ADDICTION TREATMENT MORE EFFECTIVE WITHOUT NEEDLES

A scientific study of doctors prescribing injectable heroin to heroin
addicts in Vancouver and Montreal was recently completed and
researchers have claimed it to be a resounding success (the NAOMI study).

But after reviewing the data, I disagree.

A major flaw of the study, which gave addicts oral methadone or
injectable heroin, is that results are based mostly on self-report.

This is a critical issue given how highly politicized this study was.
Clearly participants knew their future chances of getting
government-issued free heroin depended on their answers.

Even if one ignores the flaw of relying on self-report, the rest of
the research data confirmed exactly what those of us who treat heroin
addiction already know -- repeated daily injecting a powerful
narcotic directly into one's veins is a dangerous prospect even under
the most "ideal" conditions.

The NAOMI study reported more than 2,700 adverse events in the heroin
injecting group (123 individuals injecting for one year), 167 of
which were "severe."

Offering an addiction "treatment" approach involving continued
injections is an extremely high-risk proposition because regular
injecting directly into a vein bypasses all the body's normal defence
mechanisms and has no parallel in medicine. Diabetics inject into the
skin only. Consequently, difficult-to-treat bacterial infections
involving bones, the spine, deep tissues or heart valves are routine
in this group. Injectors are also at high risk for seizures and/or
respiratory depression.

The researchers appreciated these risks, which is why they sought to
ensure heroin treatment only be offered to those who repeatedly
failed the much safer oral medication, methadone.

More than one reasonable methadone treatment attempt makes sense
because of the dynamics of addiction. Anyone who has quit smoking
knows it often takes many attempts.

The researchers couldn't find enough subjects to meet their criteria,
and not because people didn't apply.

More than 1,500 applied for the free heroin, but the researchers
couldn't find enough subjects who had failed methadone treatment more
than once. This should have ended the study, but instead the
researchers did something quite surprising for a scientific study --
they changed their entry criteria.

The change meant subjects only had to have tried methadone once, for
a minimum of a month, at some time in the past. The new criteria also
included self-reporting a second other type of treatment attempt --
such as detox, which in this patient group wouldn't be expected to be
successful.

In spite of the relaxed admission criteria, it still took researchers
a year longer to recruit, and they only enrolled just over half their
original target of 470. This means the results aren't very useful.
Addiction physicians won't offer dangerous injectable treatment
unless the safer, more proven (and affordable) oral treatments have
been attempted.

Because researchers couldn't find enough patients who had truly
failed the established "gold standard" treatment, we don't have
enough information to prescribe injectable heroin.

In fact, the study showed those methadone patients who stayed in the
study actually did better than the injected heroin group.

Many more methadone patients dropped out of the study than in the
heroin group. But isn't that to be expected? The applicants who lost
the lottery and got sent to the methadone arm of the study had to
have been pretty disappointed.

Perhaps we should respond to this study by improving our ability to
attract and keep people with non-injected heroin substitutes like
methadone, or newer medications like buprenorphine, both of which are
significantly cheaper and safer than any kind of injectable drug.

We could start by making enough methadone treatment slots available
to all who want them.

The $8 million dollar cost of the study, and the millions more the
researchers now want to provide ongoing heroin injections, would buy
a significant amount of demonstrably-effective addiction treatment.