Doctors have found two medications to be as effective as methadone in keeping addicts off heroin - and, unlike the old mainstay, they do not have to be taken on a daily basis.
Researchers who studied 220 heroin users in Baltimore said the drugs might appeal to addicts who are trying to hold down jobs or who simply don't want to attend a clinic every day. The medications work when taken three times a week.
"The greater the variety of medications, the greater the likelihood you can help everyone, even with addictions," said Rolley Johnson, who directed the study at the Johns Hopkins School of Medicine.
Last month, President Clinton signed into law a measure that could make one of the drugs, called bupranorphine, even more attractive to addicts. The measure allows doctors to prescribe the medication from their offices - eliminating the need for some addicts to attend a clinic.
No overdose effect
The drug is considered safe enough to be dispensed outside clinics because, unlike methadone or the other alternative, LAMM, it does not cause an overdose when taken above recommended amounts.
While the discipline of reporting to a clinic helps many addicts comply with treatment, others reject methadone because going to a clinic makes them feel socially ostracized.
"They could go to a physician's office, receive private treatments in a traditional setting and not feel stigmatized," said George Bigelow, an addictions researcher on the study.
The study, appearing in today's New England Journal of Medicine, was the first to compare methadone with the two newer options: bupranorphine and LAMM (levomethadyl acetate).
Addicts were divided into three groups, each receiving a different treatment. Participants in each group reported a 90 percent reduction in their heroin use although urine tests showed a 50 percent drop.
Subtle differences
Over the 17-week study period, there were subtle differences from one group to the next. By a slim margin, LAMM was best in keeping people continuously clean. Methadone was best at keeping patients in treatment, though bupranorphine wasn't far behind.
Methadone, which is taken orally in a flavored syrup, has been the main pharmaceutical treatment for heroin addiction since it was developed in the 1960s. As many as 200,000 addicts are receiving methadone in the United States, according to the National Institute of Drug Abuse.
LAMM, also a syrup, was approved by the U.S. Food and Drug Administration in 1993 but has not been widely embraced by treatment programs - partly because of its cost.
Methadone costs about $3 a week, compared with $13.60 a week for LAMM, although experts say the expense of administering methadone on a daily basis narrows the gap between the overall costs.
Bupranorphine, long used to relieve pain, is expected to receive FDA approval as a heroin replacement in the next month or two; its cost has not been disclosed. When taken for heroin addiction, it is given in drops under the tongue.
The drug has generated considerable excitement among treatment specialists, in part because of its safety. It cannot cause an overdose, even when people exceed the recommended dosage.
"I would love to go to bupranorphine for maintenance," said Betsy McCaul, who runs a substance abuse program for women at the Johns Hopkins Hospital. "We treat the tip of the iceberg," she said. "To the extent we can cast a broader net and bring more people into care, it's very positive."
Kathleen Rebbert-Franklin, program manager of a recovery program at Sinai Hospital, said the data from the study might help to erase the myth that LAMM is not as effective as methadone. Because it is not taken every day, some addicts believe its effects will wear off before they receive their next dose.
Sinai is one of several clinics in Baltimore that offer LAMM in addition to methadone.
Patients like option
"The patients on LAMM really like the option," she said. "There really isn't the high-and-low syndrome that goes with methadone."
While methadone does not produce the intoxicating "high" of heroin and addicts are often able to hold down jobs, some feel drowsy for a few hours after taking the drug.
Under a federal grant, Baltimore ran a "LAMM Van" this year that offered the drug free of charge to 100 addicts who participated in the city's needle exchange program.
Steffanie Strathdee, a Hopkins researcher who studied the program, said many of the LAMM patients reduced their heroin use.
The availability of bupranorphine outside clinics could ease what Strathdee calls greatest barrier to recovery- the shortage of slots in treatment programs.
