Pubdate: Tue, 01 Jan 2008
Source: BC Medical Journal (CN BC)
Copyright: 2008 BC Medical Journal
Authors: David C. Marsh, MD, Michael Krausz, MD


The most effective and best-studied treatment available in addiction 
medicine is methadone maintenance treatment (MMT), which leads to a range 
of benefits for individuals with opioid dependence and society at large.[1] 
Unfortunately, not all those with opioid dependence benefit from MMT and 
there is no similar medication available for the treatment of stimulant 
dependence (particularly crack cocaine or crystal methamphetamine).

The Chronic Addiction Substi-tution Treatment Trials (CAST) are planned as 
a series of five scientifically rigorous, ethically sound clinical research 
studies to be conducted in Vancouver to evaluate novel pharmacological 
strategies for opioid and stimulant dependence.

As Dr Mela-med and colleagues correctly state, pharmacological treatments 
are most effective when combined with a full range of psychosocial services 
such as supportive housing, social supports sufficient to prevent abject 
poverty, addiction counseling, psychiatric care, and primary medical care, 
and participants in CAST will receive this full range of services in 
combin-ation with the study medications.

Throughout the trial, participants will be able to access these services 
regardless of whether they continue on the study medications. More 
importantly, for most of these services, the access will not be limited to 
the duration of the trials or to those who participate in CAST. For 
example, over the past year the municipal and provincial governments have 
announced several new initiatives that will significantly ex-pand access to 
supportive housing in Vancouver, and while CAST participants will be able 
to avail of these services, access will not be limited to CAST participants.

If we insisted, as Dr Melamed and colleagues suggest, that novel 
medications cannot be evaluated until access to support services is 
available to all, then we would still be limited to treating hypertension 
with diuretics while working to ex-pand dietary and exercise programs.

The second misunderstanding within the letter deals with the primary goal 
of CAST. All the trials are designed with improved health of the 
participants as the primary outcome. At the same time, it is important to 
recognize that MMT leads to dra-matic reductions in criminal activity and 
any other successful substitution treatment is likely to generate similar 
positive outcomes for society.[2]

Clinical research can be an im-portant vehicle for improving addiction 
treatment through expanding the range of effective treatment options, 
highlighting the elements of currently available treatments which can be 
improved, accessing research-specific funding streams such as the Canadian 
Institutes of Health Research and facilitating advocacy for those who do 
not benefit from the present treatment options. We believe it is time those 
in British Columbia suffering from addiction were offered these benefits.

-David C. Marsh, MD Co-Chair, Clinical Advisory Committee, CAST

-Michael Krausz, MD Co-Chair, Clinical Advisory Committee, CAST


1. Health Canada. Best practices-Metha-done maintenance treatment. Ottawa: 
Health Canada, 2002.

2. Sheerin I, Green T, Sellman D, et al. Reduction in crime by drug users 
on a methadone maintenance therapy programme in New Zealand. NZ Med J