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Treatment of heroin/opiate addiction: current evidence, failure to apply, and areas warranting special attention Treatment of heroin/opiate addiction: current evidence, failure to apply, and areas warranting special attention Professor John Strang National Addiction Centre, London, UK

declaration • DH, NTA, Home Office, NACD, WHO, UNODC • Diamo, Reckitt-Benkiser, Schering-Plough, Genus-Britannia, declaration • DH, NTA, Home Office, NACD, WHO, UNODC • Diamo, Reckitt-Benkiser, Schering-Plough, Genus-Britannia, GW, Napp, Titan, Martindale, Catalent, Viro. Pharma-Auralis, Lundbeck, Astra. Zeneca • Phoenix House, Clouds House, Lifeline, Kent Council on Addictions, Action on Addiction, Society for the Study of Addiction

• major scientific reviews of evidence about methadone maintenance and buprenorphine maintenance (NICE; • major scientific reviews of evidence about methadone maintenance and buprenorphine maintenance (NICE; Cochrane); • NICE review of naltrexone maintenance; • NICE review of psychosocial aspects of opiate addiction treatment; • three recent/current research areas, being – * take-home emergency naloxone; – * major reduction of methadone deaths – * substantial benefits seen in the RIOTT trial

Key references • Babor et al, (2010). Drug Policy and the Public Good. Oxford: Key references • Babor et al, (2010). Drug Policy and the Public Good. Oxford: Oxford University Press, 2010. • Connock M et al, (2007). Methadone and buprenorphine: systematic review. Health Technology Assessment, 11 (9). • Adi Y et al, (2007). Oral naltrexone as a treatment for relapse prevention in formerly opioid-dependent drug users: a systematic review and economic evaluation. Health Technology Assessment, 11 (6). • FEAD website– critique of UK drug treatment provision – on website www. fead. org. uk – interview number 10 at http: //www. fead. org. uk/video 289/John-Strang-critiques-thequality-of-drug-service-provision-and-oral-methadone-prescribing. html • NICE (2007) Psychosocial aspects of treatment of drug misuse (CG 51). • Strang et al (2006). Take-home naloxone to prevent heroin overdose deaths. BMJ, 333; 614 -615. • Strang et al (2010). Methadone, supervision and deaths: OD 4 analyses. BMJ, 341; c 4851. • Strang et al (2010) RIOTT main outcome results. Lancet, 375; 1885 -1895.

MMT + BMT MMT + BMT

Structured oral methadone maintenance programmes • • It’s in the title Maintenance Dose – Structured oral methadone maintenance programmes • • It’s in the title Maintenance Dose – medication Dose – psychosocial component Context – staff attitudes Coercion (soft); reinforcers/rewards Methadone; buprenorphine; LAAM; SROM; … Recovery-Orientated Methadone Maintenance

U. K. Methadone treatment: benefits in the first month (Strang, Finch et al, 1997, U. K. Methadone treatment: benefits in the first month (Strang, Finch et al, 1997, Addiction Research)

U. K. Methadone maintenance – changes in heroin use over time Source: Finch 2000 U. K. Methadone maintenance – changes in heroin use over time Source: Finch 2000 MD thesis

Retention in treatment: methadone, buprenorphine, LAAM maintenance Retention in treatment: methadone, buprenorphine, LAAM maintenance

MMT + CM MMT + CM

MMT + CM MMT + CM

MMT + CM MMT + CM

Naltrexone Naltrexone

Naltrexone compliance Naltrexone compliance

Naltrexone compliance Naltrexone compliance

Retention in treatment: methadone, buprenorphine, LAAM maintenance Retention in treatment: methadone, buprenorphine, LAAM maintenance

Retention in treatment methadone/buprenorphine/LAAM vs. naltrexone Retention in treatment methadone/buprenorphine/LAAM vs. naltrexone

Supervised methadone: a story of successful change Supervised methadone: a story of successful change

OD 4 • Defined Daily Doses • Overdose Deaths per (million) Defined Daily Doses OD 4 • Defined Daily Doses • Overdose Deaths per (million) Defined Daily Doses (OD 4)

RIOTT trial of supervised heroin maintenance RIOTT trial of supervised heroin maintenance

RIOTT research trial design Injecting heroin User ‘failing’ in Treatment for >6 months (n=127) RIOTT research trial design Injecting heroin User ‘failing’ in Treatment for >6 months (n=127) Supervised Injectable Heroin (diamorphine) (SIH) in supervised injecting clinic Supervised Injectable Methadone (SIM) in supervised injecting clinic Optimised Oral Methadone (OOM)

RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at baseline (OOM, SIH)

RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at Months 4 -6 (OOM, SIH)

RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at Months 4 -6 (OOM, SIH)

RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at Months 4 -6 (OOM, SIH)

RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at RIOTT - data on ‘responders’ and ‘non-responders’ – broken down as % - at Months 4 -6 (OOM, SIH)

Percentage of participants not using illicit heroin by week (ITT sample) Percentage of participants not using illicit heroin by week (ITT sample)

Take-home naloxone Take-home naloxone

Drug-related deaths in England Wales 1997 – 2002 (ONS) Drug Prevalence in No. of Drug-related deaths in England Wales 1997 – 2002 (ONS) Drug Prevalence in No. of deaths in general population the last 5 years (use in last year, age 16 -59) Cannabis 10. 8% 78 Cocaine 2. 4% 508 Amphetamine 1. 5% 436 Ecstasy 2% 200 Opiates (inc heroin & methadone) 0. 2% 6, 194

Drug-related deaths in England Wales 1997 – 2002 (ONS) Drug Prevalence in No. of Drug-related deaths in England Wales 1997 – 2002 (ONS) Drug Prevalence in No. of deaths in general population the last 5 years (use in last year, age 16 -59) Cannabis 10. 8% 78 Cocaine 2. 4% 508 Amphetamine 1. 5% 436 Ecstasy 2% 200 Opiates (inc heroin & methadone) 0. 2% 6, 194

Key references • Babor et al, (2010). Drug Policy and the Public Good. Oxford: Key references • Babor et al, (2010). Drug Policy and the Public Good. Oxford: Oxford University Press, 2010. • Connock M et al, (2007). Methadone and buprenorphine: systematic review. Health Technology Assessment, 11 (9). • Adi Y et al, (2007). Oral naltrexone as a treatment for relapse prevention in formerly opioid-dependent drug users: a systematic review and economic evaluation. Health Technology Assessment, 11 (6). • FEAD website– critique of UK drug treatment provision – on website www. fead. org. uk – interview number 10 at http: //www. fead. org. uk/video 289/John-Strang-critiques-thequality-of-drug-service-provision-and-oral-methadone-prescribing. html • NICE (2007) Psychosocial aspects of treatment of drug misuse (CG 51). • Strang et al (2006). Take-home naloxone to prevent heroin overdose deaths. BMJ, 333; 614 -615. • Strang et al (2010). Methadone, supervision and deaths: OD 4 analyses. BMJ 341; c 4851. • Strang et al (2010) RIOTT main outcome results. Lancet, 375; 1885 -1895.