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Review
. 2017 Jul;62(7):451-456.
doi: 10.1177/0706743716673966. Epub 2016 Oct 6.

Supervised Injectable Heroin: A Clinical Perspective

James Bell  1   2 , Rob van der Waal  1   2 , John Strang  1   2
Affiliations
Review

Supervised Injectable Heroin: A Clinical Perspective

James Bell et al. Can J Psychiatry. 2017 Jul.

Abstract
in English, French

Background: Six recent randomised control trials (RCTs) have suggested that supervised injectable heroin (SIH) can be effective in patients who persist in street heroin use during methadone treatment. However, short-term randomised control trials have limitations in assessing the effectiveness of treatments for addictive disorders, which are chronic and relapsing disorders of motivation. These RCTs particularly fail to capture the process of the SIH treatment and the diversity of influence and change over time.

Method: This narrative review is based on the analysis of published data. Conclusions are drawn from a process of reflection informed by experience in delivering one of the published trials, subsequent experiences in varying the way SIH is delivered, and through consideration of possible mechanisms of action of SIH.

Observations: Many long-term, socially marginalised and demoralised people who are addicted to heroin experience few rewards from the stability afforded by methadone treatment. Supervised injected heroin is sufficiently reinforcing for many of these individuals to attend daily and participate in highly structured treatment. With an adequate daily dose of supervised methadone to avoid withdrawal dysphoria, occasional diamorphine injections-not necessarily twice daily, or even every day-is enough to hold people in treatment. Participation was associated with reduced amounts of non-prescribed drug use, a gradual change in self-image and attitude, and for some subjects, a movement towards social reintegration and eventual withdrawal from SIH.

Conclusions: Prescribed heroin is sufficiently motivating to hold a proportion of recidivist addicts in long-term treatment. Participation in structured treatment provides respite from compulsive drug use, and a proportion of subjects develop sufficient rewards from social reintegration to successfully withdraw from treatment. Such change, when it occurs, is slow and stuttering.

Contexte:: Six essais randomisés contrôlés (ERC) récents suggèrent que l’héroïne par injection supervisée (HIS) peut être efficace chez les patients qui persistent à utiliser de l’héroïne de rue durant leur traitement à la méthadone. Toutefois, les ERC à court terme ont des limites en ce qui concerne l’évaluation de l’efficacité des traitements pour les troubles de dépendance, qui sont des troubles de motivation chroniques et récidivants. Ces ERC échouent particulièrement à saisir le processus du traitement HIS et la diversité de l’influence et du changement avec le temps.

Méthode:: Cette étude narrative est fondée sur l’analyse des données publiées. Les conclusions sont tirées d’un processus de réflexion éclairé par l’expérience d’avoir appliqué un des essais, les expériences subséquentes sur la variation de la façon dont l’HIS est administrée, et par l’examen des mécanismes d’action possibles de l’HIS.

Observations:: Bon nombre d’héroïnomanes à long terme, socialement marginalisés et démoralisés ne tirent que peu de satisfaction de la stabilité offerte par le traitement à la méthadone. L’héroïne par injection supervisée offre suffisamment de renforcement à ces personnes pour qu’elles participent chaque jour à un traitement hautement structuré. Une dose quotidienne adéquate de méthadone supervisée pour éviter la dysphorie du sevrage, des injections occasionnelles de diamorphine – pas nécessairement deux fois par jour, pas même chaque jour – ont suffi à garder ces personnes en traitement. La participation était associée à une réduction de l’utilisation de médicaments non prescrits, à un changement graduel de l’image de soi et de l’attitude, et pour certains patients, à des démarches vers une réinsertion sociale et un sevrage éventuel de l’HIS.

Conclusion:: L’héroïne prescrite est suffisamment motivante pour garder une proportion de toxicomanes récidivistes en traitement à long terme. La participation au traitement structuré procure un répit à l’utilisation compulsive de drogue, et une proportion des sujets développent des avantages suffisants de la réinsertion sociale pour réussir à se sevrer du traitement. Un tel changement, quand il se produit, est lent et hésitant.

Keywords: addiction; diamorphine; heroin; substitution treatment; supervised injecting clinic.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JS is a researcher and clinician and has worked with a range of treatment and rehabilitation service providers. He has contributed to the work of various governmental and non-governmental organisations and has been awarded project grant support and (or) honoraria and (or) consultancy funds from the Department of Health, NTA (National Treatment Agency), PHE (Public Health England), Home Office, NICE (National Institute for Health and Clinical Excellence), and EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) as well as research grants from (last 3 years) NIHR (National Institute on Health Research), MRC (Medical Research Council) and Pilgrim Trust. He has also worked with pharmaceutical companies to seek to identify new or improved treatments (including, last 3 years, Martindale, Reckitt-Benkiser, Lundbeck, MundiPharma, Viropharma, Rusan/iGen) and he and his employer (King’s College London) have been awarded honoraria, travel and (or) consultancy funds. His employer (King’s College London) is registering intellectual property on an innovative development in this area with which JS is involved, and JS has been named on a patent registration by a Pharma company as inventor of a potential novel overdose resuscitation product. A fuller account of JS’s interests is given on his personal web-page of the Addictions Department of King’s College London at http://www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx.

JB has held consultancy agreements with Reckitt-Benckiser, Britannia pharmaceuticals and Martindale Pharma, and was awarded research funds by Reckitt-Benckiser. He was awarded speaker’s and hospitality funds by Indivior, Martindale and Mundipharma.

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