CLINICAL TRIALS. There are seven positive randomized controlled trials from six countries as shown below. All the trials have shown diacetylmorphine to be more beneficial than continuing to try oral agents such as methadone. There is no randomized controlled trial that has ever found diacetylmorphine not to be superior to methadone in this context.
“The available evidence suggests an added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment refractory, opioid users, to reach a decrease in the use of illicit substances, involvement in criminal activity and incarceration, a possible reduction in mortality; and an increase in retention in treatment.”
Perneger TV, Giner F, del Rio M, Mino A. Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments. British Medical Journal 1998; 317(7150):13-8.
Uchtenhagen A, Dobler-Mikola A, Steffen T, Gutzwiller F, Blättler R, Pfeifer S, eds. Prescription of narcotics for heroin addicts: main results of the Swiss National Cohort Study. Basel: Karger Verlag, 1999
March JC, Oviedo-Joekes E, Perea-Milla E, Carrasco F, PEPSA team. Controlled trial of prescribed heroin in the treatment of opioid addiction. Journal of Substance Abuse Treatment 2006;31(2):203–11.
Haasen C, Verthein U, Degwitz P, Berger J, Krausz M, Naber D. Heroin-assisted treatment for opioid dependence. Randomised controlled trial. British Journal of Psychiatry 2007;191:55–62.
Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, Schechter MT. Diacetylmorphine versus methadone for the treatment of opioid addiction. New England Journal of Medicine 2009; 361:777–86.
Strang J, Metrebian N, Lintzeris N, Potts L, Carnwath T, Mayet S, et al. Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment(RIOTT): a randomised trial. Lancet 2010; 375:1885–95.
Oviedo-Joekes E, Guh D, Brissette S, et al. Hydromorphone compared with diacetylmorphine for long-term opioid dependence: a randomized clinical trial. JAMA Psychiatry 2016; 73(5):447-455.
"The results of the economic evaluations, considering a lifetime time horizon and societal perspective, indicated that DAM and HDM treatments each 11 provided more benefits than methadone treatment, and at lower cost for individuals who had previously used Other treatment options. Based on incremental cost-effectiveness ratios, it was found that both DAM and HDM dominated methadone."
There are four health economic studies from three countries as shown below. All the studies have shown diacetylmorphine to be more cost-effective than oral agents such as methadone, in some cases achieving better outcomes at lower overall cost.
Dijkgraaf MG, van der Zanden BP, de Borgie CA, Blanken P, van Ree JM, van den Brink W. Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials. British Medical Journal 2005; 330(7503):1297.
Byford S, Barrett B, Metrebian N, Groshkova T, Cary M, Charles V, Lintzeris N, Strang J. Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction. British Journal of Psychiatry 2013; 203:341-9.
Nosyk B, Guh DP, Bansback NJ, Oviedo-Joekes E, Brissette S, Marsh DC, Meikleham E, Schechter MT, Anis AH.
Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid dependence refractory to treatment.
Canadian Medical Association Journal 2012; 184(6):E317-28.
Bansback N, Guh D, Oviedo-Joekes E, Brissette S, Harrison S, Janmohamed A, Krausz M, MacDonald S, Marsh DC, Schechter MT, Anis AH.
Cost-effectiveness of hydromorphone for severe opioid use disorder: findings from the SALOME randomized clinical trial.
Addiction 2018; 113(7):1264-1273.