LAAM maintenance vs methadone maintenance for heroin dependence.
BACKGROUND
LAAM and methadone are both full mu opiate agonists and have been shown to reduce dependence on heroin when given continuously under supervised dosing conditions. LAAM has a long duration of action requiring dosing every two or three days compared to methadone which requires daily dosing. LAAM is not as widely available internationally as methadone, and may be withdrawn from the market following ten cases of life-threatening cardiac arrhythmias and an association with QT prolongation.


OBJECTIVE
To compare the efficacy and acceptability of LAAM maintenance with methadone maintenance in the treatment of heroin dependence.


METHODS
We searched MEDLINE (January 1966 to August 2000), PsycINFO (1887 to August 2000), EMBASE (January 1985 to August 2000), and the Cochrane Controlled Trials Register (Issue 2 2000). In addition we hand searched NIDA monographs until August 2000 and searched reference lists of articles.


METHODS
All randomised controlled trials, controlled clinical trials and controlled prospective studies comparing LAAM and methadone maintenance for the treatment of heroin dependence and measuring outcomes of efficacy or acceptability were included.


METHODS
Data on retention in treatment, heroin use, side-effects and mortality were collected by two reviewers independently. A meta-analysis was performed using RevMan. Discrepancies were resolved by consensus.


RESULTS
Eighteen studies, (15 RCTs, 3 Controlled prospective studies) met the inclusion criteria for the review. Three were excluded from the meta-analysis due to lack of data on retention, heroin use or mortality. Cessation of allocated medication (11 studies, 1473 participants) was greater with LAAM than with methadone, (RR 1.36, 95%CI 1.07-1.73, p=0.001, NNT=7.7 (or 8)). Non-abstinence was less with LAAM (5 studies, 983 participants; RR 0.81, 95%CI 0.72-0.91, p=0.0003, NNT=9.1 (or 10)). In 10 studies (1441 participants) there were 6 deaths from a range of causes, 5 in participants assigned to LAAM (RR 2.28 (95%CI 0.59-8.9, p=0.2). other relevant outcomes, such as quality of life and criminal activity could not be analysed because of lack of information in the primary studies.


CONCLUSIONS
LAAM appears more effective than methadone at reducing heroin use. More LAAM patients than methadone ceased their allocated medication during the studies, but many transferred to methadone and so the significance of this is unclear. There was no difference in safety observed, although there was not enough evidence to comment on uncommon adverse events.
Clark
N
N
Turning Point Alcohol & Drug Centre, 54-62 Gertrude St, Fitzroy, Victoria, Australia, 3065. nicoc@turningpoint.org.au
Lintzeris
N
N
Gijsbers
A
A
Whelan
G
G
Dunlop
A
A
Ritter
A
A
Ling
W
W
D002986:Clinical Trials as Topic; D006556:Heroin Dependence / Q000534:rehabilitation*; D006801:Humans; D008691:Methadone / Q000627:therapeutic use*; D008692:Methadyl Acetate / Q000627:therapeutic use*; D009294:Narcotics / Q000627:therapeutic use*
D009294:Narcotics; D008692:Methadyl Acetate; D008691:Methadone