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Part 1

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Hello and welcome to our case study on Drug Misuse.

Please answer the questions by filling in the free text box after each question. Once you submit your answer a 'model' answer for the question will be shown. The answers given for each section are example answers and do not necessarily mean that the answers you give are wrong.

Mr E is a 25 year old unemployed man. He smokes 30 cigarettes a day. Whilst consulting for smoking cessation, he admits to you that he has a problem with heroin. He says that his brother in Holland has been using both injected heroin and methadone and asks you whether this will be more successful than methadone alone.

He started using heroin 7 years ago and has not tried to stop or reduce his use of heroin before. However, he now has a new girlfriend who is encouraging him to stop.

1

How would you respond to his question about using methadone and heroin together?

  1. Yes, there is some evidence from Holland to show that there are improvements in physical, mental and social problems in patients using the combination.
  2. No, it would only be a possible option if he had already tried and not responded to oral methadone maintenance treatment.

Both could be correct. However, option two is probably more appropriate for this patient as he has not yet tried oral methadone maintenance therapy.

Studies in Holland have aimed to assess the efficacy of heroin (inhaled or injected) plus methadone compared with methadone alone. However, the studies were open-label studies (not blinded) and the outcomes used were difficult to assess. Co-prescription of heroin was found to reduce physical, mental and social problems seen in treatment-resistant heroin addicts. However, at 12 months, treatment retention was better in the methadone group than the combination group.

Injectable heroin and injectable methadone have been the subject of an National Treatment Agency (NTA) report. It recommends that oral methadone maintenance treatment should be used for the majority of heroin users. Injectable heroin should only be considered for the minority of patients who are genuinely unresponsive to oral methadone. The Dutch studies were performed in patients who had not responded to methadone alone.

References:

van den Brink W, et al. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ 2003; 327: 310

National Treatment Agency. Injectable heroin (and injectable methadone): potential roles in drug treatment. Full guidance report May, 2003

http://www.nta.nhs.uk/publications/documents/nta_injectable_heroin_and_methadone_2003_fullguide.pdf

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