BMJ  2008;336:70 (12 January), doi:10.1136/bmj.39421.593692.94

Head to head

Should heroin be prescribed to heroin misusers? Yes

¹ Centre for Addiction and Mental Health, Toronto, ON M5S 2S1, Canada, ² Centre for Addictions Research of British Columbia, University of Victoria, Canada

doi: 10.1136/bmj.39422.503241.ADdoi: 10.1136/bmj.39434.460694.AD

Some heroin addicts are very difficult to treat. Jürgen Rehm and Benedikt Fischer believe that maintenance with heroin is the way forward for this group, but Neil McKeganey argues that it is treating the effects of misuse not the addiction

Recently, a public hearing of a Danish parliament subcommittee discussed whether heroin assisted maintenance treatment should be offered experimentally to reduce health and social harm related to use of heroin (www.tekno.dk/ordineret-heroin). This is just one in a series of similar—existing or proposed—programmes in Europe, North America, and Australia.¹ We believe that such treatment is appropriate for heroin misusers under certain circumstances.

Supporting evidence

Increasing heroin misuse in the United States in the early 1970s led to a public debate about prescribing heroin as a last resort form of opioid maintenance therapy for people with chronic heroin dependence. In 1973 Lorrin Koran advocated in the New England Journal of Medicine that "carefully designed clinical research on the safety and efficacy of heroin maintenance should be undertaken, particularly with addicts not helped in current treatments."² Some 35 years later, three important research studies have been completed. In Switzerland, a small randomised trial³ and a study using natural cohort designs⁴ found heroin assisted maintenance treatment to be feasible and effective for a group of heroin misusers who were refractory to treatment, as characterised by long term heroin dependence; physical, psychological, or social deficits; and unsuccessful previous treatment.^{4 5} Effectiveness was observed in treatment retention; somatic health outcomes such as epileptic episodes, abscesses, or cachexia; mental health outcomes such as affective or anxiety disorders; heroin and cocaine misuse; and criminal outcomes such as property offences or drug trafficking (on the basis of self report and objective measures).⁵

Large randomised controlled clinical trials in the Netherlands and Germany, which compared different modes of heroin assisted maintenance treatment with methadone maintenance treatment, obtained positive results on similar outcomes.^{6 7} Moreover, heroin assisted maintenance treatment was found to be cost beneficial in Switzerland⁸ and cost effective in the Netherlands compared with methadone maintenance treatment.⁹ Since these results were obtained, this treatment option has been extended beyond the trial periods, and heroin has been approved by the regulatory bodies for treating opioid dependence. In all three countries, the intake of medical heroin is supervised and occurs a maximum of three times a day, and patients recover from acute intoxication before leaving the treatment clinic. Notably, heroin has been a treatment option for heroin misusers in the United Kingdom for several decades, albeit on a relatively small scale and under different conditions—with lower average dosing and less supervised intake.¹⁰

Use of maintenance

The above summary makes the recent use of heroin assisted maintenance treatment look like a straightforward scientific success story, and not like a topic for debate in the BMJ. However, since the original heroin assisted maintenance treatment programme was proposed in Switzerland in the early 1990s, there has been scientific, and perhaps more importantly, larger public debate on the ethics, safety, and clinical value of prescribing heroin, and to a lesser degree, on maintenance treatment in general. Overall, maintenance with buprenorphine and, to a larger degree, methadone is more successful than treatment focusing on abstinence or using placebos.¹¹ Given the nature of opioid dependence as a chronic relapsing disease,¹² these results are not surprising.

Opioid maintenance treatment generally seems to be well justified for treating this disease. And if maintenance is generally justifiable as a form of treatment, why should heroin not be used as one such pharmacological agent? One reason that has been cited is safety, both for the patient¹³ and for the general public (for example, through diversion or the risk of trivialising the dangers of heroin, leading to an increase in use). Results from the Swiss studies, however, show that mortality among patients in heroin assisted maintenance programmes is low, and lower than for patients in other maintenance programmes.¹⁴ In addition, the wider safety concerns could not be empirically confirmed in Switzerland or the Netherlands.¹⁵ Finally, the incidence of heroin dependence has decreased greatly in Switzerland since the start of the trials, and currently heroin has a more negative image than it did 15 years ago.¹⁶

Overall, we see no convincing reason why heroin assisted maintenance treatment should not be part of a comprehensive treatment system for opioid dependence. However, the development of an overall integrated treatment system is crucial. All studies to date have been conducted in samples of refractory addicts with severely compromised health and several previous failed attempts of methadone maintenance treatment. Our current knowledge about the effectiveness of heroin assisted maintenance treatment is restricted to these groups and to the context of countries where there is already an established and effective comprehensive system for treating opioid dependence. Although we currently do not have the necessary empirical evidence for establishing heroin assisted maintenance treatment in other circumstances, addition of heroin assisted maintenance treatment would be likely to improve the overall treatment system, especially with respect to so called treatment resistant and refractory opioid addicts.

doi: 10.1136/bmj.39422.503241.ADdoi: 10.1136/bmj.39434.460694.AD

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Competing interests: None declared.

References

1. Fischer B, Oviedo-Joekes E, Blanken P, Haasen C, Rehm J, Schechter M, et al. Heroin-assisted treatment (HAT) a decade later: a brief update on science and politics. J Urban Health 2007;84:552-62.[CrossRef][ISI][Medline]
2. Koran L. Heroin maintenance for heroin addicts: Issues and evidence. N Engl J Med 1973;288:654-60.[ISI][Medline]
3. Perneger T, Giner F, del Rio M, Mino A. Randomized trial of heroin maintenance programme for addicts who fail in conventional drug treatments. BMJ 1998;317:13-8.[Abstract/Free Full Text]
4. Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A, Uchtenhagen A. Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet 2001;358:1417-20.[CrossRef][ISI][Medline]
5. Uchtenhagen A, Dobler-Mikola A, Steffen T, Gutzwiller F, Blattler R, Pfeifer S, eds. Prescription of narcotics for heroin addicts: main results of the Swiss national cohort study. Basel: Karger, 1999.
6. Van den Brink W, Hendriks V, Blanken P, Koeter M, van Zwieten B, van Ree J. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ 2003;327:310-5.[Abstract/Free Full Text]
7. Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D. Heroin assisted treatment for opioid dependence: a randomised, controlled trial. Br J Psychiatry 2007;191:55-62.[Abstract/Free Full Text]
8. Frei A. Economic evaluation of the Swiss project on medically prescribed heroin substitution treatment. Psychiatrische Praxis 2001;28:S41-4.[CrossRef][ISI][Medline]
9. Dijkgraaf M, van der Zanden B, de Borgie C, Blanken P, Van Ree J, Van den Brink W. Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials. BMJ 2005;330:1297.[Abstract/Free Full Text]
10. Metrebian N, Carnwath Z, Mott J, Carnwath T, Stimson G, Sell L. Patients receiving a prescription for diamorphine (heroin) in the United Kingdom. Drug Alcohol Rev 2006;25:115-21.[CrossRef][ISI][Medline]
11. Amato L, Davoli M, Perucci C, Ferri M, Faggiano F, Mattick R. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat 2005;28:321-9.[CrossRef][ISI][Medline]
12. Leshner A. Addiction is a brain disease, and it matters. Science 1997;278:45-7.[Abstract/Free Full Text]
13. Stoermer R, Drewe J, Dursteler-Mac Farland K, Hock C, Mueller-Spahn F, Ladewig D, et al. Safety of injectable opioid maintenance treatment for heroin dependence. Biol Psychiatry 2003;54:854-61.[CrossRef][ISI][Medline]
14. Rehm J, Frick U, Hartwig C, Gutzwiller F, Gschwend P, Uchtenhagen A. Mortality in heroin-assisted treatment in Switzerland 1994-2000. Drug Alcohol Depend 2005;79:137-43.[CrossRef][ISI][Medline]
15. Bammer G, van den Brink W, Gschwend P, Hendriks V, Rehm J. What can the Swiss and Dutch trials tell us about the potential risks associated with heroin prescribing? Drug Alcohol Rev 2003;22:363-71.[CrossRef][ISI][Medline]
16. Nordt C, Stohler R. Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis. Lancet 2006;367:1830-4.[CrossRef][ISI][Medline]

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