What’s the best way to treat the most serious heroin addiction? Giving addicts therapeutic doses of heroin itself may be cheaper and more effective than methadone, according to a new Canadian study.
Researchers divided a group of heroin addicts in two Canadian cities who had repeatedly not been helped by conventional treatment, into two therapy groups. One was provided heroin plus intensive social and medical support while the other received an equally enhanced methadone program as part of the clinical trial.
The new analysis showed that even though heroin treatment can be as much as ten times more expensive than methadone, lifetime social costs related to chronic addiction were cut by an average of $40,000 Canadian for each of these previously untreatable heroin patients. The research also suggested that addicted people given heroin under medical supervision would live a year longer on average than those in methadone treatment.
The differences are mainly due to the fact that heroin therapy tends to keep patients in treatment for much longer periods of time. This leads to larger drops in drug use and crime, and improved health. The new analysis extrapolated lifetime costs for both types of treatment based on the clinical trial results and earlier research on the costs of repeat treatment sessions when patients relapsed.
“We found that a treatment strategy featuring [heroin] may be more effective and less costly than methadone maintenance among people with chronic opioid dependence refractory to treatment,” the authors conclude, “Our model indicates that [heroin] would decrease societal costs, largely by reducing costs associated with crime and would increase both the duration and quality of life of treatment recipients.”
The results of the clinical trial—which were published in the New England Journal of Medicine—showed that participants in the heroin therapy group cut their illegal drug use and crime by 67% compared to 48% of those on methadone. Only 22% of those in the heroin group dropped out of the trial, compared to 46% of people taking methadone. Employment and health improvements were also greater in the heroin group. A Cochrane review last year of eight heroin trials including nearly 1,400 participants had similar results, suggesting the financial and societal savings of heroin-based treatment.
These savings accrued despite the higher upfront cost of heroin treatment, which requires injections that need be taken under medical supervision at the treatment center — and users typically shoot heroin 2-3 times a day. The supervision helps reduce harm from overdoses and other life-threatening health problems, which were found to be common during the clinical trial. By contrast, methadone is generally given orally and stable users can be given multiple “take home” doses, just like ordinary prescriptions.
But politics and the fact that different approaches work best for different patients means that heroin is unlikely to ever completely replace methadone, which remains the most effective treatment for heroin addiction in terms of saving lives, reducing disease and cutting crime. One main issue is practicality: users need to inject heroin every 4-6 hours to avoid withdrawal, which isn’t easily conducive to the demands of work and family life. Methadone, on the other hand, lasts 24-36 hours and can ultimately become just another prescription for long term therapy.
Then there is the controversy over treating addictions with the drugs that addicts prefer. Despite the fact that Germany, Holland, the U.K., Denmark and Switzerland all have successful heroin maintenance programs, simply setting up the trial in Canada prompted vigorous political opposition.
It’s also likely that these results won’t apply broadly to most addicts. The participants were among the most serious cases who had been unsuccessful in overcoming their addictions with methadone despite repeated attempts. This group represents only about 15-20% of heroin addicts. And even here, one-fifth of those who started on heroin decided at some point to switch to methadone, likely due to the issues of having to inject so often.
The study did not look at other maintenance treatments, like buprenorphine (Suboxone, Subutex), which is another alternative. Buprenorphine is safer than methadone because at high doses it produces withdrawal rather than an increased high. This reduces overdose risk. However, it also means that people who need high doses to avoid craving don’t benefit— again meaning that methadone will always have some place in the maintenance armamentarium.
The new analysis was published in the Canadian Medical Association Journal (CMAJ).