Addiction Maintenance

Maintenance Treatment in Opiate Addiction

In theory, any opiate drug could be used for addiction maintenance. Methadone, buprenorphine, heroin (diamorphine), and LAAM (levomethadyl acetate hydrochloride) have been used as opiate substitutes, although LAAM is no longer used due to cardiac side effects. Methadone is generally used in the form of an oral liquid. although an injectable preparation is available. Buprenorphine is generally used as a tablet dissolved under the tongue, and diamorphine is only available in an injectable preparation. Methadone has become the preferred treatment because it is long acting, thereby lending itself to a once daily dose, and is available in an oral preparation, eliminating the need for injections.

Methadone maintenance treatment (MMT) has been studied extensively since it was first pioneered in 1965 by Drs. Vincent Dole and Marie Nyswander in the United States. Cochrane reviews comparing buprenorphine and methadone have found that buprenorphine is effective, but less so than methadone at adequate doses. There have been a few trials involving heroin—using diamorphine maintenance compared to other pharmacological treatments.

Diamorphine maintenance can be provided through injecting clinics where patients attend a clinic, often twice daily, for a supervised self-administration of diamorphine. Diamorphine may also be prescribed for take-home administration. Diamorphine maintenance has been found to be [Page 2]effective at reducing use of illicit drugs and retaining people in treatment. Comparisons of diamorphine maintenance with other drugs have reached no definitive conclusion with regard to their relative effectiveness.

Effectiveness of Opiate Maintenance

Many studies have been conducted over the last three decades that demonstrated to varying degrees that maintenance treatment generally can reduce the use of illicit opiates and reduce crime as well as resulting in other positive benefits for the individual and for society as a whole.

The measures used to evaluate the success of maintenance treatment are the following:

• Reduction in crime
• Improvement in employment
• Reduction in injecting and needle sharing (thereby lowering the risk of bloodborne diseases)
• Reduction in illicit opiate use during treatment
• Reduction in mortality
• Retention time in a treatment program.

Entry into maintenance treatment is significantly associated with reductions in criminal behavior, particularly drug-related crime. A 1978 trial in New York found that after 12 months, the control group (no treatment) were 53 times more likely to have been re-incarcerated compared to the methadone maintenance group. In the United Kingdom (UK), acquisitive crime was reduced by 50 percent at one year, and effects were maintained. Some of the greatest reductions in crime were among those with the highest offending rate. Similar positive findings have subsequently been found with diamorphine and buprenorphine.

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