The largest ever study of heroin and crack cocaine treatment programmes in England has shown that the first six months of treatment leads to large proportions of addicts of one drug or the other abstaining. But the programme was slightly less effective for regular users of both drugs. The findings are reported in an Article published Online First ( www.thelancet.com ) and in an upcoming edition of The Lancet , written by Dr John Marsden, Institute of Psychiatry, King's College London, UK, and Colin Bradbury, National Treatment Agency for Substance Misuse, London, UK, and colleagues.
For every 1,000 people aged 15—64 years in England, around eight are heroin users and five crack cocaine users. Drug therapy with oral methadone (or buprenorphine) is the front-line community intervention for heroin addiction as recommended by the UK's National Institute for Health and Clinical Excellence (NICE); patients receive this for as long as is required and then undergo supervised withdrawal. Addicts are supported by a key worker. Some heroin addicts also received structured psychosocial therapy* if required. As there are currently no substitute drug treatments for crack cocaine that have been proved effective, psychosocial treatment is the recommended treatment for crack cocaine.
The authors used data from the National Drug Treatment Monitoring System (NDTMS) to prepare their analysis, which was funded by the National Treatment Agency for Substance Misuse. The study involved more than 14,656 patients across England, with a heroin or crack cocaine addiction, or both. Patients were treated between January and November 2008, received at least 6 months' treatment or were discharged by the study endpoint (May 2009).
The researchers found that, during the 28 days before review, around two thirds of heroin users stopped or substantially reduced their use of heroin (42% stopping, 29% reducing); a similar proportion of crack cocaine users had stopped or substantially reduced their use of crack cocaine (57% stopping, 8% reducing). A higher proportion of users of heroin only abstained than did users of both heroin and crack cocaine (42% vs 33%), and more users of crack cocaine only abstained than did users of both drugs (57% vs 51%). Overall heroin use reduced by a mean average of 15 days per month (from 23 days per month pre-treatment to eight days at follow-up) and crack cocaine use by eight days per month (from 13 days per month pre-treatment to five days at follow-up). For clients given drug treatment, reduction in days of heroin use was smaller for users of both heroin and crack cocaine than for users of heroin alone (14 vs 16 days).
The authors suggest that the reason that individuals using both heroin and crack did less well in treatment than those using heroin only is because the concurrent use of two highly addictive substances makes it harder to make positive changes—although further research is needed to confirm this theory. The authors stress, however, that people addicted to both drugs still did well (with over half either stopping or cutting down significantly after 6 months).
The authors say: "Although design differences restrict comparison with other national and international studies, we believe that our findings are reliable and generalisable estimates of change in drug use during treatment. In view of the chronic course of heroin and crack cocaine addictions, and the long-term care usually needed for treatment, our results are an important first indication of effectiveness for the English treatment system."
They conclude: "The first 6 months of pharmacological or psychosocial treatment is associated with reduced heroin and crack cocaine use, but the effectiveness of pharmacological treatment is less pronounced for users of both drugs. New strategies are needed to treat individuals with combined heroin and crack cocaine addiction."
They add**: "This is the largest study of the most commonly available drug treatments in England, and unequivocally concludes that present drug treatment for heroin and crack addiction is very effective in the first six months. We already know from previous studies that there is a large reduction in crime associated with users entering drug treatment and reduced harm to public health, so further studies are planned which build on the known benefits of drug treatment to increase understanding of how to enable more people to recover from addiction."
Future studies will also focus on whether these changes in drug use are extended over longer periods, and the effectiveness of addiction treatment for other illicit drugs and alcohol.
In an accompanying Comment***, Dr A. Thomas McLellan, Deputy Director, White House Office of National Drug Control Policy, Washington, DC, USA, points out the growing acceptance that many serious cases of addiction are best considered as chronic conditions. He adds that short-term interventions may not produce long lasting positive effects, saying: "It may be more reasonable to expect enduring improvements through sustained outpatient clinical management with drugs and behavioural therapies—again, like expectations we have for the management of diabetes and hypertension."
He concludes: "The results and the methods of today's study are encouraging. Congratulations should go also to the National Treatment Agency for Substance Misuse of England for instituting this public health accountability effort. I would hope that the USA might mount a similar effort in the future. Citizens worldwide deserve governmental efforts to evaluate and promote quality and value from public addiction treatment."
For Dr John Marsden, Institute of Psychiatry, King's College London, UK, and Colin Bradbury, National Treatment Agency for Substance Misuse, London, UK, please contact Claire Ainsley, Public Affairs Manager. T) +44 (0)20 7972 1922 / +44 (0) 7795 036 460 E) claire.ainsley@nta-nhs.org.uk
For Dr A.Thomas McLellan, Deputy Director, White House Office of National Drug Control Policy, Washington, DC, USA, please contact Katherine A. Bush, Public Affairs Office T) +1 202 395 6618 E) Katherine_A._Bush@ondcp.eop.gov
For full Article, see: http://press.thelancet.com/hccnta.pdf
For press conference presentation, see: http://press.thelancet.com/heroinslides.ppt
An audio file is available here .
Notes to editors: *Every user in prescribing treatment should have a psychosocial intervention as well; psychosocial therapy could be described as structured counselling or psychotherapy—such as cognitive behavioural therapy
**Quote direct from authors and cannot be found in the text of the Article
***The full Comment is not available at this time, but the above extract from it has been authorised by Dr A. Thomas McLellan. For any further comments from Dr McLellan, please contact his press team using the details above
The Lancet