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Heroin on trial: Systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction

  • John Strang (a1), Teodora Groshkova (a2), Ambros Uchtenhagen (a3), Wim van den Brink (a4), Christian Haasen (a5), Martin T. Schechter (a6), Nick Lintzeris (a7), James Bell (a8), Alessandro Pirona (a9), Eugenia Oviedo-Joekes (a10), Roland Simon (a11) and Nicola Metrebian (a12)...
Abstract
Background

Supervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation.

Aims

To synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings.

Method

Randomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration.

Results

Six RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit ‘street’ heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT).

Conclusions

SIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.

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Copyright
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND) licence.
Corresponding author
John Strang, Director, National Addiction Centre, Kings College London, London SE5 8BB, UK. Email: john.strang@kcl.ac.uk
Footnotes
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Joint first authors.

See editorial, pp. 3–4, this issue.

Declaration of interest

J.S. and N.L. have contributed to National Treatment Agency/Department of Health English Guidelines on the role of injectable prescribing in the management of opiate addiction (2003; chaired by J.S.), and J.S. also chaired the broader-scope pan-UK working group when preparing the 2007 ‘Orange Guidelines' for the UK Department of Health, providing guidance on management and treatment of drug dependence and misuse and is chairing the new expert group updating the Department of Health Guidelines (2014). J.S. and his employing organisation have provided consultancy advice and received honoraria, travel and conference support, and consultancy fees from pharmaceutical companies including current and potential future suppliers of diacetylmorphine and methadone (ViroPharma, Martindale, TEVA, Reckitt Benckiser) and have conducted research involving collaboration with the pharmaceutical industry to investigate possible new treatment medications (Martindale, Mundipharma, iGen). J.S., N.M. and N.L. have previously undertaken research study of British heroin policy and have given varied commentaries and contributed to professional and public debate. A.U. has been mandated to document and evaluate the Swiss cohort study on heroin-assisted treatment by the Federal Office of Public Health, resulting in (unpaid) scientific publications and (unpaid) presentations at conferences (expenses reimbursed); expert consultation and project participation for the World Health Organization and United Nations Office on Drugs and Crime on substitution treatment for opiate addiction. W.vdB. is chair of the working group that is currently preparing the Netherlands Interdisciplinary Guideline on Opioid Addiction Treatment. He also was the scientific director of the Central Committee on the Treatment of Heroin Addiction (CCBH), which was responsible for the planning, execution and reporting on the Dutch trial on heroin-assisted treatment. W.vdB. has separately provided consultancy advice and received honoraria, travel and conference support, and consultancy fees from various pharmaceutical companies including current and potential future suppliers of buprenorphine (Reckitt Benckiser), extended-release naltrexone (Alkermes) and nalmefene (Lundbeck). C.H. has contributed to the German guidelines on opioid substitution treatment of the German Medical Association and has provided consultancy advice to the German Ministry of Health on the development of the revisions of the Narcotics Law. C.H. has undertaken research evaluation of the German and European drug policy and given commentaries and contributed to professional and public debate. He has also provided consultancy advice and received honoraria, travel and conference support, and consultancy fees from pharmaceutical companies including current and potential future suppliers of diacetylmorphine and other opioids.

Footnotes
References
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Heroin on trial: Systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction

  • John Strang (a1), Teodora Groshkova (a2), Ambros Uchtenhagen (a3), Wim van den Brink (a4), Christian Haasen (a5), Martin T. Schechter (a6), Nick Lintzeris (a7), James Bell (a8), Alessandro Pirona (a9), Eugenia Oviedo-Joekes (a10), Roland Simon (a11) and Nicola Metrebian (a12)...
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