Reverse transition from injecting to smoking heroin and crack cocaine on lower methadone dose: sub-therapeutic dosing or safer drug use?
Felicia Heidebrecht and Mary Bell Macleod
Heroin use in methadone treatment is common, especially for dual users of heroin and crack/cocaine or other stimulants. Although recommended for achieving abstinence, many people reject high doses of methadone.
This study explores reverse transition (RT) and discusses possible advantages of lower methadone doses for safer drug use and better health.
Participants: Users of heroin and crack who have ever injected heroin, and still use heroin in methadone treatment in London, UK, age over 40
Data collection: Clinical records (N=117); semi-structured interviews (N=10).
RT correlated strongly with current crack smoking (rather than injecting) (Phi=0.680, p=.001), but only weakly with good cardiovascular health (Phi=0.229, p=0.013).
Interview analysis was used to understand why RT was not always linked to good health: All interviewees in poor health were on higher dose of methadone (>75mg/day), had transitioned to regular use of high risk injecting sites (groin, neck) during or after their first methadone treatment, and switched to smoking only when their high-risk sites were exhausted or they experienced related severe health complications (DVT, stroke).
Those in good health were mainly on lower methadone doses and switched to smoking without using high-risk sites.
People’s reasons for treatment were not always abstinence. Their accounts illustrate how they adjusted their heroin and/or crack use on higher or lower methadone doses to optimize the high, suggesting that RT was easier to achieve on a low dose.
- For IV users of both heroin and crack, RT is more difficult than for smokers of crack.
- RT is linked to good health when it precedes compromised health due to high risk injecting.
- Lower methadone doses could be a harm reduction option for those who choose to continue drug use.
Methadone and psycho-social interventions could support people’s choice of safer drug use or abstinence