Medically supervised injectable heroin vs injectable methadone vs oral methadone

[sk8phaze (OP)]

http://www.kevinmd.com/blog/2010/06/injectable-heroin-methadone-addiction-treatment.html

by Charles Bankhead

Heroin addicts had almost a threefold increase in negative urine specimens when treated with supervised heroin injection rather than with oral methadone, data from a British study showed.

Overall, 72% of patients had negative specimens at least 50% of the time compared with 27% of patients assigned to oral methadone, according to the report published in the May 29 issue of The Lancet.



Treatment with injectable heroin almost doubled the success rate compared with injectable methadone, although the trial lacked statistical power for that comparison.

“We have shown that treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimized oral methadone,” John Strang, MD, of King’s College London, and co-authors wrote. “Furthermore, this difference was evident within the first six weeks of treatment.

At least 5% to 10% of heroin addicts do not benefit from conventional therapy. Whether the patients are untreatable or just difficult to treat is unclear, the authors wrote.


An evidence base has begun to emerge in support of carefully supervised medicinal heroin (diamorphine or diacetylmorphine) as second-line therapy for chronic heroin addiction, they continued, but its effectiveness has remained unclear.

The British government has allowed injectable heroin as an option for treating addiction, but injectable methadone has been used most often, the authors wrote. A 2002 update to England’s drug strategy set forth general principles for supervised heroin injection to ensure safety and prevent drug diversion. Following publication of the update, several medically supervised injection clinics opened in England.

A 2008 update opened the door for “rolling out the prescription of injectable heroin and methadone to clients who do not respond to other forms of treatment,” contingent on results of the randomized trial reported by Strang and colleagues.


For the study, the investigators enrolled 127 chronic heroin addicts who continued to inject street heroin on a regular basis, despite ongoing treatment with oral methadone. The participants were randomized to injectable methadone, injectable heroin, or optimized oral methadone treatment.

Injectable treatments were self-administered under direct nursing supervision at clinic sites. Participants assigned to injectable heroin went to the clinics twice a day to administer 450-mg doses. Injectable methadone was generally administered daily as a single 200-mg dose.

Randomized treatment continued for 26 weeks. The primary endpoint was the proportion of participants who tested negative for street heroin by urinalysis at least 50% of the time during weeks 14 through 26 (response).

The unadjusted intention-to-treat (ITT) analysis showed a response rate of 72% for injectable heroin, 39% for injectable methadone, and 27% for oral methadone. Injectable heroin achieved statistical superiority versus oral methadone (P<0.0001), but injectable methadone did not (P=0.264).

In an adjusted analysis, response rates were 66% for injectable heroin and 19% for oral methadone (P<0.0001). Injectable methadone had an adjusted response rate of 30%, also not significantly better than oral methadone.

The trial was not statistically powered to compare the two injectable treatments, nonetheless, injectable heroin demonstrated a significant advantage in the unadjusted (P=0.003) and adjusted (P=0.002) analyses.

Evidence of an advantage for injectable heroin emerged within the first six weeks.

“Treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimized oral methadone,” the authors wrote in conclusion. “U.K. 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.”

The results of the study reported by Strang and colleagues, combined with those from other studies, “should help to allay concerns about this approach, including methodological issues . . . safety, and cost,” Thomas Kerr, PhD, Julio S.G. Montaner, MD, and Evan Wood, MD, PhD, of the University of British Columbia in Vancouver, wrote in a commentary.

Nonetheless, implementation of supervised heroin injection has been delayed in several countries despite favorable results from clinical trials.

“History tells us that availability of heroin prescription can be dictated more by special interests and politics than evidence,” the commentators wrote.

“This state of affairs is sad because other medical specialties commonly embrace second-line therapies, even if only for a selected group who fail first-line treatments,” they continued.

“The existing interference and non-evidence-based opposition from politicians and care providers, who refuse to acknowledge the limitations of methadone maintenance and the superiority of prescribed heroin in selected populations, is arguably unethical,” the Canadian authors concluded.

“Denying effective second-line therapy to those in need ultimately serves to condemn many users of illicit heroin to the all too common outcomes of untreated heroin addition, including HIV infection or death from overdose.”

[sk8phaze (OP)]

I agree, not using this statistics to treat addiction is unethical

[Hooman]

If I'm reading that right - the addicts on the injectable Diamorphine route were injecting 450mg of Diamorphine twice a day!?

Whoa.

That's a fukcing *hefty* dose of DM - 450mg at a time, and nearly *1 gram* (900mg) in a day!

[dizzle]

wow.

and they're giving a single 200mg dose of methadone.

I think the idea of the study was to give them plenty to cover their actual ADDICTION. (and also get them high af) and then see if they stop using other things. Basically "we'll give you as much as we can medically, without killing you and we'd like to see if you stop doing OTHER drugs or more opiates on top of that."

It's so weird to think about this. Like "let's just give them whatever they want and see how that influences their behaviour"  you'd fucking NEVER see this happen in the olde United States of Pharmaceutical Companies and Medical Industry lobbyists, errr I mean America.

[Thoms]

So let me get this straight heroin addicts like shooting heroin more than done? Weird lol. I mean I guess if they can help get normies to see it’s the war on drug users and not the drugs themselves causing the problems than they are doing right by me. It’s just hard to see this study changing minds is all

[Hooman]

The 200mg of 'done I can understand - yes, it's a lot - especially by US standards, from what I can tell - but 2 x 450mg (900mg) of Diamorphine is a metric fuckton!

In previous studies that had populations that were on injectable Diamorphine, the injections were 3-4x per day IIRC, and the daily total amounts were more like 250-600 with 350mg or so being an 'average' daily kind of dose.

I reckon that they must be aiming to give the addicts what they seem to 'need' to remain stable and happy, without seeking out other drugs and/or poly-drug using - they can't be thinking that they're allowing the addicts to inject an amount that was roughly equivalent to what they were buying and IVing from the street.

That's nearly 1 GRAM (900mg) of PURE Diamorphine - say the street purity's a generous (IMO, these days) 20% - that's equivalent to 3.5 grams of consistent street smack a day. Do some people have and manage habits like that? Sure. Do they represent most users? I would say, no - far from it IME.

[dillydudeEL14]

I
So wishwe would do this in the states. Hell even dilaudid would be sweet.  Just not methadone or bupe

[Thoms]

Lol you would need to have an iv line with as short legs that dilly has. I don’t really see where people like it. I mean no offense we all have our own thing, morphine being the biggest example with people liking it or not

[Hooman]

I have had the chance to try quite a few different opi(ates)/(oids), but I've never tried Hydromorphone - the rush must be pretty good I'd guess from how people talk about it.

Interestingly enough, Hydromorphone is one of those closely-related Morphine derivatives which is seems is quite easily made by performing a catalytic hydrogenation of Morphine which apparently can be done without an external source of H2 and also be performed at normal pressure and with not much heating.

[Thoms]

I though someone did a write up of that on the phile when it was up. I’d would rather have the legs of morphine than the rush of dilly. I was always under whelmed by dilly. I went up to 24 mgs and never found it worth the dollar a mg that it costed. Now oxymorphone was amazing. Absolutely amazing

[Hooman]

A write up of the hydrogenation of Morphine etc.? If so, they exist in a number of other places online - they're mainly German patents from the 1930's IIRC, but also IIRC, it has been discovered that the massive quantities of Pd/C catalysts that were used in the original patents isn't actually necessary, and that an external source of H2 also isn't needed to perform the reaction.

I really want to look into those processes when I get my proper glassware and obtain some of the necessary catalyst etc.

[Thoms]

It’s been so long ago that I don’t remember if it was even a write up or someone just mentioned it. I wonder what the loss would be going from morphine to hydromorphone.. you seem like you would get along with robojunkie well or atleast have a lot to talk about..

[Hooman]

The yield is usually around 60-70% IIRC, and what's not hydrogenated is simply unreacted starting material, so no losses at all really, to speak of.

[dillydudeEL14]

Hooman you’re missing out man you gotta try hydromorphone  Some don’t like it cuz it doesn’t last too long but it probably is the best rush out there. Every opiate user needs to experience it at least once. Oxymorphone has a good rush too and also lasts longer with a great high. That dilaudid rush tho is fucking amazing.

[Snoop]

We will never see this avenue explored here @ home (USA)... We like to think we're open minded. But we're so narrow minded that we can't see the answer that's staring us right dead in the face.

Give the Fucking People What They Want.

And then, watch all the fucked up behavior that comes with a chemical/physical dependence, vanish (i.e. Theft, Prostitution, Extortion and Sign Twirling, etc.)

It really is that simple....

The rot is already there. We just have to make room for it now. It's a force of nature. Completely out of our hands.

This shit could have been squashed in the womb ages ago. But we continue to fuck around.

Pointless bullshit