heroin maintenance helped change the atmosphere, said Mads Uffe Pedersen, head of the Center for Alcohol and Drug Research at the University of Aarhus. "The politicians became convinced that it could help those with the most severe drug problems," he said. "You could not argue against the (positive) findings."

"The debate became more practical," agreed Brandt. "It was about what policies worked and which ones did not. It was no longer about morality."

And changing attitudes toward drug users also helped, Brandt said. "Drug addicts in Denmark are less stigmatized. They are no longer perceived as criminals who are a danger to society. They're seen as patients who have a disease they need help with. The new scapegoats in Denmark are the foreigners."

Europe: Government Must Support Employers in Hiring Drug Users, British Drug Watchdog Group Warns

by psmith, December 18, 2008, 11:00pm, (Issue #565)

With drug strategies and welfare reform plans in the British Isles moving toward pushing drug users into treatment and from treatment into the workplace, the British government is going to have to do a lot more to help drug users find jobs, a leading British drug policy think tank said in a report released this week. The report, Working Toward Recovery: Getting Problem Drug Users Into Jobs was published by the UK Drug Policy Commission and contains more than three-dozen recommendations aimed at easing the transition.

The report noted that while holding a job is a key component of drug user rehabilitation and integration into society, about 80% of problem drug users were unemployed. (The report defined "problem drug user" as someone dependent on heroin or crack cocaine.) And while government strategies in England, Scotland, and Wales are to get users off drugs and into jobs, the strategies are undeveloped and, and employer practices sometimes counterproductive.

In particular, the report criticized the informal "two years drug free" rule used by many employers. With the two years of abstinence including abstinence from opiate substitute medications, such as methadone, the practice is unduly harsh and unnecessary, given that many people on the controlled drug regimen have already achieved the stability employers say they want.

Employers are unlikely to want to hire problem drug users, with only 26% saying they would be prepared to hire a former drug user. Employers cited several types of risk associated with drug users -- from continuing drug use, to the firm's reputation, and to the firm's customers and employees -- and about three-quarters of them they needed more government help in developing risk assessments, support for drug using employees, and information about indemnity insurance.

The Labor government's welfare reform proposals will tie money to pay for drug treatment to drug users agreeing to a rehabilitation plan, the study noted. But with employment a big part of rehabilitation, the government is going to have to provide incentives and programmatic support if it is going to force those drug users into the job market.

Europe: Swiss Vote to Make Heroin Prescription Permanent, But Reject Marijuana Legalization

by psmith, December 04, 2008, 11:00pm, (Issue #563)

Voters in Switzerland Sunday gave overwhelming approval to a proposal to make the country's pioneering heroin prescription program legal, but at the same time rejected an initiative that would have legalized and regulated the use and sale of marijuana. The heroin program won with 69% of the vote, while the marijuana initiative got only 37% support.

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Swiss cannabis (marijuana) field (picture from cannatrade.ch)

Begun in 1994, the Swiss heroin prescription program has been proven to reduce crime among participants and improve the health and daily lives of addicts. It is currently offered in 23 centers across the country, where users who have not responded to other therapies inject carefully measured doses of heroin under medical supervision. The program also provides access to psychiatrists and social workers in its bid to help users function in society.

Making heroin prescription permanent was approved by parliament in March. But conservative forces balked at that decision and forced a national referendum.

The United States and the UN's International Narcotics Control Board have criticized the program as potentially fueling drug abuse, but other governments have started or are considering their own programs modeled on the system. The Netherlands has been offering prescribed heroin since 2006, with nearly 600 patients in the program, and in May of this year, Denmark approved a law making heroin prescribing a permanent program. Great Britain, Belgium, Germany, and Spain are also carrying out heroin prescription trials, and one just finished up in Canada.

While Swiss voters were okay with providing heroin to addicts, they were not okay with allowing pot-smokers to go unmolested. The Hemp Initiative went down in flames, despite the wide acceptance of marijuana use in the country. Some 44% of Swiss 13-to-29-year-olds have smoked pot at least once, and 9% said they smoke almost daily.

The Hemp Initiative would have decriminalized the possession and cultivation of marijuana for personal use. It made the ballot after more than 100,000 Swiss signed petitions to place it before the voters.

But the initiative incited an organized opposition, which included part of the governing coalition. Despite the seeming paradox of approving the distribution of heroin while barring the use of marijuana, the Swiss seemed concerned that relaxing the marijuana laws would increase drug tourism and encourage drug use.

"That could lead to a situation where you have some sort of cannabis tourism in Switzerland because something that is illegal in the EU would be legal in Switzerland," government spokesman Oswald Sigg told the Associated Press.

"We would have to fear Switzerland becoming a European drug hub," Hans Fehr, a People's Party lawmaker, told the AP. "There'll be more consumers, unforeseeable, costs and a wider drug trade."

Olivier Borer, 35, a musician from Solothurn, told the AP he welcomed the vote's outcome because the state needed to help heroin addicts, but not encourage pot smoking. "I think it's very important to help these people, but not to facilitate the using of drugs. You can just see in the Netherlands how it's going. People just go there to smoke," Borer said.

But Jo Lang, a Green Party member of parliament said the marijuana vote result was disappointing because it meant 600,000 Swiss pot smokers will continue to be treated as criminals. "People have died from alcohol and heroin, but not from cannabis," Lang said.

Europe: Swiss to Vote on Marijuana Decriminalization, Heroin Prescription

by psmith, November 13, 2008, 11:00pm, (Issue #560)

Swiss voters will go to the polls November 30 to decide whether to approve marijuana decriminalization and the government's ongoing "four pillars" drug strategy, which includes the prescription of heroin to hard-core addicts. A Swiss Broadcasting Corporation poll late last month showed the decriminalization effort in a virtual dead heat, leading 45% to 42%, with 13% undecided, while the referendum on the broader strategy appears headed to easy victory, with 63% in favor, 20% opposed, and 17% undecided.

The referendum on marijuana policy envisages its legalization for personal use, with its cultivation and sale being regulated by the state. It comes a decade after Swiss voters narrowly rejected a similar proposal. An attempt to decriminalize through parliament failed in 2004.

While the vote on decriminalization looks to be close, the effort is supported by a 1999 government advisory committee report and the governing coalition, and it is picking up some unexpected allies. Regulation would protect young people, argued the Social Democrats. Somewhat surprisingly, the effort is also supported by the center-right or libertarian Radical Party and the respected daily Neue Zurcher Zeitung, which described both the decrim effort and the amended drug law as steps in the right direction.

"A policy which is only based on abstinence, bans and repression ultimately leads to more spending on welfare. It also is against the spirit of liberalism and leaves no room for people to take responsibility for themselves," the newspaper editorialized.

But not everyone is jumping on the decrim bandwagon. The rightist Swiss People's Party remains staunchly opposed. "Switzerland would become the drug Mecca of Europe," said People's Party parliamentarian Andrea Geissbühler.

The government's four-pillars drug strategy appears much less controversial, especially after a decade of pilot heroin prescription programs that have proven effective. Even the grassroots of the rightist parties approve, according to the poll.

"The number of drug-related deaths per year dropped from 400 at the beginning of the 1990s to 152 last year," said Felix Gutzwiller, a Zurich Radical Party senator, adding that each year some 200 addicts graduate from heroin maintenance to methadone maintenance. "It is telling that drugs issues are no longer top of the list of public concerns, unlike 20 years ago," he said.