The ethics of experimental heroin maintenance

Prescription of diamorphine, dipipanone and cocaine in England and Wales

The vast majority of substitute prescribing to opiate addicts in England and Wales is of oral methadone. The prescription of diamorphine, dipipanone and cocaine to addicts is allowed subject to the 1971 Misuse of Drugs Act. Prescription of these drugs has aroused international interest and controversy in the United Kingdom although research is scanty. This report is a description of the current attitudes about, and practice of, prescribing diamorphine, dipipanone and cocaine by medical practitioners in the addiction field in England and Wales. A questionnaire was devised and sent to drug services in England and Wales which provided a prescribing service. Among respondents who reported that they currently hold a licence for heroin, dipipanone or cocaine, the number of patients treated by each doctor varied widely; from a handful of patients to 100 heroin patients. Dosage currently used ranged from a minimum of 10 mg to a maximum of 1000 mg daily for heroin. Doses of dipipanone were lower. More respondents thought that heroin and dipipanone were clinically justified in some situations than thought that they should never be prescribed, while the opinions were reversed in the case of cocaine.

The ACT heroin trial: intellectual, practical and political challenges

An array of intellectual, practical and political challenges will be faced both if the Australian Capital Territory "heroin trial" does or does not eventuate. The intellectual challenges include the development of new methodologies and analytical tools for some of the outcome measures; the further development of a research process which involves all the relevant disciplines and interest groups; and capitalizing on an unprecedented opportunity to investigate the pharmacokinetics of heroin. The practicalities of setting up a trial also present a number of challenges, as does incorporating a health development approach. Political challenges include getting a sensible decision made about the trial, avoiding capture of the debate by supporters or opponents of drug law reform and avoiding unrealistic expectations. The major challenge if the trial does not go ahead is to implement other well-considered proposals which can be carefully evaluated.

The current status of heroin prescription treatment for heroin dependence

Heroin prescription (HP) to treat severe heroin dependence has been available to few patients in the UK for several decades with limited, but generally favourable, evaluation. In the last decade, large trials have been reported from two countries, are presently underway in three other countries and under consideration in several other countries. The standard pharmacological treatments for heroin dependence, methadone and buprenorphine, attract and retain many more drug users than other pharmacological or nonpharmacological treatments and are strongly supported by evidence of efficacy, effectiveness, safety and cost effectiveness. On present evidence, HP is feasible and safe with limited, but increasing, evidence of efficacy and effectiveness. Although HP is more expensive than methadone, there is some evidence of cost effectiveness. HP is, at present, only considered a therapeutic option for a small minority of treatment refractory, severely heroin-dependent persons in developed countries with comprehensive treatment systems.

What can the Swiss and Dutch trials tell us about the potential risks associated with heroin prescribing?

Following on from last edition's Harm Reduction Digest on drug consumption facilities this Digest investigates what can be learnt from the Swiss and Dutch trials of heroin prescribing about the unintended consequences of this controversial intervention to reduce heroin-related harm. The authors of the paper bring considerable experience in the implementation and evaluation of such schemes in Europe and their consideration in Australia. The paper systematically addresses concerns about heroin prescribing and suggests further research to respond to some unanswered questions.

Randomised trial of heroin maintenance programme for addicts who fail in conventional drug treatments

OBJECTIVE

To evaluate an experimental heroin maintenance programme.

DESIGN

Randomised trial.

SETTING

Outpatient clinic in Geneva, Switzerland.

SUBJECTS

Heroin addicts recruited from the community who were socially marginalised and in poor health and had failed in at least two previous drug treatments.

INTERVENTION

Patients in the experimental programme (n=27) received intravenous heroin and other health and psychosocial services. Control patients (n=24) received any other conventional drug treatment (usually methadone maintenance).

MAIN OUTCOME MEASURES

Self reported drug use, health status (SF-36), and social functioning.

RESULTS

25 experimental patients completed 6 months in the programme, receiving a median of 480 mg of heroin daily. One experimental subject and 10 control subjects still used street heroin daily at follow up (difference 44%; 95% confidence interval 16% to 71%). Health status scores that improved significantly more in experimental subjects were mental health (0.58 SD; 0.07 to 1.10), role limitations due to emotional problems (0.95 SD; 0.11 to 1.79), and social functioning (0.65 SD; 0.03 to 1.26). Experimental subjects also significantly reduced their illegal income and drug expenses and committed fewer drug and property related offences. There were no benefits in terms of work, housing situation, somatic health status, and use of other drugs. Unexpectedly, only nine (38%) control subjects entered the heroin maintenance programme at follow up.

CONCLUSIONS

A heroin maintenance programme is a feasible and clinically effective treatment for heroin users who fail in conventional drug treatment programmes. Even in this population, however, another attempt at methadone maintenance may be successful and help the patient to stop using injectable opioids.