Professor John Strang National Addiction Centre, London, UK

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

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

3. 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

4. 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/video289/John-Strang-critiques-the-quality-of-drug-service-provision-and-oral-methadone-prescribing.html • NICE (2007) Psychosocial aspects of treatment of drug misuse (CG51). • Strang et al (2006). Take-home naloxone to prevent heroin overdose deaths. BMJ, 333; 614-615. • Strang et al (2010). Methadone, supervision and deaths:OD4 analyses. BMJ, 341; c4851. • Strang et al (2010) RIOTT main outcome results. Lancet, 375; 1885-1895.

5. MMT + BMT

6. 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

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

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

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

19. MMT + CM

20. MMT + CM

21. MMT + CM

26. Naltrexone

27. Naltrexone compliance

28. Naltrexone compliance

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

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

31. Supervised methadone:a story of successful change

33. OD4 • Defined Daily Doses • Overdose Deaths per (million) Defined Daily Doses (OD4)

36. RIOTT trial of supervised heroin maintenance

38. RIOTT research trial design

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

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

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

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

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

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

45. Take-home naloxone

46. Drug-related deaths in England and Wales 1997 – 2002 (ONS)

47. Drug-related deaths in England and Wales 1997 – 2002 (ONS)