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Heroin prescription — new responses for the hard to treat

Heroin prescription — new responses for the hard to treat. Christian Haasen University of Hamburg, Germany. Zentrum für Interdisziplinäre Suchtforschung der Universität Hamburg ZIS. History. 1972: American Bar Association recommends heroin assisted treatment (HAT)

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Heroin prescription — new responses for the hard to treat

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  1. Heroin prescription — new responses for the hard to treat Christian Haasen University of Hamburg, Germany Zentrum für Interdisziplinäre Suchtforschung der Universität Hamburg ZIS

  2. History • 1972: American Bar Association recommends heroin assisted treatment (HAT) • 1973: Editorial in New England Medical Journal recommending HAT • 1980: publication of first controlled study in UK on MMT vs. HAT, with some results favouring MMT, other favouring HAT • 1997: publication of Swiss study results • 2003: publication of Dutch study results • 2006: publication of Andalusian study results • 2007: publication of German study results

  3. Swiss Study • Disadvantages according to WHO evaluation: • No control group • Which effects are due to pharmacology and which are due to psychosocial intervention? • No “intention to treat” (ITT) analysis • HAT now established maintenance treatment in Switzerland with ~1200 treatment slots

  4. Dutch Study • Diamorphine as Add-On treatment • Small sample size for i.v.-treatment, main sample for inhalable diamorphine • Effect of pharmacotherapy vs. psychosocial intervention remains unclear • Target group: methadone non-responders • HAT now established maintenance treatment in the Netherlands

  5. Target groups – German study • Methadone treatment failures (MTF) • Opiate addicts presently in methadone-maintenance treatment, who have not profited sufficiently from treatment • Around 10% non-response in MMT • Untreated / not in treatment (NIT) • Heroin addicts, who have dropped out of treatment services and are presently not in treatment, but in need of treatment due to their state of health or present life situation • Only up to 50% in treatment

  6. Retention rate (“treatment-initiated” sample) • Higher total percentage of methadone group returned to illicit drug use

  7. Daily dosage over 365 days Mean: Heroin: H-dose: 442 mg,Methadone: M-dose: 99 mg

  8. Response-Definition:Primary outcome measures (POM) • Improvement of physical or mental health  Response in POM (A) • Reduction of illicit drug use  Response in POM (B) Differences in response rates are tested for significance

  9. Primary analysis (ITT) – Response by POM Health: OR = 1.41 * (1.05-1.89), Drug use: OR = 1.85 *** (1.43-2.40)

  10. Response for treatment completers (per-protocol analysis) Health: OR = 2.05 ** (1.28-3.27), Drug use: OR = 2.64 *** (1.80-3.88)

  11. Response in both POM OR = 1.67 *** (95%-CI: 1.30-2.14); NNT=8

  12. Criminality • Offences: • 79% of patients in year prior to treatment • 45% of heroin, 63% of methadone group in first year of treatment • Significant advantage of heroin group in reduction of criminality, both in number of days with criminal offences and in number of offences

  13. Contacts to other persons using drugs

  14. Health-economic analyses • Similar costs of treatment as Swiss & Dutch studies • QALY costs: heroin 155,000 € methadone 170,000 €

  15. *** * Physical health complaints(OTI health scale) N=434 | phase 1 phase 2

  16. (*) * Mental health distress(SCL-90-R, GSI) | phase 1 phase 2

  17. *** ns Use of street heroinin the past 30 days | phase 1 phase 2

  18. *** * Cocaine use past 30 days | phase 1 phase 2

  19. Currently working4 year course (N=156) Cochran-Test: Q=38,8, p<0,001 | | Phase 1 Phase 2 Follow-up Phase ZIS

  20. Drug-related mortality in Germany since 1984 year

  21. Present status in Germany • Around 300 patients still in follow-up heroin treatment • Registration status: positive review, heroin could be registered if laws are changed • Blockade by conservative party in government (CDU), but chance for positive vote soon

  22. Present status in Europe • Swiss + NL: registered normal treatment • GB: registered treatment & clinical trial • Belgium: clinical trial • Spain (Andalusia): compassionate use after clinical trial; clinical trial (oral heroin) in Barcelona • Denmark: laws changed in order to initiate heroin-assisted treatment • Norway, France: political discussions

  23. Thank you! www.heroinstudie.de

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