The current issue of the New England Journal of Medicine, probably the world’s most prestigious medical journal, details the results of a recent Canadian trial comparing injectable heroin with oral methadone as a treatment for heroin injectors.
Like the four previous European trials comparing these two treatments during the past 15 years, the Canadian researchers found that injectable heroin was more effective than oral methadone.
As in the previous trials in Switzerland, the Netherlands, Spain and Germany, the Canadians recruited a group of severely dependent heroin injectors who had not benefited from multiple previous attempts at drug treatment (including several previous episodes of oral methadone treatment).
The average age of the 251 people in this study was almost 40. Males accounted for more than 60%. Almost a quarter were of Aboriginal descent and almost three quarters were homeless, living in shelter or a single-occupancy hotel room.
The average duration of injecting drug use was 16.5 years; 94% had been charged during their lifetime for any crime and almost three quarters had committed illegal activities (other than illicit-drug use) in the previous month. More than half had a chronic medical problem and almost 10% were HIV-positive.
The average number of previous drug treatments was 11.1 (including 3.2 previous attempts at methadone treatment). The group used illicit drugs on most days of the month before entering the study (heroin 26.9, cocaine powder 5.0, crack cocaine 13.4). Median expenditure on drugs in the month before entering the study was $A1470).
Both groups in the study did well but 88% of the injectable heroin group were retained in addiction treatment compared with 54% in the methadone group.
Illicit-drug use or other illegal activity declined in 67% of the heroin group, compared to 48% in the methadone group. There results were all statistically significant.
Serious adverse events were more common in the heroin group but the only death in the study occurred in a subject receiving methadone. The results in the (optimised) methadone group in this study were better than had been achieved previously in routine treatment.
The heroin group recorded significant improvement in six of the seven subscales while the methadone group improved in two subscales. After adjusting for baseline values, the heroin group improved more than the methadone group in four of the scores (including drug use).
The average number of days in the previous month illicit heroin was used decreased by 80% in the heroin group compared to 56% in the methadone group. Cocaine use remained the same in both groups.
All five trials considered the same variables (drug use, illegal activities, health, and social adjustment) and showed greater benefit from injectable heroin than oral methadone. The heroin group in the Canadian study showed greater improvements in medical and psychiatric status, economic status, employment and family and social relations.
The authors (rightly) recommended that methadone should remain the mainstay of treatment for the majority of patients. However, for a minority of heroin users with very severe problems who have not benefitted from a range of previous treatments (including high quality methadone maintenance), injectable heroin appears to be a safe and more effective treatment.
The Canadian study was published 12 years and one day after federal Cabinet (at the behest of then Prime Minister John Howard) aborted an Australian heroin trial because this would have “sent the wrong message”.
Since then 68% of Swiss voters in a national referendum and 63% of federal politicians in the German parliament have voted in support of heroin treatment as an option for the “worst of the worst”. A stable 5% of patients undergoing heroin treatment in Switzerland have required injectable heroin.
Although more expensive than other treatments, economic savings (mainly from reduced crime) are twice the cost of the treatment. No doubt the gnomes of Zurich fully understand that it is more important to invest in cost-effective treatments than to cancel scientific research in order to “send a message to the electorate”.
The small minority of severely dependent heroin users who require treatment with injectable heroin account for something like 30% of the crime associated with heroin. It is better for these individuals, their families and communities that they are attracted, retained and benefit from injectable heroin treatment rather than be allowed to continue to create major problems in the community or to be made even worse at great expense to taxpayers in prison.
Should Australia conduct a heroin trial? There will be insufficient political support for an Australian heroin trial as long as the heroin shortage continues (bringing with it lower numbers of heroin overdose deaths and lower crime rates).
Denmark has decided that the research evidence is strong enough to start this treatment without conducting additional research. That is what Australia should also do, 29 years after this was first officially recommended in Australia (to Premier Neville Wran).
Heroin shortages do not last forever.
This is an issue crying out for the kind of rational approach you are advocating. But our political environment unfortunately doesn’t favour this kind of cool deliberation.
But the evidence is clear – so let’s just do it!
“Sending the wrong message” will remain the biggest block to implementing this, no matter how clear the science is.
Despite the intellectual laziness of that throw-away expression, it’s going to need some serious sociological inquiry to find out just what “message” harm minimisation would send, and whether anyone at risk is actually listening to that “message” anyway.
My personal feeling is that using the best possible means to save addicts’ lives would send a “message” that people who make mistakes are still valued as humans and given the best possible help if they seek it.
It would also send a “message” to narcotics retailers that any market they can artificially generate by manipulating the vulnerable, can be undercut by the government with superior product, service and price, and in total safety. See how many new addicts turn up in the long run, when the economics of getting customers hooked with freebies no longer has any payoff.
Given that in the UK medicinal heroin costs less than a quid a gram (enough for a week for the worst ‘abuser”) YTF are we still buggerising around with Methadone, a commercial product, far more addcitive & toxic than pure heroin? The sole reason, for the wowsers, is that there is (relatively) little pleasure – can’t be doing with them lowlifes getting unearned pleasure when i’m so psychically constipated.
Memories are so short – until 1971 any GP in the UK could prescribe heroin (and cocaine and Methedrine) and there was NO, repeat NO, black market. It bloomed overnight in Dixon St Soho when the UK, in one of their traditional Sterling crises, succumbed to US pressure, under threat of not receiving an IMF loan. So much for principal and the rest is history, written in blood.
The treatment of heroine users by our governments is appalling. It is the politics of “hate.”
The ranking of heroine as the most dangerous drug is a fallacy. It is not the drug that is the problem, but the criminalisation of it and the social stigma that this brings. Yes heroine can cause death throught repiratory depression at high doses, so can alcohol and even water in extreme excess. But when used under reasonably controlled conditions where the concentration of the active drug is known and where the tolerance of the patient is known, the worst thing that happens is constipation, generally not an insurmaountable obstacle for the average GP.
The war on heroine and its precursor morphine is based on ill informed prejudice, base ignorance and the most appalling cycncism of our politicians. They have worked out that heroine users are small, relatively harmless minority who probably don’t turn up to vote because they are too busy trying to get there next dose to worry about who is shafting them. But having bogeymen in the form of irrational, dirty and criminal drug users is great for deflecting voters concerns from real issues. And of course it gives them a great excuse for oppressive laws and overweight lay enforcement.
Alcohol, mental illness and poverty are far more important than the addiction of heroine users, but these things are a lot harder to fix . They are invisible to the voter, don’t pander to public prejudice and do not win votes.
AR, that really is interesting and, if it holds true in other cases, explodes the furphy that “sending the wrong message” leads to an increase in illicit drug use.
I came across a nasty little (unconfirmed) theory in the criminology library that periodic waves of extra-concentrated heroin hitting the streets are not expensive packaging errors by distributors, but deliberate measures to clean out the old consumers and turn over the market.
The motive, according to the theory, is that long-term customers lose their value over time as their health and earning power declines and the chance of becoming police informers increases.
Furthermore the often-quoted fact that “demand will always exceed supply” is not quite as simple as in legitimate markets, because unknown buyers could be undercover detectives or police informants.
So the safest market, both for retailers and distributors, is one that the seller cultivates himself, not one that comes looking for him with a handful of money. Hence the constant drive to manipulate the vulnerable into getting addicted — until the time comes to kill them off with an overdose if they don’t do it to themselves sooner.
Lovely business.