Medically prescribed heroin — called diacetylmorphine — and the programs to deliver it to addicts trying to get clean are more expensive than methadone therapy. But the researchers say savings accrued from reduced drug-related criminal activity and other health-care costs make the former more cost-effective over time.
"If you are on treatment, you're basically well-behaved," said principal investigator Aslam Anis, a health economist at the University of British Columbia. "When you're not taking treatment, for instance when you relapse, you're doing all kinds of bad things, criminal activity, getting into jail.
"So the cost benefit is through an indirect effect," said Anis, noting that many addicts commit property crimes like robbery to support their habit, affecting victims and leading to costly involvement by the police and court system.
"People who take (medical) heroin are retained on the treatment for longer periods of time and they have shorter periods of time when they relapse," he said from Vancouver. "And when you add it all up, you find that you've actually saved money."
The conclusion is based on an analysis of data from the North American Opiate Medication Initiative (NAOMI ), a 2005-2008 study that compared the use of diacetylmorphine and methadone in street addicts.
Researchers, whose study is published in Monday's Canadian Medical Association Journal, looked at cost-effectiveness of the two treatments over one-, five- and 10-year periods, as well as lifetime projections.
Those in the methadone group generated an average lifetime societal cost of $1.14 million, while those in the diacetylmorphine group cost a projected $1.10 million — a difference of about $40,000 per person. An estimated 60,000 to 90,000 Canadians are dependent on heroin or other opioids.
The NAOMI study involved more than 250 subjects in Vancouver and Montreal, who had been addicted to heroin for at least five years and had twice failed methadone treatment. Participants were randomly selected for one treatment or the other.
Taken orally, usually mixed with juice in the morning, methadone works by blocking opioid receptors in the brain, taking away cravings for heroin and preventing withdrawal symptoms.
"Methadone can be a very effective medication for some people, but it doesn't work for everybody with heroin addiction," said co-author Dr. Martin Schechter, an epidemiologist at UBC's School of Population and Public Health. "And there is a subset of folks who go in and out of treatment and ultimately end up back using street heroin.
"They would be unlikely to be attracted into yet another methadone program," he said. But giving them injections of medically prescribed heroin in a clinic setting staffed by doctors, nurses and counsellors gets them back into the health-care system. It also cuts the risk of infection with hepatitis C and HIV from needle-sharing.
"So diacetylmorphine is a medically prescribed heroin that we show in the study was more likely to keep people in treatment. And we know that keeping people in treatment is a very important predictor of success."
The study also found individuals in the diacetylmorphine group were more likely to live longer than those receiving methadone maintenance therapy.
Still, Schechter concedes that the federal government's tough-on-drugs stance would make even medically prescribed heroin a tough sell to politicians, given that funding would be needed both for the drug and secure sites staffed by care providers trained to treat addicts.
"The fact is that these people are taking heroin right now. They're in the back alleys in the Downtown Eastside, they're buying the heroin on the street, contributing to the black market and crime and violence," he said. "And they're not in any treatment and they're costing the system lots and lots of money.
"So our proposal says rather than having them do that in the back alley, why don't we attract them into a clinic where they will be in contact with doctors and nurses and counsellors, we stabilize them by getting them out of a life of crime."
While lauding the researchers for trying to find an alternative to methadone, Dr. Meldon Kahan believes their conclusion that diacetylmorphine is more cost-effective is based on flawed data from the original NAOMI trial.
Kahan, who treats opioid dependency as part of his Toronto practice, suggested addicts who received methadone in the trial were given sub-optimal doses of the drug, leading to a higher drop-out rate than occurred in the prescribed heroin group.
He said there are other drugs besides diacetylmorphine that can be tried to help street heroin addicts kick the habit, among them buprenorphine (Suboxone or Subutex) and oral morphine.
"I agree with the general sentiment that methadone isn't the answer for everyone. I would laud them for (seeking an alternative). It was a very difficult trial to do," Kahan said of the NAOMI researchers.
"I just think that people in Vancouver, the policy makers and the care providers, need to go with what makes most sense from a public health perspective, which is to approve access to methadone treatment, to expand to other forms of maintenance treatment, including Suboxone, and for those who have failed methadone and Suboxone, then morphine by mouth."
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