Providing diehard addicts with heroin is far more effective than treating them with methadone, according to the results of a much-anticipated study.
The research, published in Thursday's edition of the New England Journal of Medicine, shows that patients treated with injectable diacetylmorphine (the active ingredient in heroin) are 62 per cent more likely to remain in addiction treatment and 40 per cent less likely to take street drugs and commit crimes to support their habit than are those treated with oral methadone.
"We've tried to convince those in government that they should pursue this because it's a public health program that works," Martin Schechter, director of the school of population and public health at the University of British Columbia, and lead author of the paper, said in an interview.
He stressed, however, that only the most intractable addicts should be treated with heroin.
"We're talking about a small population that most people have written off as beyond hope, and the message that emerges from this research is that they are not beyond hope," Dr. Schechter said.
The study, formally called the North American Opiate Medication Initiative (NAOMI) was conducted at clinics in Vancouver and Montreal between March, 2005, and July, 2008.
Funding came from the Canadian Institutes of Health Research.
The study involved long-term users of injectable heroin who had repeatedly failed in addiction treatment programs.
Participants were divided randomly into groups: 111 received methadone and 115 got diacetylmorphine. Another 25 were given injectable hydromorphone, a prescription drug.
The patients received the treatment drugs at the clinic under the supervision of nurses and physicians. Those on methadone maintenance received 96 milligrams a day. Diacetylmorphine patients took, on average, 392 milligrams daily, although they tended to inject two or three times a day.
Researchers found that 88 per cent of those treated with heroin remained in treatment for at least 12 months, compared with 54 per cent in the methadone group.
As long-term addicts, participants continued to use street drugs, but their use fell dramatically.
Researchers found those treated with heroin took the street version of the drug on average five days a month, down from 27 days before they started treatment. In the methadone group, use of street heroin dropped to an average of 12 days from 27. Members of both groups, however, remained heavy users of cocaine.
Study participants, before they entered treatment, spent on average $1,200 a month on illicit drugs. During treatment, that fell to $320 for the diacetylmorphine group and $400 for the methadone group.
Dr. Schechter noted that addicts tend to raise that money through illicit activities such as theft, selling drugs and sex work, so those activities presumably decreased.
One of the surprises in the research was how well the participants taking hydromorphone did, but the small number means a larger study will be conducted.
In an editorial also published in the New England Journal of Medicine, Virginia Berridge of the school of hygiene and tropical medicine at the University of London said the Canadian research confirms the results of similar trials in Germany, the Netherlands, Spain and Switzerland.
"The prescription of heroin is now recognized in some European countries as the optimal treatment for patients for whom options are running out and in whom methadone maintenance has not worked," she said.
But Dr. Berridge also noted that, while the NAOMI study is published in a prestigious medical journal in the United States, the research could not be conducted in that country because of strict prohibition against heroin, even for medicinal uses.
"Will the 'homegrown' results of the NAOMI trial have more impact in North America than results from Europe?" she wondered. "We will wait now to see."
Dr. Schechter remains cautiously optimistic.
"There is a political and moral side of this that you just don't get with other medical research," he said. "But I hope Canada will be pragmatic and follow the science."
A person with untreated heroin addiction costs the health and social services system at least $50,000 annually and about as much again in the criminal justice system, and those costs fall sharply when they are in addiction treatment.
Canada has an estimated 100,000 heroin addicts. According to the new study, about 15 per cent of long-term addicts would benefit from treatment with diacetylmorphine rather than methadone.