Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London,...
-
Upload
skylar-crosse -
Category
Documents
-
view
216 -
download
2
Transcript of Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London,...
![Page 1: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/1.jpg)
Treatment approaches in the addiction field
Professor John StrangNational Addiction Centre, London, UK
2MMF conference Palermo, September 2008
![Page 2: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/2.jpg)
declaration
* DH, NTA, Home Office, NACD, WHO, UNODC
* Diamo, Reckitt-Benkiser, Schering-Plough, Genus-Britannia, GW, Napp, Titan, Catalent, Auralis
* Phoenix House, Clouds House, Action on Addiction, Society for the Study of Addiction
![Page 3: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/3.jpg)
NHS University
![Page 4: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/4.jpg)
Development and pilot testing of new
Prevention and Treatment Interventions
Research into the causes,consequences and influences
upon Addictions
Policy analysis and input into
Policy formation
![Page 5: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/5.jpg)
Structure of today’s talk
Some initial thoughts
Old wine in old bottles
Old wine in new bottles
New wine, well worth drinking
Wine still in development
![Page 6: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/6.jpg)
Structure of today’s talk
Some initial thoughts
Old wine in old bottles
Old wine in new bottles
New wine, well worth drinking
Wine still in development
![Page 7: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/7.jpg)
… from Faith to Science …
![Page 8: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/8.jpg)
How do we define ‘drug’?
‘les drogues sont des substances qui provoquent des comportements irrationnels et deliriants …..
…chez ceux qui n’en prennent jamais’.
(Timothy Leary)
Opiate, stimulant, hallucinogen, sedative, alcohol, nicotine
![Page 9: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/9.jpg)
Outcome measures
Outcome Measures
Drug use UDS & self-report
((Treatment retention)) Clinic records (& self report)
Injecting practices Frequency, risk & complications
Psychosocial functioning & Quality of Life Measures
SF-36, EQ-5D, OTI
((Crime)) Self-report (drug related expenditure & criminal activity)
((Cost effectiveness)) Service costs (internal & external)
((Community Impact Evaluation))
‘Nuisance’ issues for local community
![Page 10: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/10.jpg)
benefit matrix
Health Social Economic
Individual
Community
Societal
![Page 11: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/11.jpg)
Which harms and benefits are the most important?
Scientist must measure
Society must assign weightings
![Page 12: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/12.jpg)
Structure of today’s talk
Some initial thoughts
Old wine in old bottles
Old wine in new bottles
New wine, well worth drinking
Wine still in development
![Page 13: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/13.jpg)
Old wine in old bottles
MMT (and, more recently, BMT)
… but …
![Page 14: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/14.jpg)
(a) Methadone maintenance
• Major treatment for heroin dependence: highly effective
• 40 years of experience
• Oral, long half-life (daily), cross-tolerant: • prevents withdrawal symptoms• ‘universal anodyne’ psychological effect• To some extent it “blocks” euphoric effects of heroin
• Reduces illicit heroin use more than no treatment (USA, Australia), drug-free treatment (Sweden), placebo (Hong Kong, USA) and detoxification (Thailand, USA) in RCTs
• Better retention than placebo, drug-free treatment, detoxification and wait-list controls (Mattick, 2002)
![Page 15: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/15.jpg)
Evidence and interpretation:Clinical effectiveness
Most trials used a fixed-dose designMTD 50-150mg/dayBP 1-15mg/day
2 main outcomes reported:Retention in treatment Illicit use of opioids [proportion of people taking illicit
opioids, mean rate of heroin intake assessed by self-report and/or urinalysis]
![Page 16: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/16.jpg)
Gunne & Gronbladh (1981) RCT:Methadone versus no methadone
34 subjects using heroin by injection 17 experimental (methadone)
17 controls (no methadone)
Controls not allowed to enter MMT for 2 years
Followed up at 2 years and again at 4 years
![Page 17: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/17.jpg)
Gunne & Gronbladh (1981): Baseline
Experimental Group (methadone)
Control group (no methadone)
U U U U U U U U
U U U U U U U U
U U U U U U U U
U U U U U U U U
U U
U – ongoing daily heroin Use
![Page 18: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/18.jpg)
Gunne & Gronbladh (1981): 2 years
Experimental group (methadone)
Control group (no methadone)
U U U A
U U U U
U U U U
U U U D
D
A – Abstinent U – on-going daily UseD – Deceased
![Page 19: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/19.jpg)
Gunne & Gronbladh (1981): 2 years
Experimental group (methadone)
Control group (no methadone)
A A A A U U U A
A A A A U U U U
A A A A U U U U
U U U U U U U D
U D
A – Abstinent U – on-going daily UseD – Deceased
![Page 20: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/20.jpg)
Gunne & Gronbladh (1981): 4 years
Experimental Group (methadone)
Control group (methadone)
Control group (no methadone)
U A
U U
U D
D D
D
A – Abstinent U – on-going daily UseD – Deceased
![Page 21: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/21.jpg)
Gunne & Gronbladh (1981): 4 years
Experimental Group (methadone)
Control group (methadone)
Control group (no methadone)
A A A A U A
A A A A U U
A A A A U D
U U U A D D
U D
A – Abstinent U – on-going daily UseD – Deceased
![Page 22: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/22.jpg)
Gunne & Gronbladh (1981): 4 years
Experimental Group (methadone)
Control group (methadone)
Control group (no methadone)
A A A A U U U A
A A A A A A U U
A A A A A A U D
U U U A A A D D
U D
A – Abstinent U – on-going daily UseD – Deceased
![Page 23: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/23.jpg)
29
42
89
15
85
1716 14
82
13
2228
0
20
40
60
80
100
Heroin (Weekly)*
Cocaine (Weekly)*
Heavy Alcohol
Illegal Activity*
No FT Work SuicidalIdeation
Pre Post
% of DATOS Sample (N=727)
USA - Outpatient Methadone Treatment
Changes from Before to After Treatment
*p<.001
Hubbard, Craddock, Flynn, Anderson, & Etheridge 1997, PAB
![Page 24: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/24.jpg)
29
42
89
15
85
1716 14
82
13
2228
0
20
40
60
80
100
Heroin (Weekly)*
Cocaine (Weekly)*
Heavy Alcohol
Illegal Activity*
No FT Work SuicidalIdeation
Pre Post
% of DATOS Sample (N=727)
USA - Outpatient Methadone Treatment
Changes from Before to After Treatment
*p<.001
Hubbard, Craddock, Flynn, Anderson, & Etheridge 1997, PAB
![Page 25: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/25.jpg)
29
42
89
15
85
1716 14
82
13
2228
0
20
40
60
80
100
Heroin (Weekly)*
Cocaine (Weekly)*
Heavy Alcohol
Illegal Activity*
No FT Work SuicidalIdeation
Pre Post
% of DATOS Sample (N=727)
USA - Outpatient Methadone Treatment
Changes from Before to After Treatment
*p<.001
Hubbard, Craddock, Flynn, Anderson, & Etheridge 1997, PAB
![Page 26: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/26.jpg)
The benefit of retaining patients in treatment - HIV infection rates in and
out of methadone maintenance treatment (Metzger et al. 1993)
21
273536 3639 39 42484951
13
15 1617 1718 19 1921
Out of tx %
In tx %
![Page 27: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/27.jpg)
The benefit of retaining patients in treatment - HIV infection rates in and
out of methadone maintenance treatment (Metzger et al. 1993)
21
273536 3639 39 42484951
13 15 16 17 17 18 18 19 19 20 21Out of tx %
In tx %
![Page 28: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/28.jpg)
The benefit of retaining patients in treatment - HIV infection rates in and
out of methadone maintenance treatment (Metzger et al. 1993)
2127
35 3636
39 39 42 48 49 51
13 15 16 17 17 18 18 19 19 20 21Out of tx %
In tx %
![Page 29: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/29.jpg)
(b) Buprenorphine maintenance
• Agonist with very high affinity for opiate receptor (heroin cannot compete at opioid receptor)
• Similar treatment retention as methadone, but not quite as good (MMT: 63%, Bup:53%; Mattick, 2002)
• No significant difference between methadone and buprenorphine in reducing heroin use, cocaine use, benzodiazepine use or crime (Mattick, 2002)
• Probably less overdose risk (but not yet firmly demonstrated how much better)
![Page 30: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/30.jpg)
![Page 31: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/31.jpg)
![Page 32: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/32.jpg)
1 year retention during buprenorphine
maintenance (16 mg qd)
Kakko et al. (2003)Treatment duration (days)
# R
emai
ning
in t
reat
men
t
0
5
10
15
20
0 50 100 150 200 250 300 350
Control (6 day taper)
buprenorphine maintained
75% retained at 1 year; no deaths
75% of urine drug screens negative
![Page 33: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/33.jpg)
![Page 34: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/34.jpg)
0 1 2 4 8 16 32
10
11
12
13
14
15
16
17
Bre
aths
/Min
ute
PL Buprenorphine (mg, sl)
Human respiratory rate
Adapted from Walsh et al., 1994
Ceiling effect on respiratory depression
![Page 35: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/35.jpg)
![Page 36: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/36.jpg)
![Page 37: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/37.jpg)
![Page 38: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/38.jpg)
![Page 39: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/39.jpg)
![Page 40: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/40.jpg)
![Page 41: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/41.jpg)
![Page 42: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/42.jpg)
![Page 43: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/43.jpg)
![Page 44: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/44.jpg)
![Page 45: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/45.jpg)
(c) Levo-alpha-acetylmethadol (LAAM)
• Full opiate agonist with longer duration of action than methadone (48 or 72 hours or longer), 3x week dosing
• 10 cases of life threatening cardiac arrhythmias: withdrawn (Europe) and not be used as first line therapy (US)
• Need to clarify risks of LAAM treatment, particularly cardiac arrhythmia from QT prolongation
![Page 46: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/46.jpg)
Retention in treatment: methadone, buprenorphine, LAAM maintenance
![Page 47: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/47.jpg)
(d) Prolonged-release oral morphine
Oral, long duration of action (24 hours)
comparable retention and illicit drug use to methadone treatment and significantly lower depression, anxiety and physical complaints (Eder, 2005)
An open label 3-week study of 110 opioid dependent subjects showed high retention, reduced somatic complaints and reduced cravings (Kraigher, 2005)
MMT patients transferring to SROM (n=18) showed similar outcomes as methadone, improved social functioning, and less side-effects (Mitchell, 2004)
![Page 48: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/48.jpg)
(e) Codeine or dihydrocodeine
![Page 49: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/49.jpg)
![Page 50: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/50.jpg)
Naltrexone – the classic antagonist
• Opioid antagonist – oral, 24-hour, remarkably effective
• However - only rarely prescribed by doctors
• Widespread disappointment of poor uptake by patients
• Also - separately used (unlicensed) in opiate detox
• Also - long-acting depot form recently developed (2006)
• Separate alcohol interest in relapse-preventing benefit (perhaps ?? anti-craving effect for alcohol??)
![Page 51: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/51.jpg)
… but …
![Page 52: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/52.jpg)
Retention in treatment: methadone, buprenorphine, LAAM maintenance
![Page 53: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/53.jpg)
Retention in treatment methadone, buprenorphine & LAAM vs. naltrexone
![Page 54: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/54.jpg)
Move to NICE slides
![Page 55: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/55.jpg)
![Page 56: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/56.jpg)
U.K. Methadone treatment:benefits in the first month
(Strang, Finch et al, Addiction Research)
4.7
6.36
1.2
2.2
3.5
1.8
2.56
0.50.8
0.5
0
1
2
3
4
5
6
7
herointimes/ wk
heroinmgX10
cocainetimes/ wk
coc mgX10 shopliftingper week
pre-entry1 month
![Page 57: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/57.jpg)
U.K. Methadone treatment:benefits in the first month
(Strang, Finch et al, Addiction Research)
4.7
6.36
1.2
2.2
3.5
1.8
2.56
0.50.8
0.5
0
1
2
3
4
5
6
7
herointimes/ wk
heroinmgX10
cocainetimes/ wk
coc mgX10 shopliftingper week
pre-entry1 month
![Page 58: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/58.jpg)
U.K. Methadone maintenance –changes in heroin use over time
0
0.5
1
1.5
2
2.5
3
3.5
Am
ou
nt
of
he
roin
in
Gm
pe
r w
eek
Methadone maintenance
Source: Finch 2000 MD thesis
![Page 59: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/59.jpg)
U.K. Methadone maintenance –changes in heroin use over time
0
0.5
1
1.5
2
2.5
3
3.5
Am
ou
nt
of
he
roin
in
Gm
pe
r w
eek
Methadone maintenance
Source: Finch 2000 MD thesis
![Page 60: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/60.jpg)
![Page 61: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/61.jpg)
Opioid Overdose Deaths 1964-1997 (per million Australian adults, 15-44 years)
(Hall, Degenhardt & Lynskey, 1999)
15 44 yrs
0
10
20
30
40
50
60
70
80
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
15 44 yrs
![Page 62: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/62.jpg)
Structure of today’s talk
Some initial thoughts
Old wine in old bottles
Old wine in new bottles
New wine, well worth drinking
Wine still in development
![Page 63: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/63.jpg)
Old wine in new bottles
(Naltrexone in alcohol field)
(Disulfiram with cocaine)
Heroin maintenance (re-conceptualisation)
Naloxone ‘technology transfer’
![Page 64: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/64.jpg)
![Page 65: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/65.jpg)
![Page 66: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/66.jpg)
![Page 67: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/67.jpg)
![Page 68: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/68.jpg)
![Page 69: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/69.jpg)
WHAT INJECTABLE PRODUCTS?
Two products:
- heroin ampoules (dry amps) (1%)
- methadone ampoules (wet amps) (3-10%)
![Page 70: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/70.jpg)
What is the RIOTT trial?
![Page 71: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/71.jpg)
![Page 72: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/72.jpg)
Results
…… to follow ……
However, as a clinician I can tell you …We are seeing some transformational changesEnough to guide policy-making process?
Retention approx 85% at 6/12 (vs 50% typical)Follow-up approx 95% (vs 75% typical)
![Page 73: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/73.jpg)
![Page 74: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/74.jpg)
![Page 75: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/75.jpg)
![Page 76: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/76.jpg)
Opioid Overdose Deaths 1964-1997 (per million Australian adults, 15-44 years)
(Hall, Degenhardt & Lynskey, 1999)
15 44 yrs
0
10
20
30
40
50
60
70
80
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
15 44 yrs
![Page 77: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/77.jpg)
Oxygen saturation: IV versus IM
0 10 20 30 40 50 60
90
92
94
96IV
IM
Minutes post-injection
Sp
O2
(%)
![Page 78: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/78.jpg)
Oxygen saturation: case study
0 10 20 30 40 50 60
84
87
90
93
96
Male, age 49Intravenous diamorphine (6 years)This dose = 120 mgDaily dose = 400mg
Minutes post-injection
Sp
O2
(%)
![Page 79: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/79.jpg)
Actions on Discovering Overdose
CALL AMBULANCE
Check Airway – clear if blocked, Check breathing.
If breathing, place in recovery position – if not breathing, begin basic life support or place in recovery position to maintain a good airway and prevent them from choking
Administer naloxone
![Page 80: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/80.jpg)
Naloxone Administration
Quickest route of injection is intravenous However INTRAMUSCULAR injection
recommended as easier. Inject into a muscle Upper outer buttock, thigh area or upper arm. Hold needle 90 degree above skin Insert needle into muscle Slowly and Steadily push plunger all the way down
![Page 81: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/81.jpg)
Client confidence in administering naloxone
0
10
20
30
40
50
60
V.confident Confident Unsure Not confident Not at allconfident
level of confidence
%
pre-training
post-training
![Page 82: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/82.jpg)
![Page 83: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/83.jpg)
![Page 84: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/84.jpg)
![Page 85: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/85.jpg)
Interviews in confidence (n=1009)
Face-to-face
Independent research staff
Enquiry about sexual and injecting behaviours
Now; recent past; distant past
![Page 86: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/86.jpg)
Table 1. Persistence of drug use on imprisonment
Ever used(n=557 out of 1009)
Year beforeprison
Month beforeprison
Heroin (n=324) 63% a (n=204)
52%(n=169)
Cocaine (n=387)
72%(n=280)
54%(n=209)
Amphetamines (n=417)
52%(n=216)
30%(n=125)
a All percentages are calculated based on the numbers who have ever used
![Page 87: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/87.jpg)
Table 1. Persistence of drug use on imprisonment
Ever used(n=557 out of 1009)
Year beforeprison
Month beforeprison
Heroin (n=324) 63% a (n=204)
52%(n=169)
Cocaine (n=387)
72%(n=280)
54%(n=209)
Amphetamines (n=417)
52%(n=216)
30%(n=125)
a All percentages are calculated based on the numbers who have ever used
![Page 88: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/88.jpg)
Table 1. Persistence of drug use on imprisonment
Ever used Year beforeprison
Month beforeprison
First month in
prison
Ever used it in
prison
Ever injected it
inprison
Amphetamines (n=417)
52%(n=216)
30%(n=125)
5%(n=19)
26%(n=108)
4%(n=15)
a All percentages are calculated based on the numbers who have ever used
![Page 89: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/89.jpg)
Table 1. Persistence of drug use on imprisonment
Ever used Year beforeprison
Month beforeprison
First month in
prison
Ever used it in
prison
Ever injected it
inprison
Cocaine (n=387)
72%(n=280)
54%(n=209)
11%(n=41)
35%(n=135)
3%(n=10)
Amphetamines (n=417)
52%(n=216)
30%(n=125)
5%(n=19)
26%(n=108)
4%(n=15)
a All percentages are calculated based on the numbers who have ever used
![Page 90: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/90.jpg)
Table 1. Persistence of drug use on imprisonment
Ever used Year beforeprison
Month beforeprison
First month in
prison
Ever used it in
prison
Ever injected it
inprison
Heroin (n=324) 63% a (n=204)
52%(n=169)
36%(n=118)
71%(n=230)
16%(n=51)
Cocaine (n=387)
72%(n=280)
54%(n=209)
11%(n=41)
35%(n=135)
3%(n=10)
Amphetamines (n=417)
52%(n=216)
30%(n=125)
5%(n=19)
26%(n=108)
4%(n=15)
a All percentages are calculated based on the numbers who have ever used
![Page 91: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/91.jpg)
Post-release ‘carnage’
Seaman Brettle Gore, BMJ, 1998
Bird & Hutchinson, Addiction, 2002
Farrell & Marsden, Addiction, 2008
![Page 92: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/92.jpg)
![Page 93: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/93.jpg)
Prevalence of drug dependence
15%
11%
17%
9%
10%
8%
16%
8%
24%
17%
11%
2%
13%
10%
12%
5%
0
10
20
30
40
50
60
%
M remand M sentenced F remand F sentenced
Opiates & stimulants Opiates only Stimulants only Cannabis only
Drug dependence prior to prison
Substance Misuse in Prisoners 2002 Singleton N, Farrell M, Meltzer H ONS.
![Page 94: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/94.jpg)
Excess mortality ratio for different time periods post-release by cause of death (Singleton, Farrell, Marsden et al 2003)
05
1015202530354045
Time since release (w eeks)
Exce
ss m
orta
lity ra
tio
Drug-related deaths Not drug-related
![Page 95: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/95.jpg)
N-ALIVE trial – pilot & main phase
N-ALIVE research trial proposal to test/prove reduced deaths post-release
Pilot – n=5600 Main study – n=56000 (28k + 28k)
![Page 96: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/96.jpg)
Structure of today’s talk
Some initial thoughts
Old wine in old bottles
Old wine in new bottles
New wine, well worth drinking
Wine still in development
![Page 97: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/97.jpg)
Treatment Research Institute Mc Lellan et al
Levels of Treatment in Methadone Maintenance Programs
Random Assignment 6 Months
‘Bare-bones’ Standard ‘deluxe’ (n=29) (n=34) (n=36)
Methadone: > 65mg >65mg >65mgCounseling: Regular RegularOther Services Employment
Family Therapy Psychiatric Care
![Page 98: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/98.jpg)
Levels of care Study
0
10
20
30
40
50
60
70
Using Heroin Using Cocaine Sharing Needles Illegal Acts Unemployed
barebones standard deluxe
Target behaviors at 6 months
![Page 99: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/99.jpg)
Levels of care Study
0
10
20
30
40
50
60
70
Using Heroin Using Cocaine Sharing Needles Illegal Acts Unemployed
barebones standard deluxe
Target behaviors at 6 months
![Page 100: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/100.jpg)
Levels of care Study
0
10
20
30
40
50
60
70
Using Heroin Using Cocaine Sharing Needles Illegal Acts Unemployed
barebones standard deluxe
Target behaviors at 6 months
![Page 101: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/101.jpg)
![Page 102: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/102.jpg)
Move to NICE Forest plots of meta-analyses
![Page 103: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/103.jpg)
Structure of today’s talk
Some initial thoughts
Old wine in old bottles
Old wine in new bottles
New wine, well worth drinking
Wine still in development
![Page 104: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/104.jpg)
Wines in development
(migrant medications)
Tele-prompting/monitoring
Vaccines
Ultra-long duration meds (nx; bup; …)
HR moderation medications (?nalmef; ?)
![Page 105: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/105.jpg)
![Page 106: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/106.jpg)
… add cocaine vaccine slide …
![Page 107: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/107.jpg)
![Page 108: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/108.jpg)
![Page 109: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/109.jpg)
![Page 110: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/110.jpg)
![Page 111: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/111.jpg)
![Page 112: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/112.jpg)
![Page 113: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/113.jpg)
conclusion
… exciting times
![Page 114: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/114.jpg)
Thank you
![Page 115: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/115.jpg)
Bup-nalox effects –by different routes
(version 1)
![Page 116: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/116.jpg)
![Page 117: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/117.jpg)
![Page 118: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/118.jpg)
Bup Nalox
Su
b-lingu
alBup Nalox
![Page 119: Treatment approaches in the addiction field Professor John Strang National Addiction Centre, London, UK 2MMF conference Palermo, September 2008.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516d6545503469d338b4723/html5/thumbnails/119.jpg)
Bup Nalox
Inject
Bup Nalox