In the United States alone, approximately one-half million people are addicted to heroin. Estimates of heroin incidence (122,000 new users) in recent years suggest an increased incidence and an emerging pattern of drug use among the young. For many years, heroin addiction has been associated with increased criminal activity and human suffering. In the past 10 years, there has been a dramatic increase in the prevalence of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and tuberculosis among intravenous heroin users. From 1991 to 1995 in major metropolitan areas, the annual number of heroin-related emergency room visits has increased from 36,000 to 76,000, and the annual number of heroin-related deaths has increased from 2,300 to 4,000. The associated morbidity and mortality further underscore the human, economic, and societal cost of heroin addiction.

Over the last 20 years, a significant body of evidence has accumulated on the neurobiology of heroin addiction and on the safety and efficacy of narcotic (methadone) maintenance treatment. Although there have been other medications (e.g., levo-alpha acetylmethadol [LAAM]) subsequently determined safe and effective in narcotic maintenance treatment, the focus of this consensus development conference was on methadone, because methadone has been the medication used in most narcotic treatment research. Evaluation studies have consistently shown methadone treatment to be effective in reducing drug use and crime and in enhancing social productivity. More recent studies demonstrate that methadone treatment is an effective method for preventing the spread of HIV, HCV, and tuberculosis among intravenous drug users.

Most heroin users are not receiving treatment. Most recent data indicate that there are approximately 112,000 patients in narcotic maintenance treatment. Barriers exist to both access to narcotic maintenance treatment and effective treatment, despite the science on the neurobiology of heroin addiction and the evidence demonstrating the effectiveness of treatment in reducing drug use and crime and preventing the spread of HIV and HCV. An important reason for some of these barriers is that narcotic maintenance treatment remains controversial. The science has not yet overcome the stigma of addiction and public perception about narcotic maintenance treatment. Many members of the medical community and the public conceive of opiate addiction as a self-inflicted disease of the will, methadone treatment as mere narcotic substitution with relapses likely to follow treatment, drug-free treatment as the only valid rehabilitative method, and total abstinence from all drugs, including methadone, as the only valid treatment goal. Other obstacles include Federal and state government regulations limiting treatment providers and patient access and concerns about methadone diversion by patients and its consequences.

The consensus development conference brought together national and international experts to present and discuss the most important and controversial issues surrounding narcotic maintenance treatment. An independent, non-Federal consensus panel addressed the following key questions:

• What is the scientific evidence to support conceptualization of opiate addiction as a medical disorder including natural history, genetics and risk factors, and pathophysiology, and how is diagnosis established?

• What are the consequences of untreated opiate addiction to individuals, families, and society?

• What is the efficacy of current treatment modalities in the management of opiate addiction including detoxification alone, non-pharmacological/psychosocial treatment, treatment with opiate antagonists, and treatment with opiate agonists (short-term and long-term)?

• What is the scientific evidence for the most effective use of opiate agonists in the treatment of opiate addiction?

• What are the important barriers to effective use of opiate agonists in the treatment of opiate addiction in the U.S. including perceptions and adverse consequences of opiate agonist use, legal, regulatory, financial, and programmatic barriers?

• What are the future research areas and recommendations for improving opiate agonist treatment and improving access?

This bibliography is organized along the same lines as the conference agenda with additional subsections for specific medical complications of opiate addiction. Citations include journal articles, books and book chapters, conference proceedings, conference papers and posters, hearings, and meeting abstracts. The majority of selected references are from January 1994 to September 1997 and are in English with the focus on heroin addiction in the United States. Older references were selected to provide background for the main topics of the conference. References within each subject category are listed alphabetically by author; a reference may be included in more than one category

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