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Schäfer I., Eiroa-Orosa F.J., Verthein U. et al.
Psychopathology: 2010, 43, p. 88–95.
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In Germany, heroin-addicted patients suffering from mental disorders benefited more from being prescribed heroin than methadone and did so to almost the same degree as other patients, including greater remission in psychiatric symptoms.
Summary Whether heroin addicted patients also suffering from poor mental health benefit from being prescribed heroin was the question addressed by the featured report from the German heroin prescribing trial. This account draws on an earlier Findings analysis of the study, of which the featured report was a sub-study.
The parent study trialled the prescribing of heroin for the treatment of heroin addiction at seven German clinics. Over the years 2002 and 2003 it successfully recruited 1015 patients who were regularly injecting heroin and in poor physical or mental health despite being in methadone maintenance treatment, or having been treated for their addiction in the past, but not in the last six months.
Patients were randomly allocated to either be prescribed heroin to be taken under supervision at the clinics plus oral methadone, or only oral methadone. Cutting across this allocation, they were also randomly allocated to two forms of psychosocial support: case management conducted along motivational interviewing lines and intended to flexibly coordinate an individualised care package from various services; or a more standard and directly delivered series of individual counselling and group therapy sessions. Which of these support programmes a patient was allocated to made no difference to the main outcomes, so reports have focused on the pharmacotherapy options.
Earlier reports recorded that compared to methadone, the heroin option retained more patients for a year and enabled more to substantially curb illicit heroin use without countervailing increases in cocaine use. More heroin patients also experienced improved health. However, the new methadone programme was itself far from ineffective; though previous treatment had been unsuccessful, many methadone patients also substantially cut their heroin use and experienced improved health.
The featured report was based on findings from 626 patients who completed an extended assessment of their psychological health. To do this they had to have been retained in the study for at least a month. Among these, 485 completed a year of the treatment to which they had been allocated.
Initial assessment revealed that at the start of treatment about half were 'dually diagnosed' as suffering from a diagnosable psychiatric condition, mainly a disorder of mood, neurosis, stress, or psychosomatic conditions. Regardless of whether prescribed heroin or methadone, only slightly and non-significantly fewer such patients were retained in treatment for a year as patients not suffering mental health problems (in all 75% v. 80%). Regardless of whether they were dual diagnosis patients, among those who were retained, psychological distress and psychiatric symptoms remitted more fully among patients prescribed heroin. Like patients in general, given heroin rather than just methadone, dual diagnosis patients more often substantially curbed illicit heroin use without countervailing increases in cocaine use, and more often experienced substantially improved health. However, in these respects the advantage gained by heroin was slightly less than among patients not diagnosed with a psychiatric condition.
Among the study's caseload (continuing to regularly inject heroin and in poor physical or mental health despite prior or current treatment), as with other patients, patients with psychiatric conditions benefited more from heroin prescribing than methadone-only programmes in terms of improved health and reduced illicit drug use. However, these benefits were slightly less marked than among other patients, perhaps partly because anxiety or depressive disorders respond to methadone's sedative effects. However, the study excluded patients whose mental disorders were so severe that they jeopardised participation in the trial, accounting for the unusually low number suffering from schizophrenia-type disorders. The same limitation applies to patients with personality disorders.
The implication is that psychiatric comorbidity of the kind included in the trial need not be a reason to exclude patients from heroin-based treatment and that, more so than methadone, such treatment can help resolve their psychiatric and substance use problems. The structure and clinical contact imposed by having to visit the clinic several times a day for supervised heroin consumption may have been one reason why dual diagnosis patients responded well to this treatment.
This draft entry is currently subject to consultation and correction by study authors.
Last revised 24 January 2012
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REVIEW 2003 Role Reversal