Heroin Dependence Implant

The October issue of the Archives of General Psychiatry contained a report about the potential usefulness of an implant containing sustained release naltrexone for the treatment of heroin dependence. Heroin dependence is very difficult to treat with relatively few users who are able to maintain abstinence. The standard treatments now include both methadone and buprenorphine which are heroin substitution therapies that greatly reduce the risk of complications such as HIV, hepatitis C, unemployment, criminality and prostitution. There are limitations to both of these treatments however and many patients continue to use heroin despite taking these medications so anything new that shows promise is very encouraging.

Since 1984 an oral form of naltrexone has been available to treat heroin dependence but has essentially been useless. Naltrexone is an opioid antagonist. It sits on the opioid receptors and blocks the ability of heroin and other opioids to bind to these receptors. As a result, using heroin has no effect. The problem is though that all one has to do is stop taking the naltrexone and the ability to get high returns quickly. So oral naltrexone has been of very limited usefulness. What has been developed is a sustained release version of naltrexone which can be implanted under the skin and which can have an effect for up to 6 months providing a long period in which the user can move away from the heroin lifestyle.

The study included 70 adult patients who were randomly assigned to receive oral naltrexone plus a placebo implant or daily placebo tablets with a naltrexone implant. During the 6 month period 63% of patients receiving the implant reported complete abstinence with 17% returning to daily heroin use and the rest reporting heroin use a few times per month. In contrast the patients taking only oral naltrexone had 62% returning to regular heroin use, 26% reporting abstinence and the others heroin use several times per week. Although not looked at in this study about 20% of heroin addicts remain abstinent in this time period with psychosocial treatments only.

63% 6 month abstinence is amazing in heroin addiction and I hope that these findings can be replicated by others in follow-up studies.

Thought for the day

Most heroin users hate their lifestyle. They just feel trapped.

Medically Prescribed Heroin

There was a very interesting study that just came out in the New England Journal of Medicine. It was a Canadian study which compared medically prescribed heroin and methadone to see which is more effective for long term, chronic, treatment refractory opioid addiction. Chronic intravenous heroin addiction is extremely difficult to treat with most patients experiencing multiple relapses and often simply dropping out of treatment. There are multiple complications including very high rates of Hepatitis C and HIV infections as well as strong association with various criminal behaviors. As most heroin addicts are unable to successfuly maintain abstinence the concept of harm reduction is often used as a goal rather than sustained abstinence. The idea is to reduce the risks of chronic communicable infections and criminal behavior by various means such as providing needle exchange programs, safe injection sites, and opioid substitution with either methadone or buprenorphine. Rates of illicit drug use and criminal behavior drop about 50% with use of methadone but there remains a large number of addicts who continue to use even while on methadone or drop out of treatment altogether.

Medically prescribed heroin has been used in Europe before but never in North America. The plan was to do the study both in Canada as well as the United States but the researchers could not get govermental approval here. At 12 months 87.8% of individuals taking the heroin remained in treatment compared to 54.1% of those on methadone and reduction in rates of illicit drug use and criminality was 67% compared with 47.7%  with methadone. The average daily dose was 392.3 milligrams per day and generally was given twice per day. It is interesting that there were 51 serious adverse events out of a total of 89,924 injections including 10 overdoses and 6 seizures. The overdoses were treated and the was no long term effect.

What was not commented on by the researchers were what the base rate of hepatitis C and HIV were and whether the one year treatment resulted in any change in newly diagnosed cases. I think this is important to know to help determine whether or not it is cost effective to provide heroin to addicts. There was also no comment on what rates of illegal diversion are seen in Europe. I also would like to see some comparison in disease rates with needle exchange programs.

I do not think that we will be seeing medically prescribed heroin in the United States in any near future but am interested in the experiences in Canada if they at some time adopt this approach.

Thought for the day

Harm reduction is controversial in the United States but I believe has real merit as an alternative strategy to abstinence and I would like to see more needle exchange programs here.

Heroin, Opioids, Overdose, Death

I heard some sad news yesterday. A young man at my daughter's high school recently died of a drug overdose. This was the third overdose death this school year. The deaths were presumed accidental and the drugs in each case were opioids, the class of medication that I have talked about here as being an increasing problem in teens and young adults. One of the favored opioids in our area is not a prescription pill but heroin. Heroin is easy to obtain here in Tucson and now can be used not just intravenously but smoked as "black tar". Many young people who would never consider putting a needle in their arm now have access to one of the most powerful and dangerous(except for nicotine) drugs. They smoke it feeling "safe" and don't realize that like intravenous use it can result in overdose and death.

My immediate reaction is that they should be teaching about drugs in the schools! But I realize that has been done before nationwide with the D.A.R.E. program. The D.A.R.E. program was found to be totally ineffective and had no positive benefit in reducing teen drug use. It was a waste of time and money. So it is not just education but the type of education that is important. Finding that is not easy. We do know that teens accept things more from their peer group than from adults in general but also that we as adults do have influence. A peer group that is against drug use and parents who are not addicted to drugs, alcohol, or tobacco are the best first line of defense. But other than that we don't yet know the best ways for teens to communicate and educate their peers.

There is one thing that I want to talk further about, though, and that is a significant factor in influencing young men's behavior. Young men may be motivated by ideals and ideas but when it actually comes down to behavior, men follow other men not ideas and concepts. I will talk more about this in the next several days.

Thought for the day

Men follow men.