Drug users should be able to get heroin from the health system
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1753 (Published 14 April 2015) Cite this as: BMJ 2015;350:h1753
- Martin T Schechter, professor, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- martin.schechter{at}ubc.ca
At first glance, the idea of heroin assisted treatment may seem preposterous. Rona Ambrose, Canada’s health minister, certainly thinks so. When physicians in Vancouver continued to prescribe heroin on compassionate grounds to a small number of patients who had benefited from it in a clinical trial, essentially implementing the first heroin prescription programme in North America, the minister changed some regulations to try to end the practice.
“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”—said Ambrose in October 2013—“by giving them the very drugs they are addicted to.” Similarly, John Walters, the US drug czar under President George W Bush, called such harm reduction activities “state assisted suicide.”
However, before responding with a similar knee jerk reaction, pause to consider an especially vulnerable subgroup of people with heroin addiction. I refer to those with longstanding illness for whom our best available treatments, such as detoxification, abstinence programmes, and methadone maintenance, have not been successful. Because we can offer no effective treatment, members of this subgroup remain outside the healthcare system, deeply affected by the illness of addiction and its consequences.
Heroin assisted treatment works . . .
A physician attempting to get such a person into treatment faces the following clinical question: should I make yet another offer of an existing treatment that evidence has shown to be unlikely to engage and keep the patient in treatment; or should I try something different that may be more likely to succeed? The best way that medical science answers such a question is by randomised controlled trials that compare the outcomes of the two treatment options.
And medical science has provided an unequivocal answer. No fewer than six randomised controlled trials—in Switzerland,1 the Netherlands,2 Germany,3 Spain,4 Canada,5 and England6—have all concluded that heroin assisted treatment is more effective than conventional treatments in this subgroup. The most recent Cochrane Collaboration review concurred with this,7 stating, “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.”
If being evidence based is not your thing and the use of medically prescribed heroin is still too radical for you, it is incumbent on you to provide an alternative. Is it another attempt at methadone or an abstinence programme based on a fervent hope and prayer that this time it will work? Given their histories of unsuccessful treatment, the evidence is overwhelming that many people will relapse quickly to using illicit heroin.
But illicit heroin is a dangerous street drug that leads to substantial morbidity and mortality.8 Because its dose and purity are unknown, users will face the risk of overdose and death. And, because it is illegal, they will inject it in unsafe places with contaminated syringes that can transmit HIV, hepatitis, and other life threatening infections. They will visit emergency rooms and be in and out of hospital continually. To obtain their next fix they will be slaves to a daily grind of crime and sex work, while enriching the gangs and cartels that supply their black market drug. They will visit police cars, jails, and courtrooms and be in and out of prison recurrently. They will cost society a fortune while suffering immeasurably because they have an illness that society does not like. So, if you’d like to debate the ethics of heroin assisted treatment, let’s debate the ethics of your alternative.
. . . and it’s cheaper
Then there’s the cost. Despite overwhelming evidence opponents of heroin assisted therapy argue, to the point of perseveration, that it is simply too expensive. Nothing could be further from the truth. It is true that the direct cost of the treatment is about four times higher than conventional therapies,9 but all expenditures and savings must be considered in comparing the cost effectiveness of different interventions.
With this “societal perspective” in mind, the investigators in the Netherlands trial estimated that heroin assisted therapy led to overall savings of about €13 000 (£9530; $14 100) a patient a year when compared with methadone, even after the direct costs of the treatments were taken into account.10 In the North American Opiate Medication Initiative (NAOMI) study we found that heroin assisted therapy led to better outcomes at an overall lower societal cost than with methadone maintenance.9 Similarly, British investigators examined costs in the Randomised Injectable Opiate Treatment Trial (RIOTT) and reported that heroin assisted therapy was more cost effective than oral methadone.11
The argument that therapeutic heroin is too expensive is false. Treatments like this represent the holy grail of medical research seeking to support a sustainable healthcare system: they achieve better outcomes at lower overall cost. Those savings could be redirected towards addiction prevention programmes and other priorities. The key question is not whether we can afford this new treatment, but whether we can afford the status quo.
Conventional therapies such as methadone maintenance should remain the preferred treatment for patients with heroin addiction 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 specialised clinics that can assure safety.
Notes
Cite this as: BMJ 2015;350:h1753
Footnotes
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.”
Provenance and peer review: Commissioned; not externally peer reviewed.
References
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