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Addiction Treatment More Effective Without Needles

http://www.canada.com/theprovince/news/editorial/story.html?id=0750a336-0bbe-4164-9649-dee9a6dda03c

By Dr. Stanley DeVlaming

November 13, 2008 British Columbia, Canada   A scientific study of doctors prescribing heroin to heroin addicts in Vancouver and Montreal was recently completed and researchers have claimed it to be a resounding success (the NAOMI study).

But after reviewing the data, I disagree.

A major flaw of the study, which gave addicts oral methadone or inject able heroin, is that results are based mostly on self-report.

This is a critical issue given how highly politicized this study was. Clearly participants knew their future chances of getting government-issued free heroin depended on their answers.

Even if one ignores the flaw of relying on self-report, the rest of the research data confirmed exactly what those of us who treat heroin addiction already know – repeated daily injecting a powerful narcotic directly into one’s veins is a dangerous prospect even under the most “ideal” conditions.

The NAOMI study reported more than 2,700 adverse events in the heroin injecting group (123 individuals injecting heroin for one year), 167 of which were “severe.”

Offering an addiction “treatment” approach involving continued injections is an extremely high-risk proposition because regular injecting directly into a vein bypasses all the body’s normal defense mechanisms and has no parallel in medicine. Diabetics inject into the skin only. Consequently, difficult-to-treat bacterial infections involving bones, the spine, deep tissues or heart valves are routine in this group. Injectors are also at high risk for seizures and/or respiratory depression.

The researchers appreciated these risks, which is why they sought to ensure heroin treatment only to be offered to those who repeatedly failed the much safer oral medication, methadone.

More than one reasonable methadone treatment attempt makes sense because of the dynamics of addiction. Anyone who has quit smoking knows it often takes many attempts.

The researchers couldn’t find enough subjects to meet their criteria, and not because people didn’t apply.

More than 1,500 applied for the free heroin, but the researchers couldn’t find enough subjects who had failed methadone treatment more than once. This should have ended the study, but instead the researchers did something quite surprising for a scientific study – they changed their entry criteria.

The change meant subjects only had o have tried methadone once, for a minimum of a month, at some time in the past.

The new criteria also included self-reporting a second other type of treatment attempt – such a detox, which in this patient group wouldn’t be expected to be successful.

In spite of the relaxed admission criteria, it still took researchers a year longer to recruit, and they only enrolled just over half of their original target of 470. This means the results aren’t very useful. Addiction physicians won’t offer dangerous injectable treatment unless the safer, more proven (and affordable) oral treatments have been attempted.

Because researchers couldn’t find enough patients who had truly failed established “gold standard” treatment, e don’t have enough information to prescribe injectable heroin.

In fact,the study showed those methadone patients who stayed in the study actually did better than the injected heroin group.

Many more methadone patients dropped out of the study than in the heroin group. But isn’t that to be expected? The applicants who lost the lottery and got sent to the methadone arm of the study had to have been pretty disappointed.

Perhaps we should respond to this study by improving our ability to attract and keep people with non-injected heroin substitutes like methadone, or newer medications like buprenorphine, both of which are significantly cheaper and safer than an kind of injectable drug.

We could start by making enough methadone treatment slots available to all who want them.

The $8 million dollar cost of the study, and the millions more the researchers now want o provide ongoing heroin injections, would buy a significant amount of demonstrably-effective addiction treatment.

Dr. Stanley DeVlaming specializes in addiction treatment.

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  1. November 13, 2008 at 5:03 pm

    This was a very thought provoking column and opinion.

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