THE HEROIN TRIAL FAILURE

by Anders Ulstein

Read the full article here. Summary below.
Read related article: Dodgy dossier 2. 

 

The Lancet report (29 May 2010) of a recent heroin prescription trial has been widely promoted as a success. But only five out of 43 clients - who received a 450 mg of legal heroin twice a day plus a nightly oral methadone supplement over a 26 week period - managed to get off street heroin.

The remaining 38 decreased their consumption of street heroin while on the legal stuff but are still involved in the illegal heroin market, still involved in the crime, harm and misery related to it.

Regardless of the results, the authors make the following recommendation based on their study: "UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts." 

What is a significan and surprise finding is that, even when offering free heroin, the programme has such a limited impact on the use of street heroin. And it is far costlier than rehab - up to five patients could go to rehab with a possibility of becoming drug free for the cost of each one still on drugs and with unchanged lifestyles in the Riott trial.

The cost of heroin prescription per client is estimated to be about €18.000 a year, far more than for other treatment options. The UK government has spent about €700,000 on two heroin trials last year.

MISLEADING MEDIA REPORTS

Even Reuters fell victim to the prescribers' interpretation. "Prescribing heroin to addicts who can't kick their habit helps them stay off street drugs, British researchers said Friday", under the headline "Prescription heroin helps addicts off street drugs". This is misleading. 

Associated Press reports that "Some heroin addicts who got the drug under medical supervision had a better chance of kicking the habit than those who got methadone, a new study says", under the title "Study: heroin better than methadone to kick habit".

First of all, to "kick the habit" means to get off the addiction. The aim of the trial was not to get people off addiction, and it did not even measure that. Second, the study does not say that heroin is better than methadone, it suggests that for some hard to treat clients (5-10% of the heroin addicts) heroin might give better results.

To see such inacurate and misleading reporting by the world's two most serious news agencies should worry everyone who is interested in how science is translated.

What this trial illustrates is the limitations of such harm reduction measures rather than its strengths. It also illustrates how scientific results may be distorted and misleading, possibly intentionally.

The researchers display a profound lack of understanding of what addiction is. The report's lead author Johon Strang says the results shows they have "turned around" the users' drug problem. What is in fact "turned around" is a small piece of the symptoms of addiction in a small group of people. The drug problem is not turned around and certainly not the addiction.

REFERENCE 

The study is called 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, written by John Strang and collegues.

Addiction Today's earlier comment: Dodgy dossier 2.

Comments

[Frugal Dougal]

I'd had high hopes for heroin prescription schemes, but I hope that your report is widely read. I'll be leaving the industry soon, but what I've learnt is that an amount of toleration of illicit drug use is built into the subsitution prescribing industry. We've tried it, and it didn't work: time to try something else.

[matt]

Always a pleasure to read informed views from the Daily Mail of the addictions field. Cutting edge comment, thoroughly thought through...you are to be congratulated.

[Steve Rolles]

The trial/paper was titled:

"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"

and its key finding was:

"Treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone"

I'm unclear why that result is therefore seen as a 'failure', even if there is a debate about whether the results justify the recommended roll out on cost grounds.

You should also be careful about confusing potentially misleading reporting with your critique of the report itself. That said I'm not convinced that saying heroin 'helped' keep people off street drugs was misleading (it did, just as the methadone also did), nor that saying it was 'better' at doing so that methadone was misleading, as this was actually what the results suggested (see key finding - above).

It is worth noting that there is a UK monopoly on diamorphine supply (which has been tyhe subject of a DTI investigation) that means it is 6 times more expensive (£12k compared to £2k) per year than it is in the Netherlands for example. If this issue is resolved the cost comparison with methadone would be much more favourable.

[Kenneth Eckersley]

BACK TO THE FUTURE

Diamorphine three times a day under supervision? How do you supervise doses at work and at midnight?

It was because this didn't work in the 1950s that the psycho-pharms were able to "sell" methadone to governments.

Now that methadone has also been recognised as a failure, these industries want to turn the clock back to keep their hold on so-called "treatment" supplies.

Kenneth Eckersley,
CEO
Addiction Recovery Training Services.

[Rory Green]

You column also fails to recognise the Swiss experience, which has been running for ten years, where rates of crime, and invections of HIV and Hep A and B decreased dramatically.

It is clear from your intepretation that the title of your publication is accurate, for you are addicted to the policies of prohibition and law enforcement.

[Kathy Gyngell]

If Rory Green wants rigorous research, I recommend he look to the last substantive Cochrane Review of four such randomised trials to test the efficacy of heroin maintenance versus methadone or other substitution treatments.
Its “Heroin Maintenance for chronic heroin dependents” was published in 2005 and looked at patient treatment retention, reducing illicit use and for improved health and social functioning – and concluded: “No definitive conclusions about the overall effectiveness of heroin is possible”.
You can access the research here:
www2.cochrane.org/reviews/en/ab003410.html

[Steve Rolles]

Kathy - regards your point on the Cochrane study, I think it is rather unfair not to mention that the commentary accompanying the Strang study in the Lancet (discussed by Ulstein in the full EURAD piece) by Thomas Kerr, Julio S G Montaner, Evan Wood specifically says:

"..several randomised trials have compared
prescribed injectable heroin with optimised methadone as a second-line treatment. Whereas some early studies implied benefits of this approach, a 2005 Cochrane review of four randomised trials of heroin prescription stated that firm conclusions about efficacy could not be
made because of heterogeneity across studies."

it then points out that:

"Since then, randomised trials of prescribed heroin have been completed in Germany, Spain, and Canada, with every
trial showing consistently better results for prescribed heroin in reducing use of illicit heroin and criminal activity, with further favourable improvements in physical and mental health and in social functioning. The German and Canadian trials, which included more direct comparisons of methadone with heroin, also showed higher treatment retention in those randomised to prescribed heroin."

References are given for all the relevant studies which I have copied below.

Im quite sure that, especially with the addition of this latest work, that the Cochrane Collaboration would agree their 2005 review was due an update. Indeed their summary, from the link you provided, notes that:

"Because of the variation in maintenance treatment programs and in the way the results of the studies were reported, the authors could not draw general conclusions. However, new heroin maintenance programs have begun in a number of countries and the Cochrane review authors will begin analysing the new data once it is available."

----

refs from the Lancet commentary:

Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D.Heroin-assisted treatment for opioid dependence: randomised controlled trial. Br J Psychiatry 2007; 191: 55–62.

Oviedo-Joekes E, Brissette S, Marsh DC, et al. Diacetylmorphine versus
methadone for the treatment of opioid addiction. N Engl J Med 2009;
361: 777–86.

March JC, Oviedo-Joekes E, Perea-Milla E, Carrasco F, and the PEPSA team.
Controlled trial of prescribed heroin in the treatment of opioid addiction.
J Subst Abuse Treat 2006; 31: 203–11.

[Doctor Beam]

Well done on the Riott assessment. I saw plenty of their clients in HMP Brixton.

[Kathy Gyngell]

Steve,
I am happy to wait for the findings of the next Cochrane review but I won't be holding my breath. Here is the summary of the results of just one of the trials referred to in justification. It is for the reader to make up his mind about the marginality of the results of Canadian study referred to in the Lancet:

The primary outcomes were determined in 95.2% of the participants. On the basis
of an intention-to-treat analysis, the rate of retention in addiction treatment in the
diacetylmorphine group was 87.8%, as compared with 54.1% in the methadone group
(rate ratio for retention, 1.62; 95% confidence interval [CI], 1.35 to 1.95; P<0.001).
The reduction in rates of illicit-drug use or other illegal activity was 67.0% in the
diacetylmorphine group and 47.7% in the methadone group (rate ratio, 1.40; 95% CI,
1.11 to 1.77; P = 0.004).
The most common serious adverse events associated with diacetylmorphine injections were overdoses (in 10 patients) and seizures (in 6 patients).

The costs of heroin prescribing if implemented nationally will be staggering and for only very marginal outcomes.

It is very sad that there has been no comparable investment in or enthusiasm for investigating non-drug treatment for addicts resistant to orthodox treatments - especially since so many former hardcore but now recovered addicts have told me that orthodox treatment delayed or stood in the way of their drug-free recovery.

[Charlie Junio]

The withdrawal symptoms of crystal meth addiction treatments, according to those who have experienced them, are fairly easy to overcome. However, relapses of crystal meth abuse can also happen because of the presence of social triggers. For example, an athlete might go back to using crystal meth illegally if he finds that his performance in the team has weakened. Women are very susceptible to crystal meth abuse because of the pressure society puts on them to lose more weight.

[Phatpoochproductions]

The Harsh Reality of Drug Addiction richardmclaughlin007 — January 18, 2009 — after 11 months of sobriety from drug addiction, in 7 short days this man hits the depths of despair and insanity.

http://healthznews.com/the-harsh-reality-of-drug-addiction.html

Chaos on the streets, lives destroyed "Harm Reduction" Is it really working?? you judge for your self A slideshow of the Downtown Eastside in all it's glory and at it's best. See first hand the lives destroyed by misguided harm reduction

http://www.youtube.com/watch?v=1TxCjrJzoD8&feature=fvsr

These video’s were shot in Vancouver's downtown eastside by the narrator they are quite extreme, It shows how common place and and readily available drugs are and how people can succumb to a extreme physical reaction from lack of sleep, nutrition and dehydration. The video’s were made for many different reasons, one being educational the other as mentioned earlier it’s common place here in Vancouver, in any other city or town in North America this man[ Harsh Reality of Drug Addiction] would have received immediate medical attention but here in Vancouver both the police and ambulance just drive by. If you do not believe me come on down and see our little human circus slash “HARM REDUCTION EXPERIMENT”

This man was spotted two hours later sleeping on a concrete curb as his pillow.

Both the narrator and producer of this video have had spent many years struggling with addiction and have spent hard time in Vancouver's “NOTORIOUS” downtown eastside.

Today they have escaped and are clean and sober and now dedicate there lives to those who still suffer from “THE HARSH REALITY OF ADDICTION”

If you have any questions about these videos or would like any back ground info on the making or producing of them please feel free to respond to below

Contact Producer Richard Mclaughlin @ 604-312-8046 Director/ Videographer Sean @604-720-9335 phatpoochproductions@live.com