Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial.
Haasen C., Verthein U., Eiroa-Orosa F.J. et al. European Addiction Research: 2010, 16, p. 124–130.

Uniquely among modern heroin prescribing trials, the trial in Germany was not confined to heroin-addicted patients who had done poorly on methadone, offering the opportunity to assess whether heroin should be reserved for these patients. The conclusion was that other patients too benefit more from injectable heroin than oral methadone.

Summary
This account also draws on the main report from the trial of which the featured report was a sub-study. The study trialled the prescribing of heroin for the treatment of heroin addiction at seven German clinics. Over the years 2002 and 2003 it successfully recruited 1015 patients who were continuing to regularly inject heroin and were in poor physical or mental health despite currently being in methadone maintenance treatment, or having been treated for their addiction in the past but not in the last six months. Uniquely among modern trials, because the past treatment need not have been opiate substitute prescribing, the trial was not confined to patients who had previously done poorly on methadone, offering the opportunity taken by the featured report to assess whether heroin prescribing should be reserved to these patients.

Patients were randomly allocated to either be prescribed heroin to be taken under supervision at the clinics plus oral methadone, or only oral methadone. Cutting across this allocation, they were also randomly allocated to two forms of psychosocial support: case management conducted along motivational interviewing lines and intended to flexibly coordinate an individualised care package from various services; or a more standard and directly delivered series of individual counselling and group therapy sessions. Which of these support programmes a patient was allocated to made no difference to the main outcomes, so reports have focused on the pharmacotherapy options.