[Download] ~ Is There a Need for Heroin Substitution Treatment in Vancouver's Downtown Eastside? Yes There is, And in Many Other Places Too (Counterpoint) (Report) * by Canadian Journal of Public Health ~ Book PDF Kindle ePub Free
eBook details
- Title: Is There a Need for Heroin Substitution Treatment in Vancouver's Downtown Eastside? Yes There is, And in Many Other Places Too (Counterpoint) (Report)
- Author : Canadian Journal of Public Health
- Release Date : January 01, 2011
- Genre: Law,Books,Professional & Technical,Health, Mind & Body,Health & Fitness,
- Pages : * pages
- Size : 81 KB
Description
When methadone maintenance treatment (MMT) for heroin addiction was first introduced in the 1960s, there was considerable opposition to this advance, particularly from some existing addiction treatment providers who promoted abstinence-based therapies. (1,2) It is thus not without historical irony that the introduction of heroin maintenance treatment is currently being opposed by some existing methadone providers who promote methadone-based therapies. For the North American Opiate Medication Initiative (NAOMI) trial, this opposition occurred before, during and after the study in the form of articles; (3) letters to ethics committees, provincial medical colleges and medical journals; (4) and the commentary in this issue of CJPH. (5) The commentary states: "The first major flaw in the trial is that the MMT subjects received a suboptimal maintenance dose". It appears the authors confuse the issue of maximum allowable dose and mean or median dose. NAOMI provided individualized doses without a dose cap, the approach recommended in the literature on the issue of dose and outcome. In practice, the dose prescribed is limited by several factors: some patients respond well to doses less than 100 mg/day, for example, because of very slow clearance, and would be killed by forcing them to take 100 mg/day or more; some patients refuse dose increases because of fear of difficulty getting off a high dose or because they want to be able to feel the effect of street heroin when used in addition to methadone; missed appointments limit the potential to increase doses safely; and treatment interruptions necessitate re-titration from low doses. Forcing patients to take a dose above what they will tolerate or accept is at best paternalistic rather than patient-centered, resulting in increased patient drop-out, and at worst dangerous, resulting in patient death. Doses above 100 mg were often prescribed in NAOMI but only when it was safe to do so and acceptable to the patient who was being treated. The authors correctly note that there were no differences in treatment response between NAOMI subjects who received daily doses above or below 100 mg (68% vs. 62%, p=0.63), supporting the fact that each patient was receiving an optimized dose for their circumstances. The commentary notes that patients retained in MMT used heroin a mean of 6 days per month (although the median was only 1 to 2 days), suggesting the doses were inadequate. However, this is a common finding. For example, the RIOTT study, (6) to which the authors appear to give greater credence than NAOMI, reported that only about 10% of subjects retained on oral methadone were abstinent of street heroin at the study's endpoint. One way to reduce illicit heroin use to zero in MMT study participants would be to withdraw anyone from the MMT group who chooses to use street heroin, even if only very occasionally. It is this kind of punitive programming that undermines the effectiveness of MMT and is hardly in keeping with the flexible program rules that the authors appear to advocate.
 (Report) * by Canadian Journal of Public Health ~ Book PDF Kindle ePub Free){kind=link}