Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction†

John Strang; Teodora Groshkova; Ambros Uchtenhagen; Wim van den Brink; Christian Haasen; Martin T Schechter; Nick Lintzeris; James Bell; Alessandro Pirona; Eugenia Oviedo-Joekes; Roland Simon; Nicola Metrebian

doi:10.1192/bjp.bp.114.149195

Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction†

Br J Psychiatry. 2015 Jul;207(1):5-14. doi: 10.1192/bjp.bp.114.149195.

Affiliations

¹ John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK john.strang@kcl.ac.uk.
² John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK.

PMID: 26135571
DOI: 10.1192/bjp.bp.114.149195

Abstract

Background: Supervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation.

Aims: To synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings.

Method: Randomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration.

Results: Six RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit 'street' heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT).

Conclusions: SIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

MeSH terms

Heroin / administration & dosage*
Heroin / adverse effects*
Heroin Dependence / drug therapy*
Humans
Methadone / administration & dosage*
Methadone / adverse effects
Opiate Substitution Treatment
Randomized Controlled Trials as Topic
Treatment Outcome

Substances

Heroin
Methadone