A public health expert from Canada is calling for access to heroin through the health system for addicts who have not benefited from conventional treatment. Currently, treatment with diamorphine (the medical name for heroin) is not offered in Canada following regulations put in place by their government in 2014.
“Politicians may not like it, but evidence shows that giving heroin to some users reduces harm,” said Martin Schechter, M.D., Ph.D., of the University of British Columbia, Canada, in The British Medical Journal.
“At first glance, the idea of heroin-assisted treatment may seem preposterous,” he writes. “However, before responding with a knee-jerk reaction, pause to consider an especially vulnerable subgroup of people with heroin addiction.”
For those with a longstanding addiction not helped by detoxification treatment, abstinence programs, and methadone maintenance, “we can offer no effective treatment.” So “members of this subgroup remain outside the health care system, deeply affected by the illness of addiction and its consequences.”
He said there is overwhelming evidence that these addicts will relapse into using illicit heroin and suffer immeasurably while costing society a “fortune.”
Schechter said that six randomized controlled trials, in Switzerland, the Netherlands, Germany, Spain, Canada, and the UK “have all concluded that heroin-assisted treatment is more effective than conventional treatments in this subgroup.”
Even a recent Cochrane review found, “Available evidence suggests an added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment refractory, opioid users, to reach a decrease in the use of illicit substances, involvement in criminal activity and incarceration, a possible reduction in mortality, and an increase in retention in treatment.”
He concludes that conventional therapies should always be the preferred treatment, and should be readily accessible. “But heroin-assisted therapy should be offered to patients who have not benefited from conventional treatments, provided that the diamorphine is prescribed by physicians at specialized clinics that can assure safety.”
Individuals who buy illicit heroin on the street risk overdose and death because its dose and purity are unknown. In addition, unsafe practices such as using contaminated syringes increase the risk of life-threatening infections such as HIV and hepatitis.
Heroin-assisted treatments should be offered to this vulnerable group, said Schechter, because they can improve outcomes, reduce harm, lower societal cost, and make savings for the health care system.
Initially, the direct cost of heroin-assisted treatment is four times that of traditional treatments, but Professor Schechter believes that it still works out to be cheaper than other interventions in the long run, when accounting for all associated costs.
“Treatments like this represent the holy grail of medical research seeking to support a sustainable health system: they achieve better outcomes at lower overall cost,” he writes. The savings could then be used in addiction prevention programs, he adds.
However, in October 2013, when physicians in Vancouver prescribed heroin on compassionate grounds to a small number of patients who had benefited from it in a clinical trial, Canada’s health minister, Rona Ambrose, changed some regulations to try to end the practice.
Speaking at the time, she said, “The prime minister and I do not believe we are serving the best interests of those addicted to drugs and those who need our help the most by giving them the very drugs they are addicted to.”
And this form of treatment may be impossible to deliver in an effective way, warns a doctor from York Teaching Hospital, U.K. Responding to the article, Dr. Murray R. Williams said he “agrees with the sentiment of the article at a society level,” but “was left pondering the practicalities of such a program at the individual level.”
For example, there may be serious difficulties finding a site to deliver diamorphine intravenously in patients who are currently injecting one to two times a day, often into the major vessels. And inserting a central line, PICC (peripherally inserted central catheter) line or midline for the course of the treatment, giving the patient intravenous access, “may come with its own risks.”
Allowing the patient to self-administer in a safe environment “seems suboptimal and fraught with danger, after seeing the vascular injuries and abscesses caused by misplaced needles,” Williams says.
Furthermore, health care staff who provide this care would need access to airway management equipment and opioid reversal agents, along with the skills to deal with addiction. “Idealistically, the concept is sound,” he writes, “however, I would worry this would be impossible to deliver in a safe and effective way.”
Heroin-assisted treatment (HAT) is a part of the national health systems in Switzerland, Germany, the Netherlands, Denmark, and the United Kingdom. At present, heroin is banned except for research purposes in the United States, but there is a mechanism for making it available for federally approved scientific studies.
Schechter, M. T. Personal View: Drug users should be able to get heroin from the health system. BMJ, 15 April 2015, doi: 10.1136/bmj.h1753