In 2008, researchers conducting the North American Opiate Medication Initiative (NAOMI), a study which found that diacetylmorphine–also known as prescription heroin–was more effective than methadone for the treatment of chronic heroin dependent people, were surprised to find evidence that suggested hydromorphone, a licensed painkiller, might be just as effective.
While it was only a small group of NAOMI participants who received hydromorphone, the reaction was enough to get researchers to sit up, take notice and decide to investigate further. SALOME was born out of that need to narrow the comparison of pharmaceutical heroin to hydromorphone.
“One treatment will not always fit all. This means it is necessary to have diversified treatments to cater to different needs and different profiles,” said Dr. Eugenia Oviedo-Joekes, one of two principal investigators. SALOME aims to test whether hydromorphone is as effective as pharmaceutical heroin for chronic heroin dependent people who are not benefitting from other treatments.
According to Dr. Martin Schechter, a SALOME co-investigator, a further barrier to treatment is methadone’s image problem among drug users. This stigma on the street comes from bad experiences with punitive approaches in methadone programs, as well as the perception that methadone is “just as addictive” as heroin. For some users, methadone’s oral intake method also proves challenging, since it does not provide the same rush as injection. European studies show that methadone and other traditional addiction treatments just do not work for about 15-20% of opiate dependent individuals. “We are lucky that for most people, methadone works as well as it does,” said Oviedo-Joekes. “But sometimes it doesn’t.”
While SALOME researchers would like to see an end to illicit opiate use, Dr. Oviedo-Joekes acknowledges that complete heroin abstinence is sometimes not immediately possible. For people who have suffered from heroin addiction for many years, more realistic goals may be getting them off the street into a clinical setting, and most importantly, enabling them to engage with the healthcare system and other social services. “In many treatment programs, the number one goal is survival [of the patient],” she adds.
The population that doesn’t benefit from conventional substitution treatments still needs more options. “If I have a headache, there are 15 different drugs out there to help me. For heroin addiction, there are currently only two main [legal] methods,” she said. “[Through this study], we are simply trying to provide an alternative. If, once the study is completed, SALOME were to show that hydromorphone is as effective as pharmaceutical heroin, it would be a much-needed addition to the addiction-fighting arsenal of physicians.”
“We know that from NAOMI and other European studies that diacetylmorphine [pharmaceutical heroin] treatment is effective,” said Dr. Schechter. “[And] we’ve seen from recent controversy in Canada that prescription heroin won’t be accepted in many countries. Hydromorphone opens the possibility of treatment, with all the advantages of diacetylmorphine without all the disadvantages of its regulatory barriers.”
by Sonia Renger