Should heroin be prescribed to heroin misusers? No

Prescribing heroin to heroin addicts is a strategy beloved by top police officers1 and successive home secretaries.2 It is a strategy, though, borne of utter frustration at our seeming inability to tackle an escalating drug problem. If you cannot stop addicts committing crimes to fund their drug habit then, so the argument goes, the next best thing is to provide them with the drugs that are the reason they are committing the crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question, “Is it treatment or is it social problem prescribing?”

The evidence in relation to heroin prescribing is far from conclusive. On the positive side Nordt and Stohler have suggested that heroin prescribing led to a large reduction in incidence of heroin addiction in Switzerland, although the authors also point out that such prescribing may have reduced individual’s inclinations to cease their heroin use.3 A London study found no health benefits associated with heroin prescribing,4 whereas various Dutch and Swiss heroin trials have identified a range of benefits including improved social functioning and psychological and physical health.5 6 What is often quite difficult to identify from these studies is the degree to which the improved outcomes are the result of the heroin prescribed or other elements of the therapeutic programme provided. The cost of treating an addict with heroin is estimated to be three to four times that of treating an addict with methadone.7

Risks of prescribing

In the face of the additional costs and inconclusive evidence, many clinicians are wary of prescribing heroin. Their anxieties are understandable, given the high profile cases of doctors who have prescribed heroin to addicts and then subsequently found themselves facing a General Medical Council inquiry into their prescribing practices.8

At a clinical level prescribing heroin to heroin addicts is a risky strategy. Once you start, it is difficult not to feel that you have ceded authority for your prescribing to your patient. What, for example, do you say to patients who threaten to resume their previous life of crime if you reduce their heroin prescription? What do you say to the cocaine addict who asks why he cannot have cocaine provided in the same way as the heroin addict? Opening up heroin prescribing to addicts could lead to massive pressure on doctors to prescribe increasing amounts of the drug.

It was in part as a result of that pressure that the Interdepartmental Committee on Drug Addiction advised the UK government in 1965 that only appropriately certified doctors should prescribe heroin to addicts. The committee’s decision was influenced by the case of Lady Frankau, a noted London psychiatrist who in 1962 prescribed more than 600 000 heroin tablets to her addict patients.9

What are we treating?

Prescribing heroin to heroin addicts, however, makes sense only if your primary concern is to treat not their drug dependency but the consequences of their drug use. You may want to reduce their use of street drugs, the risks to health from HIV or hepatitis C virus, the risks of overdose, or their criminality. With all of these aims in mind you may conclude that it makes sense to provide addicts with a prescription for the drug that they have become dependent on. And yet the reason they are committing those crimes, and taking such enormous and persistent risks with their health, is because the drugs have become more important than life itself—that is the nature of drug addiction. And that is the problem that drug treatment services need to tackle.

Research has shown that with the right services in place it is possible to do more than simply stabilise addicts’ continued drug use through the prescribing route. For example, the Australian treatment outcome study, which followed up 429 heroin users recruited from a random sample of drug treatment agencies 36 months after starting treatment, found that 40% of drug users had been abstinent for the preceding 12 months and 25% had been abstinent for the preceding 24 months.10 In a similar Scottish study of 695 addicts, re-interviewed 33 months after they had started treatment for drug misuse, 29.4% of those who had been provided with residential rehabilitation had been abstinent for at least 90 days before being interviewed compared with only 3.4% of those receiving methadone maintenance.11 All of the residential rehabilitation services included in this study followed an abstinence based programme.

But do addicts coming forward for treatment actually want heroin to be prescribed to them? A study of over 1033 drug users starting treatment in 2001 asked participants what they wanted to get from the drug treatment services they were contacting.12 Most of those questioned said that they wanted the services to help them become drug free. Health services need to ensure that they are supporting addicts’ attempts to become drug free, and they need to be extremely cautious about any extension of a policy that could be seen as a route to maintaining rather than reducing an individual’s drug dependency.

Footnotes

• doi: 10.1136/bmj.39421.593692.94
• doi: 10.1136/bmj.39434.460694.AD

• Competing interests: None declared,

References

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   Hartnoll R, Mitcheson MC, Battersby A, Brown G, Ellis M, Flemming P, et al. Evaluation of heroin maintenance in controlled trial. Arch Gen Psychiatry1980;37:877-84.

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   Van den Brink W, Hendricks V, Blanken P, Koeter M, van Zweiten B, van Ree J. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ2003;327:310.

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   Uchtenhagen A, Dobler-Mikola A, Steffen T, Gutzwiller F, Blatter R, Pfeifer S. Prescription of narcotics for heroin addicts: main results of Swiss national cohort study. Basel: Karger, 1999.
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   Stimson G, Metrebian N. Prescribing heroin what is the evidence?. York: Joseph Rowntree Foundation, 2003.
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   Interdepartmental Committee on Drug Addiction. Drug addiction in the United Kingdom; the second report of the interdepartmental committee on drug addiction. London: HMSO, 1965.
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    Darke S, Ross J, Mills K, Williamson A, Harvard A, Teesson M. Patterns of sustained heroin abstinence among long term dependent heroin users: 36 months findings from the Australian treatment outcome study. Addict Behav2007;32:1897-1906.

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Prescription heroin helps addicts off street drugs

Prescribing heroin to addicts who can’t kick their habit helps them stay off street drugs, British researchers said Friday.

So far, doctors have had little hope of treating the 10 percent or more of heroin users who don’t respond to methadone, the standard anti-addiction medication. Fueled by drug cravings, those users often spiral downward into crime and diseases spread by dirty needles and unhealthy living.

Short of actually getting addicts off the drug, „heroin clinics“ can at least get them off the streets.

„What we are dealing with here is a very severe group of heroin addicts, where all of the treatments have been tried and have failed,“ said Dr. John Strang, an addiction expert at King’s College London, who led the new study.

„They are like oil tankers heading for disaster,“ he added. „The question we were asking was, ‚Can we change the trajectory of these tankers?‘ And the answer was, ‚Yes we can.'“

To test how prescription heroin would work for this group, Strang and his colleagues invited 127 addicts into supervised injecting clinics. The researchers then randomly chose who would get heroin, injected methadone or typical swallowed methadone.

After six months, 101 addicts had stuck with their treatment. More than two-thirds of those on heroin had no sign of street heroin in their urine at least half the time they were tested; before the study, they had been using the street drug almost every day.

In comparison, less than a third of the addicts on either type of methadone had a similar number of „clean“ tests.

At this point, said Strang, several users have continued in the program for more than two years. He did not have exact numbers, but told Reuters Health that some had been able to get jobs and reconnect with their families.

„These sorts of changes are typical of what we are seeing,“ he said. „People are not only physically getting better, but they’re getting back into society.“

The researchers had to treat about two addicts for each one who get off of street drugs at least half of the time.

An estimated 3.7 million people in the US have used heroin at some point in their lives, according to the National Institute on Drug Abuse. Of current users, studies suggest that some 200,000 spend time in jails each year.

The most common drug treatment for heroin users is methadone, a synthetic drug related to heroin. Although methadone decreases the cravings for its chemical cousin, it doesn’t produce the same high, according to experts. This could help explain why a substantial proportion of addicts in treatment backslide.

Before the new study, a handful of other reports had indicated that prescription heroin could help these people. But the scientific community wasn’t completely convinced, in part because earlier urine tests weren’t very sophisticated.

„What this study did is that it used a very novel urine test that can differentiate between street heroin and prescription heroin,“ said Thomas Kerr, director of the Urban Health Research Initiative at the University of British Columbia in Vancouver, Canada. Street heroin contains papaverine, a remnant of the opium poppy that can be detected in the urine.

Now, he said, „the evidence is quite clear that there is a place for prescription heroin for the treatment of individuals who do not respond to methadone.“

Only a few European countries prescribe heroin to addicts, and in the US this practice has been illegal since before World War I.

Many argue that giving addicts more of the substance they abuse makes little sense, and would be like treating an alcoholic with whiskey. But Kerr said that analogy wasn’t apt. „I would argue it’s completely immoral and unethical to fail to treat those individuals and to allow them to suffer and allow the community around them to suffer,“ Kerr said. Strang said he supported the UK Government’s 2008 Drug Strategy, which proposes rolling out prescription heroin. „Now that we know that it works, we have to debate whether or not we should use it,“ he said. SOURCE: The Lancet, May 28, 2010. http://www.thelancet.com/