Heroin-assisted treatment in the Netherlands: History, findings, and international context

doi:10.1016/S0924-977X(10)70001-8

European Neuropsychopharmacology

Volume 20, Supplement 2, April 2010, Pages S105-S158

https://doi.org/10.1016/S0924-977X(10)70001-8 Get rights and content

Summary

This monograph describes the history, findings and international context of heroin-assisted treatment (HAT) in the Netherlands. The monograph consists of (1) a short introduction and seven paragraphs describing the following aspects of HAT in the Netherlands: (2) history of HAT studies and implementation of routine HAT in the Netherlands; (3) main findings on efficacy, safety and cost-effectiveness from the two randomized controlled HAT trials in the Netherland; (4) new findings from a large cohort study on the effectiveness of HAT in routine clinical practice in the Netherlands; (5) unique data on the patient's perspective of HAT; (6) data on the pharmacological and pharmaceutical basis for HAT in the Netherlands; (7) description of the registration process; and (8) account of the international context of HAT. Together, these data show that HAT can now be considered a safe and proven-effective intervention for the treatment of chronic, treatment-resistant heroin dependent patients.

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Measuring the preferences of injectable opioid agonist treatment (iOAT) clients: Development of a person-centered scale (best-worst scaling)
2023, International Journal of Drug Policy
Citation Excerpt :
The research team reviewed an extensive library of literature on treatment with injectable opioids for OUD, including peer reviewed papers (e.g., Strang et al., 2010), clinical guidelines (e.g., Canadian Research Initiative in Substance Misuse (CRISM), 2019a, 2019b; Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group, 2017; Office Fédéral de la Santé Publique, 2004), reports (e.g., The NAOMI Patients Association & Boyd, 2012), conference presentations (e.g., Birkemose, 2017) and media interviews (e.g., CBC News: The National, 2016). Specifically, we concentrated on literature and prior data that focused on iOAT delivery and client/provider perspectives on iOAT delivery (e.g., Blanken et al., 2010; Demaret et al., 2012; Plaza et al., 2007). The literature in this area is scarce, in part due to the relatively few research teams investigating iOAT beyond RCTs.
Injectable opioid agonist treatment (iOAT) is effective for opioid use disorder (OUD), yet little is known about client preferences for accessing iOAT (e.g., with diacetylmorphine, hydromorphone, buprenorphine, fentanyl, etc.). Best-worst scaling (BWS) is a preference elicitation method from health economics that has never been applied to addiction care broadly, or iOAT specifically. We describe the stages of developing a BWS scale that assesses iOAT clients’ treatment delivery preferences to inform program planning and maximize healthcare efficiency.
We underwent several steps to reveal the relevant attributes/levels and design the scale structure. An initial list of potential attributes and levels was established from a literature review and prior qualitative data. Then, we conducted semi-structured interviews and focus groups with clients (n=21) on their iOAT preferences to confirm the attributes and prioritize/include new ones. Next, we conducted semi-structured interviews and focus groups with iOAT experts and stakeholders to receive their input on the draft list of attributes and levels. A BWS profile case design was piloted with iOAT clients (n=18) from different sites during a think aloud interview. After several rounds of revisions, the final version was tested by iOAT clients (n=2) before the scale was launched.
We developed a person-centered scale that assesses current and former iOAT clients' most and least wanted aspects of iOAT delivery. The final version yielded 7 unique attributes: choice of medication, choice of dose, convenience, location & space, scheduling & routines, staff & training, and types of services offered.
This scale can help expand iOAT programs in a way that is person-centered, rapid, and affordable. The methodology is a guide for other regions with similar populations who aim to develop strong quantitative methodologies that prioritize client collaboration.
Discontinuation of opioid agonist treatment following release from prison in a cohort of men who injected drugs prior to imprisonment in Victoria, Australia: A discrete-time survival analysis
2023, Drug and Alcohol Dependence
Retention in opioid agonist treatment (OAT) following release from prison is associated with improved outcomes, however factors associated with post-release OAT discontinuation in Australia are poorly understood. We examined post-release OAT discontinuation in a cohort of men who engaged in approximately monthly injecting drug use (IDU) prior to imprisonment in Victoria, Australia.
Longitudinal data were used to calculate incidence of first-event post-release OAT discontinuation among men released from prison receiving OAT, and single-event discrete-time survival methods were used to estimate associations with post-release OAT discontinuation.
Among 110 participants, 55 OAT discontinuations were observed in the two years post-release, an overall crude incidence rate (IR) of 46 per 100 person-years (PY) (95 % confidence interval [95 %CI]: 36–60 per 100PY). Incidence was greatest between release from prison and first follow-up (IR: 84 per 100PY, 95 %CI: 62–116 per 100PY). Initiating OAT during index imprisonment (versus transitioning from community OAT; adjusted hazard rate [AHR]: 2.17, 95 %CI: 1.14–4.13) and identifying as Aboriginal and/or Torres Strait Islander (AHR: 4.95, 95 %CI: 2.00–12.25) were associated with an increased hazard of OAT discontinuation.
In a cohort of men with recent histories of IDU released from prison receiving OAT, half reported OAT discontinuation within two years of release from prison, with incidence of discontinuation greatest soon after prison-release. Targeted support for men who initiate OAT during episodes of imprisonment and Aboriginal and/or Torres Strait Islander peoples is necessary to reduce incidence of OAT discontinuation among people at greatest risk of discontinuation.
The suitability of oral diacetylmorphine in treatment-refractory patients with heroin dependence: A scoping review
2021, Drug and Alcohol Dependence
Citation Excerpt :
Other service users simply do not want to inject DAM due to fear of infection or due to cultural aspects (Blanken et al., 2010). Consequently, alternatives to intravenous HAT were explored and tested, such as the prescription of inhalable DAM in the Netherlands (Blanken et al., 2010; van den Brink et al., 2003). In addition, HAT professionals in Switzerland have developed a more manageable form of DAM delivery to patients with treatment-refractory heroin dependence by prescribing oral DAM (Frick et al., 2010, 2006).
To review the scientific literature on the pharmacokinetics, pharmacodynamics and clinical efficacy and safety of (supervised) oral diacetylmorphine for patients with severe heroin dependence.
The PubMed, Embase, Web of Science and PsycINFO databases were searched. Eleven published studies were identified and selected based on defined eligibility and exclusion criteria.
Four pharmacokinetic studies reported negligible plasma concentrations of diacetylmorphine and its active metabolite 6-monacetylmorphine. Among six pharmacodynamic studies, three trials showed that oral diacetylmorphine reduced opioid withdrawal symptoms, one open-label pilot study reported that two patients experienced a modest ‘rush’ after oral diacetylmorphine and two studies found that patients could not distinguish between oral diacetylmorphine, methadone, or morphine. Regarding the clinical studies, a Swiss prospective cohort study in patients with heroin dependence showed high retention rates of oral diacetylmorphine treatment with few serious adverse events, whereas in the Canadian SALOME trial, oral diacetylmorphine treatment was prematurely discontinued because treatment retention of oral diacetylmorphine was lower than injectable diacetylmorphine maintenance treatment. Finally, two case studies illustrate the limitations and potential problems of oral diacetylmorphine in the treatment of treatment-refractory heroin dependent patients.
Based on all published data, it is unlikely that oral diacetylmorphine produces a substantial ‘rush’. Prescription of oral diacetylmorphine might therefore be effective only for treatment-refractory patients with heroin dependence (i) as maintenance treatment for those who never injected or inhaled opioids; (ii) as maintenance treatment for those who want to switch from injection to oral administration of diacetylmorphine; and/or (iii) to reduce opioid withdrawal symptoms.
Longitudinal patterns of cocaine use among patients receiving injectable hydromorphone or diacetylmorphine for the treatment of opioid use disorder: A growth curve modeling approach
2021, Drug and Alcohol Dependence
Cocaine use is prevalent among people receiving injectable opioid agonist treatment. Investigations of cocaine use in this population have been descriptive and the potential heterogeneity existing in patterns of use have not been characterized. As such, among patients receiving injectable opioid agonist treatment, this study aimed to: 1) quantify intra- and inter-individual variation in cocaine use over 24-months and; 2) determine how predictors of interest explained this variation.
Participants were patients receiving injectable opioid agonist treatment for opioid use disorder. Study visits were completed at baseline prior to receiving treatment, and 3,6,9,12,18, and 24 months after baseline. A multi-level regression approach to growth curve modeling was employed to estimate and explain intra- (within-person) and inter-individual (between-person) variation in cocaine use.
Significant intra and inter-individual variation in cocaine use was identified over 24-months. Treatment engagement was on average associated with reductions in the prior month number of days of cocaine use (range: 0–30)(Estimate (standard error): -0.05(0.02), p = 0.003). On average, men reported less cocaine use compared to women (Estimate (standard error): -5.91(1.57), p=<0.001), and participants reporting ever regularly using cocaine at baseline reported more cocaine use over 24-months compared to participants reporting never regularly using cocaine (Estimate (standard error): 4.72 (1.91), p = 0.013).
Significant reductions in cocaine use were observed and significant heterogeneity in patterns of cocaine use was identified. These heterogeneous cocaine use profiles suggest that an individualized approach to care will be critical in responding to patients’ cocaine use in injectable opioid agonist treatment.
Problematizing the DSM-5 criteria for opioid use disorder: A qualitative analysis
2020, International Journal of Drug Policy
This paper includes the voices of people who are members of a peer-led drug user group (SNAP) in Canada who are receiving heroin-assisted treatment (HAT) outside of a clinical trial. Drawing from critical drug studies, we problematize the criteria for severe opioid use disorder (OUD) from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, by exploring SNAP members' experiences in relation to heroin-assisted treatment, and examining how SNAP participants' narratives challenge conventional notions of what constitutes severe opioid use disorder.
Drawing on critical analysis and research guidelines developed by drug user unions and organizations, and critical methodological frameworks on ethical community-based-and-responsive research for social justice, in this paper we focus on semi-structured interviews conducted with 36 SNAP members at the Vancouver Area Network of Drug Users site in the Downtown Eastside of Vancouver, Canada. We included opened ended questions about experiences prior to receiving HAT, experiences while receiving HAT, experiences of drug use and cessation, and future hopes.
Although SNAP participants were diagnosed as suffering from OUD, the DSM-5 criteria for OUD fails to encompass their diverse experiences of opioid use. Nor does the DSM diagnosis capture the complexities of their lived experience. The DSM OUD constructs an idea of addiction and the addicted person based on a list of symptoms thought to be associated with extended use of opioids. The problem with this is that many of these "symptoms" of drug use are, in the case of SNAP participants, tied to contextual issues of living in the DTES, experiencing structural vulnerability, and being the target of punitive drug policies and laws.
To label someone as having a severe disorder shifts the focus from political and social issues, including the lived experiences of people who use heroin. The DSM-5 de-contextualizes drug use. How addiction and heroin are constituted has political implications that will determine what types of services and programs will be set up. Treating a disorder, or a person with a disorder, requires a much different approach than understanding heroin use as a habit. SNAP, and their allies, are rupturing conventional ideas about heroin and taken for granted assumptions about people who use heroin.
Association of variants of prodynorphin promoter 68-bp repeats in caucasians with opioid dependence diagnosis: Effect on age trajectory of heroin use
2019, Neuroscience Letters
The dynorphin/kappa opioid receptor (Dyn/KOR) system is involved in reward processing and dysphoria/anhedonia. Exposure to mu-opioid receptor agonists such as heroin increases expression of the prodynorphin gene (PDYN) in the brain. In this study in a Caucasian cohort, we examined the association of the functional PDYN 68-bp repeat polymorphism with opioid use disorders. In this case-control study, 554 subjects with Caucasian ancestry (142 healthy controls, 153 opioid-exposed, but never opioid dependent, NOD, and 259 with an opioid dependence diagnosis, OD) were examined for association of the PDYN 68-bp repeats with the diagnosis of opioid dependence (DSM-IV criteria), with a dimensional measure of heroin exposure (KMSK scale), and age trajectory parameters of heroin use (age of heroin first use, and age of onset of heaviest use). The PDYN 68-bp repeat genotype (classified as: “short-short” [SS], “long-long” [LL], and “short-long” [SL], based on the number of repeats) was not associated with categorical opioid dependence diagnoses. However, the LL genotype was associated with later age of first heroin use than the SS + SL genotype (19 versus 18 years; p < 0.01). This was also confirmed by a significant positive correlation between the number of repeats and the age of first use of heroin, in volunteers with OD (Spearman r = 0.16; p = 0.01). This suggests that the functional PDYN 68-bp repeat genotype is associated with the age of first use of heroin in Caucasians diagnosed with opioid dependence.

View all citing articles on Scopus

: The production of this monograph was sponsored by the Central Committee on the Treatment of Heroin Addicts (CCBH), installed and funded by the Netherlands Minister of Heath, Welfare and Sports (VWS).

^†: Both authors contributed equally.

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Heroin-assisted treatment in the Netherlands: History, findings, and international context

Summary

Health Policy

Drug Alcohol Depend.

Drug Alcohol Depend

J Subst. Abuse Treat.

J. Pain Symptom Manage.

Br. J. Anaesth.

J. Pharm. Sci.

Eur. Neuropsychopharmacol.

Life Sci.

Drug Alcohol Depend

Forensic Sci. Int.

J. Pharm. Biomed. Anal.

Int. J. Pharm.

Drug Alcohol Depend.

J. Subst. Abuse Treat.

Report of the external panel on the evaluation of the Swiss scientific studies of medically prescribed narcotics to drug addicts

Sucht

Diagnostic and Statistical Manual of mental disorders

What can the Swiss and Dutch trials tell us about the potential risks associated with heroin prescribing?

Drug Alcohol Rev.

Analysis of cost data in randomized trials: an application of the non-parametric bootstrap

Stat. Med.

Matching of treatment-resistant heroin-dependent patients to medical prescription of heroin or oral methadone treatment: results from two randomized controlled trials

Addiction

Outcome of long-term heroin-assisted treatment offered to chronic, treatment-resistant heroin addicts in the Netherlands

Addiction

British Pharmacopoeia

Selectie van drugge-bruikers voor heroine experiment: Een vooronderzoek

Methadon verstrekking in Amsterdam 1997. Centrale Methadon Registratie

Leukoencephalopathy after inhalation of heroin vapor

J. Formos. Med. Assoc.

Comparison of intravenous and intranasal heroin self-administration by morphine-maintained humans

Psychophar-macology (Berl.)

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

Arch. Gen. Psychiatry

Variations in methadone treatment practices: results from a national study

JAMA

Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial

Addiction

De verstrekking van injecteerbare opiaten: Doelstelling van het morfine-verstrekkingsexperiment

Tijdschr. Sociale Gezondheidszorg

Het Amsterdamse morfine-verstrekkings-experiment

The dispensing of injectable morphine in Amsterdam: experiences, results and implications for the Swiss project for the medical prescription of narcotics

Jaarboek Verslaving 1997: Over gebruik en zorg in cijfers

Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials

Br. Med. J.

A medical treatment for diacetylmorphine (heroin) addiction. A clinical trial with methadone hydrochloride

JAMA

Methadonverstrekking in Nederland

Methadoncliënten in Nederland

De ontwikkeling van de situatie van methadoncliënten gedurende twee jaar

A meta-analytic review of psychosocial interventions for substance use disorders

Am. J. Psychiatry

Clinical relevance of response and improvement in psychopharmacology: a statement from the ECNP. Report of Consensus Meeting

Eur. Neuropsychopharmacol.

The Swiss heroin trials: testing alternative approaches

Br. Med. J.