Methadone substitution for heroin addiction is not the only effective treatment

Methadone substitution has long been used as a treatment for heroin addiction. But a new 33-year follow-up study has found that equally satisfactory results are possible without recourse to long-term prescribing of opioids.

Until now there has been no long-term study of people addicted to injected heroin who have been treated without the prescribing of methadone substitute.

This study set out to look at the outcome for patients treated for injected heroin 33 years after they were first seen, and 26 years after they were first followed up. Measures included sustained abstinence from heroin, continued maintenance on methadone and deaths.

86 people with heroin addiction first seen in 1966-67 in a small town in the south-east of England were studied. At the time of diagnosis the patients were aged between 16 and 20, were single and living at home with their parents. They all injected heroin.

All the patients were treated in the local general psychiatric service, which differed from most other UK services for heroin addiction in that it did not prescribe methadone substitute for 23 years after recruitment of the patient group (i.e. until 1989).

The main provisions of the service were immediate help in times of crisis; personal counselling; regular follow-up; an ongoing relapse prevention group; and symptomatic relief with drugs other than methadone.

The first follow-up took place after six years. At that assessment 13% of the patient group were judged to have stopped using any illegal drugs, 51% were still injecting, 6% had died and 12% had experienced alcohol-related problems.

For this follow-up study, 45 of the original patient group were located and their clinical state assessed using multiple sources, including personal interviews with some of them.

It was found that 42% of the group had been abstinent for at least 10 years. 10% were taking methadone and were classified as addicted. 22% had died. 8% of the group could not be located.

The authors of this study compared their results with three other British studies. They found the death rates comparable (15%-20%), but the rates of abstinence and methadone dependency differed.

The researchers comment that it is encouraging that trend studies show agreement that the proportion of people maintaining sustained abstinence rises with time, whilst the proportion of those still addicted declines.

One worrying feature, however, is the high proportion of premature deaths, mainly due to overdoses. As overdose with opioid drugs is often mentioned as a cause of death, there is a need for closer monitoring of these drugs, and regular health screening and intervention to reduce premature deaths.

The advantages of long-term substitute prescribing of methadone are obvious in terms of increased social stability and reduction of crime. However, the researchers were struck not only by the number of premature deaths in people taking methadone, but also by the negative perceptions of life among those who are currently prescribed this opioid.

The findings of this study highlight the need to compare outcomes between people prescribed substitute drugs for addictions, and those who are not.

Reference Nehkant H, Rathod R, Addenbrooke WM and Rosenbach AF (2005) Heroin Dependence
in an English town: 33-year follow-up. British Journal of Psychiatry, 187, 421-425

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