OPIATE SUBSTITUTION TREATMENT IN THE 21ST CENTURY

UNODC Scientific Consultation – December 2015

OPIATE SUBSTITUTION TREATMENT IN THE 21ST CENTURY

John Strang Director, National Addiction Centre Head, Addictions Department, King’s College London Leader, Addictions Clinical Academic Group of Kings Health Partners Academic Health Science Centre

Opiate substitution treatments (OST) such as methadone maintenance and buprenorphine maintenance are amongst the most strongly evidence-based treatments in medicine today, and yet they remain controversial in many cultures and countries and are often delivered sub-optimally with only partial benefit to the individual patient and to society. The pervasive acceptance of stigmatisation alongside institutional inertia allow this incomplete benefit to continue – we have a responsibility to address this and to correct it.

Benefits from OST include improved individual health (treatment of the addiction and also of related health conditions), improved public health (especially preventing illness from viral transmission of HIV, HCV, HBV) and improved public security (by breaking the power of the drug-crime link).

Evidence from clinical trials are extensively summarised in Cochrane reviews and other technology appraisals, which also examine and report on the importance of distinctive elements of the treatment (attention to dose, medication adherence, duration of treatment). Treatment is more than just medication. The provision of OST in the context of wider attention to recovery also increases the extent of benefits and recovery achieved.

A substantial minority of patients fail to benefit properly from the OST treatment provided and often drop out of treatment programs – this failure of treatment provision requires full attention. Other agonist maintenance medications are potential new contributors, such as slow-release oral morphine as used in several European countries. The development of ultra-long-acting implant forms of buprenorphine and of long- acting depot injections of buprenorphine opens up new possibilities for different ways of providing treatment. In recent years several trials have identified benefit from supervised heroin injectable maintenance for entrenched heroin addicts who have previously failed to benefit from existing treatments, and this challenging form of treatment needs to be considered seriously as an intensive treatment for the most severely affected.

OST treatments represent important tools in the armamentarium in helping opiate addicts break the damaging patterns of behaviour which are characteristics of their addictive disorders. Despite the robust evidence of major benefit from OST treatments, we need greater attention to the proper availability and effective delivery of OST treatment, alongside exploration of synergy between medication and psychosocial components of care as well as investigation to identify integration of recovery- orientated psychosocial interventions alongside medication interventions, as well as trial studies of other potential new medications alongside the long-established methadone and buprenorphine OST treatment.

About the author

Professor John Strang is a medic and an academic. He is Director of the National Addiction Centre (NAC) and Head of the Addictions Department at King’s College London from where diverse research studies are conducted and educational activity provided. He is Leader of the Addictions Clinical Academic Group of Kings Health Partners AHSC (Academic Health Science Centre). He has also been an addictions psychiatrist for over 30 years, and has led the group at the Maudsley/Institute for many years. Professor Strang has published over 400 scientific papers in the addiction field and has contributed to national and international policy including the chairing of policy-informing committees and expert groups for Department of Health, NICE and Public Health England. He has worked with, and he and his employer have received project grant support and/or honoraria and/or consultancy payments and/or travelling and/or accommodation and/or conference expenses from, a range of governmental and non-governmental organisations and from various pharmaceutical companies concerning identification and study of medicinal products potentially applicable in the treatment of addictions and related problems and has argued for the development of improved formulations. His employer (the university) has registered intellectual property on a novel buccal naloxone formulation with which JS is involved, and JS has been named in a patent registration by a Pharma company as inventor of a concentrated nasal naloxone formulation. For updated information see

John Strang’s info on Departmental website at http://www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx