Heroin maintenance for chronic heroin-dependent individuals.

BACKGROUND Several types of medications have been used for stabilizing heroin users: Methadone, Buprenorphine and levo-alpha-acetyl-methadol (LAAM.) The present review focuses on the prescription of heroin to heroin-dependent individuals. OBJECTIVES To compare heroin maintenance to methadone or other substitution treatments for opioid dependence regarding: efficacy and acceptability, retaining patients in treatment, reducing the use of illicit substances, and improving health and social functioning. SEARCH STRATEGY A review of the Cochrane Central Register of Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to 2008), EMBASE (1980 to 2005) and CINAHL until 2005 (on OVID) was conducted. Personal communication with researchers in the field of heroin prescription identified other ongoing trials. SELECTION CRITERIA Randomised controlled trials of heroin maintenance treatment (alone or combined with methadone) were compared with any other pharmacological treatment for heroin-dependent individuals. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS Eight studies involving 2007 patients were included. Results show marginal significance in favour of heroin for remaining in treatment until the end of the study (8 studies, N= 2007, RR=1.23, 95%CI=0.96-1.57; heterogeneity P < 0.01). Adverse events are significantly more frequent in the heroin group. Heroin plus methadone prescription for maintenance treatment in adult chronic opioid users who failed previous methadone treatment attempts decreases the use of other illicit substances (3 Studies, N=1289, RR=0.63, 95%CI=0.49, 0.81, heterogeneity P=0.21), and reduces the risk of being incarcerated (2 studies, N=1103, RR=0.64, 95%CI=0.51-0.79, heterogeneity P=0.31). In addition, we also found a marginally significant protective effect of heroin prescription plus methadone for the use of street heroin (3 studies, N=1512, RR=0.70, 95%CI=0.49-1.00, heterogeneity P < 0.01) and for criminal activity (4 studies, N=1377, RR=0.80, 95%CI=0.61-1.04, heterogeneity P=0.31). There was not enough power to detect statistically significant results for the risk of death (5 studies, N=1817, RR=0.77, 95%CI=0.32-1.87, heterogeneity P=0.79). AUTHORS' CONCLUSIONS The available evidence suggests a small added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment-refractory opioid users, considering a decrease in the use of street heroin and other illicit substances, and in the probability of being imprisoned; and an increase in retention in treatment. Due to the higher rate of serious adverse events, heroin prescription should remain a treatment of last resort for people who are currently or have in the past failed maintenance treatment.