BMJHeroine

Introduction
An estimated 25 000 heroin addicts live in the Netherlands
(population 16 000 000 inhabitants).1 Most users
(75-90%) inhale heroin (“chasing the dragon”).2 About
three quarters of these addicts are served by a comprehensive
treatment system, including various kinds of
abstinence oriented treatment facilities and a wide
range of facilities focusing on stabilisation or
minimisation of harm.1 However, 5000-8000 people
on methadone maintenance treatment regularly use
illegal heroin, have serious physical and mental health
problems, and live in socially marginalised conditions,
characterised by illegal activities and a lack of social
contacts outside the drug scene.3–5
A large cohort study in Switzerland ascertained the
feasibility, safety, and efficacy ofmedical prescription of
injectable heroin to 1969 addicts. There were considerable
improvements in physical and mental health, various
aspects of social integration, and illegal drug use in
237 patients who completed 18 months of heroin
treatment.6 Although this study indicated that heroin
assisted substitution treatment is feasible, the effectiveness
of treatment was difficult to judge because no
(random) controls were available, before and after
comparisons were restricted to those who completed
treatment, and participants were obliged to take part in
mandatory psychosocial counselling and care.7–9 In a
small randomised controlled trial (n = 51) in which
intravenous heroin was compared with some standard
treatment, functioning of the participants in the heroin
group was significantly better after six months.10 However,
these positive effects could have been the result of
the additional, and mandatory, psychosocial interventions
in the group allocated to heroin.
We examined the effectiveness of medically coprescribed
heroine in two open label randomised controlled
trials among heroin addicts who had responded
insufficiently to methadone maintenance treatment.

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