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Hydromorphone vs. diacetylmorphine for long-term opioid addiction

In most analyses, injectable hydromorphone hydrochloride was not worse than diacetylmorphine hydrochloride (pharmaceutical heroin) to treat long-term severe opioid dependence and that could provide alternative treatment for patients where diacetylmorphine is unavailable because of political or regulatory reasons or for patients in whom it was unsuccessful, according to an article published online by JAMA Psychiatry.

Addiction to opioids, including heroin, exacts a heavy toll on people and communities around the world. Oral maintenance treatment, such as methadone hydrochloride and buprenorphine hydrochloride, has been effective for many people. Effective treatment can help to decrease drug use, infectious disease transmission and illegal activity.

But some individuals with severe opioid addiction aren’t attracted to or retained in oral maintenance treatment so alternatives are needed. Previous research has suggested that injectable diacetylmorphine hydrochloride (the active ingredient in heroin), when delivered under supervision can be effective. However, diacetylmorphine is not available in many countries around the world because of regulatory and political reasons.

Eugenia Oviedo-Joekes, Ph.D., of Providence Health Care, St. Paul’s Hospital, Vancouver, Canada, and coauthors tested whether injectable hydromorphone was noninferior to injectable diacetylmorphine. Hydromorphone is licensed for analgesia (pain relief) but not for opioid maintenance, according to the study.

The authors’ randomized clinical trial included 202 long-term injection street opioid users who were assigned to receive either injectable diacetylmorphine or hydromorphone (up to three times a day) under supervision for six months. About 30 percent of the study participants were women and their average age was 44.

The authors report noninferiority was demonstrated in some analyses.

“Taken together, these results suggest that injectable hydromorphone is as effective as injectable diacetylmorphine for long-term injection street opioid users not currently benefitting from available treatments. … In jurisdictions where diacetylmorphine is currently not available or in patients in whom it is contraindicated or unsuccessful, hydromorphone provides a licensed alternative, once its use for maintenance treatment of opioid use disorder is permitted,” the study concludes.

Editorial: Meeting the Growing Need for Heroin Addiction Treatment

“To these ends, the results of the study by Oviedo-Joekes et al suggest that supervised injection of hydromorphone may be as effective as supervised injection of heroin in individuals with severe opioid dependence who continue to inject heroin and do not respond to multiple attempts at optimized treatments with methadone or buprenorphine. Because heroin is prohibited from medical use in many countries where hydromorphone is currently approved for specific medical indications, supervised hydromorphone injection with flexible methadone dosing may be more feasible to implement. However, with the exception of methadone and buprenorphine, many countries (including the United States) prohibit the use of other opioids for the treatment of opioid use disorder, and regulatory changes would be required to permit supervised hydromorphone injection. Nonetheless, one of the great values of the study by Oviedo-Joekes et al is its focus on developing and evaluating treatments for some of the most difficult-to-reach and difficult-to-treat persons who inject heroin,” writes Richard S. Schottenfield, M.D., and Stephanie S. O’Malley, Ph.D., of the Yale School of Medicine, New Haven, Conn., in a related editorial.