Comparison of 3 L-α-acetyl-methadol (LAAM) maintenance strategies for heroin dependence

AIMS: Heroin dependence continues to be a major public health concern, with high relapse rates. The gold standard treatment for this disorder is long-term opioid maintenance. Dosing strategies for maintenance treatments have evolved over several decades, with lingering questions concerning optimal dosing regimens. DESIGN AND SETTING: The current study compared the effectiveness of 3 dosing regimens of the opioid agonist L-α-acetyl-methadol (LAAM) in a randomized controlled double-blind trial. INTERVENTION: One hundred and fourteen active heroin-dependent subjects meeting study criteria were randomly assigned to 1 of 3 LAAM dosing strategies (fixed dose, dose on the basis of subject weight, or variable dosing on the basis of efficacy and side effects). Subject selection included a stated goal of subsequent participation in a dose-reduction study. Subjects underwent a 28-day induction period followed by 5 months of LAAM maintenance therapy. FINDINGS: Treatment with LAAM resulted in a significant decrease in non-LAAM opioid-positive urine screens in all dosing groups, with few (∼10%) positive urine screens by the end of the 5-month maintenance period. No differences were detected between the 3 dosing strategies. Rates of attrition during medication induction were 20% and reached 50% by the end of the study period. LAAM was well tolerated, with few side effects. Subjects with methadone treatment experience reported a clear preference for LAAM. CONCLUSIONS: This study demonstrates the efficacy of LAAM, with equivalent results across the 3 dosing conditions. Although no significant difference among the conditions emerged, dosing to weight may be the most useful standardizing strategy for early maintenance beyond research settings.