‘Medical’ Heroin Beats Methadone in Kicking Habit

Diacetylmorphine, the active ingredient in heroin, may be more effective and less costly than methadone for refractory opioid addiction, researchers found.

In a mathematical model, patients on diacetylmorphine gained slightly more quality-adjusted life-years (QALYs) at a lower cost than those on methadone maintenance therapy, Aslam Anis, MD, of the University of British Columbia, and colleagues reported online in CMAJ.

“Over a lifetime horizon, the provision of diacetylmorphine in the hypothetical cohort provided greater incremental health benefits and reduced the total costs to society compared with methadone maintenance treatment,” they wrote.

The benefit arose largely from the fact that patients on diacetylmorphine remained in treatment longer, which substantially reduced the costs associated with crime, because patients were less likely to break the law while in therapy, the researchers explained.

Methadone is the most common form of opioid substitution therapy, but it doesn’t work for 15% to 25% of patients, the researchers said.

Diacetylmorphine, on the other hand, has been proven to be more effective than methadone maintenance for opioid addiction, but its direct costs are higher, they said.

What is a QALY?

A quality-adjusted life-year (QALY) takes into account both the
quantity and quality of life generated by healthcare interventions. It
is the arithmetic product of life expectancy and a measure of the
quality of the remaining life-years.

- A QALY places a weight on time in different health states. A year of
perfect health is worth 1 and a year of less than perfect health is
worth less than 1. Death is considered to be equivalent to 0; however,
some health states may be considered worse than death and have
negative scores.

- QALYs provide a common currency to assess the extent of the
benefits gained from a variety of interventions in terms of
healthrelated quality of life and survival for the patient.
When combined with the costs of providing the interventions,
cost–utility ratios result; these indicate the additional costs
required to generate a year of perfect health (one QALY).
Comparisons can be made between interventions, and priorities can
be established based on those interventions that are relatively
inexpensive (low cost per QALY) and those that are relatively
expensive (high cost per QALY).

- QALYs are far from perfect as a measure of outcome, with a number
of technical and methodological shortcomings. Nevertheless, the use
of QALYs in resource allocation decisions does mean that choices
between patient groups competing for medical care are made explicit
and commissioners are given an insight into the likely benefits from
investing in new technologies and therapies.

So to assess its cost-effectiveness in refractory patients over the long haul, Anis and colleagues created mathematical models using data from the North American Opiate Medication Initiative trial.

This Canadian trial found diacetylmorphine to be more effective than methadone at keeping patients in treatment, and at improving health and social functioning in patients with chronic opioid dependence refractory to treatment (N Engl J Med 2009; 361: 777-786).

Heroin is one of a group of drugs known as “opioids”. Other opioids include opium, morphine, codeine, pethidine, oxycodone, buprenorphine and methadone. Heroin and other opioids are depressants. Depressants do not necessarily make you feel depressed. Rather, they slow down the activity of the central nervous system and messages going to and from the brain and the body. 

Heroin is known by a variety of other names, including: horse, hammer, H, dope, smack, junk, gear and boy.

Physical effects
Heroin produces a ‘rush’ minutes after taking it, leading to a feeling of warmth and contentment. In larger doses it can cause the user to feel drowsy and very relaxed. Heroin is also known to greatly reduce physical and psychological pain when taken. A central nervous system depressant, heroin actually slows down the brain functions, and in particular the control of breathing, which can slow down or even stop. At the same time blood pressure and body temperature drops and the heartbeat can become irregular.

The signs and symptoms of using heroin can include:

• Confusion
• Decreased blood pressure and heart rate
• Dry mouth
• Slurred/slow speech
• Reduced coordination
• Nausea and vomiting
• Suppressed cough reflex
• Reduced sexual urges
• Lethargy
• Drowsiness
• Constipation
• Constricted pupils
• Slowed breathing

The consequences of using heroin may include:

• High risk of addiction
• Mood swings
• Depression
• Menstrual irregularity and infertility in women
• Loss of sex drive in men
• Anxiety disorders
• Chronic constipation
• Infection at the site of injections
• HIV and hepatitis infections through needle sharing
• Non-fatal overdose
• Death from overdose

The current researchers supplemented this data with administrative data from British Columbia and other published data to develop a semi-Markov cohort model. Costs were calculated in Canadian dollars.

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