IV heroin – I predict a RIOTT
Image: Pete Chapman under Creative Commons Attribution ShareAlike 3.0 License
There is almost a sad inevitability about the discussion in the media around the issue of giving heroin to heroin users. When it come to heroin-assisted treatment (HAT) it is inevitable that any reasonable discussion will be drowned out by the clamouring commentariat.
The UK has been using heroin as part of the treatment of users in one form or another since 1926. More recently, there have been studies of HAT in Switzerland, Germany, the Netherlands and Canada which have shown benefits in health, psycho-social adjustment and illicit drug use to socially excluded heroin dependent patients resistant to other treatments.
However, it’s inevitable that ill-informed parallels will be drawn with alcohol, smoking and the funding of almost anything else in the NHS deemed more worthy. It’s even possible to drag in ‘our boys’ fighting the drugs (spot of mission creep here) war in Afghanistan if one wants to work up a proper lather. The RIOTT study (I am assuming the obligatory acronym is an ironic nod to the impact this study will have on Daily Mail readers) isn’t even published yet and already the hysteria begins…
Is it even worth discussing the science amongst this hubbub? It might be better to crawl back under the duvet, let the dust settle and have a more rational discussion when we actually have the results of the UK study.
But there is some science to look at and consider. It is only last month that the New England Journal of Medicine published the results of NAOMI, the North American Opiate Medication Initiative (another tortured acronym) which looked at exactly this issue and it’s probable that RIOTT will have similar results. NAOMI compared oral methadone versus injectable diamorphine. It was open-label and there was no attempt to blind users to their treatment. They had better retention in the diamorphine arm at 88% versus the methadone arm at 54%. The reduction in rates of illicit drugs were 67% in the heroin group and 48% in the methadone group. Overall, the diamorphine arm tended to do better.
There were clear benefits but it wasn’t without issues and there were serious adverse events. There were 18 events in the methadone group (n=111) but none of them were felt to be related to the treatment. In the diamorphine arm (n=115) there were a total of 51 serious adverse events. However, it was reckoned that 27 of these were directly related to the diamorphine and included overdoses and seizures. This has to be put in context: a total of 89,924 doses of diamorphine were self-administered during the course of the study so that’s 0.03% of injections causing an event.
There are some issues around the methodology. Users know what kind of trial they are entering and many will drop-out when they get randomised to methadone rather than injectable. Indeed, this was the case in this study and it raises some issues around bias. The methodology of RIOTT was published in the Harm Reduction Journal in 2006 and is available for free.
The final conclusion of the NEJM paper is a reasonable one:
In this trial, both diacetylmorphine treatment and optimized methadone maintenance treatment resulted in high retention and response rates. Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmor-phine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system.
It will certainly need to be given in a specialised environment so it is likely to remain a very limited intervention. The headlines have tended to highlight that crime rates fall. How can this be surprising? UK studies have shown reductions in criminal activity across all treatment modalities for years. Part of the reason for this emphasis is presumably to make it as palatable to the public as possible. It’s not enough for it to be a useful option to improve health in a limited group of treatment resistant users. There has to be a fringe benefit to society as well.
There is an excellent paper by the authors of NAOMI commenting on some of the controversies around HAT. Again, it is freely available at the Harm Reduction Journal and will give you as good a background knowledge of the issues around HAT as anything. The authors commented on the media:
Treating heroin addiction with heroin tends to evoke a knee-jerk reaction. Lack of understanding, restrictions on time and resources, and the need for a catchy headline often lead to sensationalism by the media. As previously mentioned, opposition both within Canada and the US also contributed to misleading reports from local, national, and international media. The resulting focus has been on a seeming shift in Canadian drug policy in direct contradiction to the US war on drugs, rather than on the scientific or medical merits of the NAOMI study.
Much hand-wringing will be provoked by these studies for the simple reason that some will perceive that the logical development of this whole debate is that the next step will be de-criminalisation of drugs. It is entirely possible that we are waging a phoney ‘war on drugs’ but that’s really not what these studies are all about.
Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, & Schechter MT (2009). Diacetylmorphine versus methadone for the treatment of opioid addiction. The New England journal of medicine, 361 (8), 777-86 PMID: 19692689
We have written much the same on the transform blog here:
http://transform-drugs.blogspot.com/2009/09/heroin-trials-welcome-but-wait-has-cost.html
although I disagree on the last point. What is legally supplied heroin if not a proven and working model of legally regulated drug supply and its advantages over criminal markets and criminalising users?
Hi Steve. Thanks for the comment, enjoyed your own post too and I take your point re my last para. On reflection, I think I’ve kept this far too brief and I should have expanded on it. The excellent @Schroedinger99 made much the same point on Twitter.
I’m not sure how good a working model of a legally regulated drug supply it is because I think the trials are designed in such a way as to confine the option to a relatively small subgroup of treatment-resistant users. I would also emphasise the adverse effects and there must have been quite a heightened clinical atmosphere to deliver the care. I don’t think you could confidently give heroin as a treatment in primary care for example. So I’m not sure these clinics represent an expandable model and as with all medical evidence one has to be careful about how far the results get extrapolated.
I think that’s my fuller point – just because I think there are some very strong arguments for liberalisation of the drug laws I’m wary of how the medical evidence is wielded in support of that argument.
Hiya
I cannot think of a better example of patient abuse than the way British doctors treat heroin addict. Just be clear where I am coming from, I am a layman with a great deal of experience in this field. Is their another form of medical treatment that is set by the media and their political gofers? If so I have not come across it, the mass of the medical profession, to justify their shoddy and negligent treatment of narcotic addicts, have convinced themselves addicts are all mad, bad or sad. Is it any wonder, knowing this prejudiced attitude exist, many addicts act to this type when coming into contact with doctors, otherwise they are unlikely to get treatment.
In truth the research programe you mention is a total waste of money as you and your profession are well aware the English system of dealing with drug addicts worked successfully for decades, before the said media and their political gofers crashed it. Still, I suppose we should be thankful for small mercies
I agree drug addicts can be difficult, but demanding they drink daily a tiny amount of oral methadone at a chemist shop counter in full view of other shoppers, is hardly going to instill them with self respect. I could go on but you have probably heard it all before but I just wish the medical profession would say sorry to drug addicts, we fucked up and started showing drug addicts some respect.
By the way like the blog and will drop by.
How can informed consent to take part in a heroin prescribing research study be ethically obtained from opiate dependent patients? I don’t believe that it can
Tony Mercer
Anything to put road blocks in the way of progress, Ah Tony, One could equally ask how can informed consent be given by people who are suffering from terminal cancer and are asked to take part in a research project that may bring them respite or a cure. (But you would not dare, would you?)
As I wrote in my comment, you lot should start showing some respect to people who have problems with drug addiction, is it any wonder that members of your own profession who fall into this category hide their addiction from colleagues, when the average doctor displays more ignorance and bigotry on this subject that the economically deprived.
I think you’ve missed my point. BTW I’m not a doctor but the lead commissioner for drugs treatment for Birmingham Drug Action Team and a bioethicist. I’m not against heroin prescribing in principle–in fact I believe that cocaine should also be precribed!
My point is that experiments should not be carried out on human subjects without their informed consent. The very nature of opiate dependancy, ie. the reason that people need treatment in the first place, by definition, means that the person will not be able to give informed consent to accept or refuse free, pharmaceutical grade heroin. You are arguing that the “ends justify the means”, ie. that it is ok to do something wrong to achieve a good outcome. Try to focus on my original point–how can someone who is receiving treatment for opiate dependancy be free to refuse the offer of free top grade heroin?
Tony,
If we are to have a sensible debate, instead of trying to throw the ball back in my court whilst stamping your feet, why not deal with my point about terminal ill cancer patients, if any thing they are in less of position than a heroin addict to make an informed choice about entering a research program. Yet you do not seem to have any objection to this.
Nevertheless, to suggest that ‘all’ heroin addicts are unable to make an informed decision about entering this particular research project is insulting and plain wrong, it confirms my suspicion that a majority of people who work in your field believe all drug addicts are mad, bad, or sad.
I have met many addicts who would not go near such a research project, as the restrictions would be far to tight for them to continue to live a normal life and they have ‘absolutely’ no wish to become submerged within the drug treatment system or become the plaything of what many of them regard as the drug treatment mafia. I’m presuming, to receive there’re daily supply, the addict on this research project would have to attend a set place at a set time each day. There are also I’m sure the usual reasons why tens of thousands of addicts refuse to attend NHS DDU’s , etc.
You say you are not against the prescribing of heroin in principle, how about in practice, for under the current system, principles are something few street heroin addicts can afford. In a civilized society these trials would be un-necessary, as there is plenty of research out there to prove prescribing injectable heroin [or methadone] to long term addicts works well to improve the quality of there lives, and brings benefits to society as a whole.
In any case, I’m sure you are aware this current research was window dressing to persuade politicians to straighten their backbones and prove they have a spine for once. My language may seem blunt, but hell, so many lives have been ruined by prohibition and the infantile tightening of prescribing practice since the 1960s and the acquiescence of the medical profession to go along with it, that I feel anger and contempt is totally justified.
By the way please do not lay that means justify the end crap on me, that is not what I said or meant.
PS. The heroin will not be free, as addicts pay tax, if not directly then through VAT, Fuel, alcohol tax, etc.
Regards
Mick
after being referred to my local pct (york) for diamorphine treatment almost two years ago by compass drug dependency clinic i have had my appeal denied on the grounds that i am not considered an exceptional case (money) and the only avenue left to me is to make a formal complaint which i have learnt over 9 years in treatment would not be of any help. i was therefore wondering if you know of any alternative avenues such as the trials you speak of that could help me into this method of treatment.