(Download) "Is There a Need for Heroin Substitution Treatment in Vancouver's Downtown Eastside?(Point) (Report)" by Canadian Journal of Public Health # Book PDF Kindle ePub Free

July 13, 2021

eBook details

Title: Is There a Need for Heroin Substitution Treatment in Vancouver's Downtown Eastside?(Point) (Report)
Author : Canadian Journal of Public Health
Release Date : January 01, 2011
Genre: Law,Books,Professional & Technical,
Pages : * pages
Size : 263 KB

Description

The North American Opiate Medication Initiative (NAOMI) (1) conducted in Vancouver and Montreal is the first North American trial to compare the effectiveness of oral methadone and injection heroin for treatment-refractory heroin addicts. NAOMI addresses an important public health concern; many of the estimated 10,000 heroin users in Vancouver's Downtown Eastside (DTES) are not in treatment. In the NAOMI trial, 350 heroin addicts were randomized to heroin substitution treatment (HST) or methadone treatment (MT) in an open label manner.1 The investigators reported that HST was more effective than MT at reducing illicit opioid use and improving treatment retention. The NAOMI study has generated much interest and its investigators have called for the establishment of HST and hydromorphone clinics in the DTES. Given the significant limitations of the trial, these calls are premature. The first major flaw in the trial is that the MT subjects received a suboptimal maintenance dose. This may have contributed to the high early drop-out rate and ongoing heroin use. While the subjects' mean maintenance dose (96.0 mg) is reasonable for most methadone programs, it is low for patients who had failed previous methadone treatment and who continue to use heroin. A number of studies have shown that methadone doses of 100 mg or above are more effective than lower doses at reducing heroin use and improving treatment retention. (2-5) The investigators do not describe their clinical criteria for dose titration, a serious oversight for a trial in which the primary outcome depends on individualized dosing. In one publication, the investigators state that the dose was increased if the patient used heroin more than twice per week. (1) This is neither standard nor evidence-based. In the Ontario and British Columbia methadone guidelines, physicians are advised to increase the dose until withdrawal symptoms and cravings have resolved and regular heroin use has ceased. (6,7) The trial probably did not use these standard dose criteria since the mean street heroin use was six days per month in the MT group while the mean dose was only 96 mg. The investigators state that there were no differences in "treatment response" between subjects who received daily doses above or below 100 mg (68% vs. 62%, p=0.63), (8) but the study was not powered to detect dose effects, and the dose difference between those over and under 100 mg might have been too small to affect outcome.