Heroin
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Heroin 

Heroin is actually the brandname of the Bayer aspirin company.  They developed a way to mix morphine with acetic acid and make the somewhat more concentrated heroin in 1898 and introduced heroin worldwide as a wonderful non-additive treatment for diarrhea and for morphine addiction.  Boy, were they wrong.  Opium smugglers found out by converting their opium to heroin, they could considerably reduce the weight of product that they had to smuggle.  Of course, heroin is just as addictive as morphine or probably any other opiate.

I haven't gotten around to writing much about this very serious addiction, since I have been putting a lot of time into medically prescribed narcotics.  Methadone maintenance has a well proven track record for treating heroin addiction.  Hopefully, I will get around to gathering the research studies here.  However, the newly available Suboxone (buprenorphine plus naloxone) may be much safer than methadone and equally successful.  I highly recommend it.

Personally, I think that better law enforcement could eliminate drug abuse from America without increasing prison space or enforcement costs and with a dramatic decrease in costs after several years.  Every drug epidemic in the history of the world which has ended has ended through law enforcement.  I personally think that the current methods of law enforcement are the problem, not law enforcement per se.  

Unfortunately, I have failed to interest government in funding my research in this area.  The fields of law enforcement and law have very little appreciation for research or interest in having research done.  In fact, in my experience, with some notable exceptions, law enforcement and the legal system don't really care about eliminating drug abuse.  They only want to do what they perceive is their job.

Slow-Release Morphine Did Better than Methadone for Heroin Addicts: In a 14-week DB PC study of 64 adults with opioid dependence, a mean methadone dose of 85 mg was compared to a mean slow-release morphine dose of 680 mg. No significant differences in retention or use of illicit substances (opioids, benzodiazepines, cocaine) were observed. However, patients receiving slow-release morphine had lower depression (P < 0.001) and anxiety scores (P = 0.008) and fewer physical complaints (P < 0.001). Comparative study of the effectiveness of slow-release morphine and methadone for opioid maintenance therapy. Eder H, et al. Medical University, Vienna, Austria. Addiction. 2005 Aug;100(8):1101-9

Higher Methadone Dose and Contingency Management Both Help in DB: A 120-patient DB random assignment study found that 70 mg/d of methadone did better than 50 mg/d and patients who were given vouchers with a monetary value for clean urines did better than patients who were given vouchers non-contingently. NIDA. Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance. Preston KL, Umbricht A, Epstein DH. Arch Gen Psychiatry. 2000 Apr;57(4):395-404

Baclofen Studied in DB : 40 opioid dependent patients in a 12-week DB PC with half on baclofen 60 mg/d. While the baclofen helped with withdrawal side-effects and depression and while it caused no more side-effects that the control group, there was also no difference in the numbers of urine tests positive for opioids. Tehran. Baclofen for maintenance treatment of opioid dependence: A randomized double-blind placebo-controlled clinical trial [ISRCTN32121581]. Assadi SM, Radgoodarzi R, Ahmadi-Abhari SA. BMC Psychiatry. 2003 Nov 18;3(1):16; Ed: Baclofen is a GABA B receptor agonist and has been found of some value in cocaine and alcohol addicts, although the results have not been impressive. It is currently being research for all sorts of conditions, perhaps financed by the manufacturer.

Baclofen as Good as Clonidine for Opioid Withdrawal: A 14-day Tehran DB PC trial of detoxing opioid addicts given baclofen 40 mg or clonidine 0.8 mg/d divided into t.i.d. doses. There was no difference in effectiveness although there were more problems with hypotension with clonidine.  Baclofen versus clonidine in the treatment of opiates withdrawal, side-effects aspect: a double-blind randomized controlled trial. Ahmadi-Abhari SA, Akhondzadeh S, et al. J Clin Pharm Ther. 2001 Feb;26(1):67-71

Fluoxetine (Prozac) Increases Program Retention of Naltrexone Patients: In a 1-year randomized study of 112 heroin addicts treated with naltrexone, those also given 20 mg/day of fluoxetine had an 81% higher 6-month and 46% higher 12-month retention rate, both quite significant statistically as well. A randomized trial of adding fluoxetine to a naltrexone treatment programme for heroin addicts. Landabaso MA, et al. Vizcaya, Spain. Addiction. 1998 May;93(5):739-44. Ed: Fluoxetine reduces the pain relief of morphine.  It is also very long-acting.  Perhaps, it reduces the reinforcing properties of morphine and heroin as well. However, in a smaller (44-patient), shorter (12 week) study, fluoxetine did not decrease heroin or cocaine use. No other agents were used in that study (Drug Alcohol Depend. 1998 May 1;50(3):221-6). 

Buprenorphine

    Buprenorphine is primarily prescribed to patients who currently fulfill the DSM-IV-TR criteria for opioid dependence, but it may also be used for patients with a history of opioid abuse who are at risk to relapse. buprenorphine maintenance (16 mg/day) has been shown to be as effective as methadone treatment (60 mg/day) for reducing opioid use in addicted persons (Greenwald et al., 2002; Mattick et al., 2002). Preliminary studies suggest that buprenorphine is also effective when used in a physician's office (Fiellin et al., 2002; Ling and Smith, 2002; O'Connor et al., 1998). Data from France also support buprenorphine's efficacy: the country's death rate due to heroin overdose dropped noticeably following the legalization of buprenorphine treatment (Deveaux and Vignau, 2002). 

    Buprenorphine monotherapy (Subutex) and buprenorphine/naloxone (Suboxone) are available in 2 mg or 8 mg tablets (2 mg/.5 mg and 8 mg/2 mg for the combination) (FDA, 2002). Patients who cannot take combination tablets may be prescribed monotherapy tablets if they either have demonstrated that they can remain substance-free and are stable psychosocially or are willing to take buprenorphine only under direct supervision. If these conditions cannot be met, an alternative therapy, such as methadone maintenance, may be more appropriate. Side-effects are usually minor although hepatitis can develop. Use in pregnancy, with hepatic impairment are contraindicated. Methadone is approved for use during pregnancy. It is metabolized by CYP 3A4, so fluoxetine, erythromycin, and protease-inhibitors may increase its concentration.

Thomas E. Radecki, M.D., J.D.

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