The prescription of substitution drugs, such as methadone and buprenorphine, has become a mainstream, first-line treatment for opioid dependence, with around 700 000 of Europe’s 1.3 million problem opioid users receiving substitution treatment today. But a small minority of entrenched opioid users repeatedly fails to respond to interventions of this kind. Findings from international trials now suggest that the supervised use of medicinal heroin can be an effective second-line treatment for this small, and previously unresponsive, group. In this latest EMCDDA Insights report, experts describe the development as ‘an important clinical step forward’. 

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The report provides the first state-of-the-art overview of research on the subject, examining the latest evidence and clinical experience in this area in Europe and beyond. A small population of chronic heroin users, once thought to be‘untreatable’, is now benefiting from a novel type of therapy usingmedicinal heroin as the substitution drug. In this report experts describe the development as ‘an important clinical step forward’. The reportprovides the first state-of-the-art overview of research on thesubject, examining the latest evidence and clinical experience in thisarea in Europe and internationally.

The prescription of substitution drugs (e.g. methadone, buprenorphine) has become a mainstream, first-line treatment for opioid dependence, with around 700 000 of Europe’s 1.3 million problem opioid users receiving substitution treatment today. But a small minority of entrenched opioid users repeatedly fails to respond to interventions of this kind. Findings from international trials now suggest that the supervised use of medicinal heroin can be an effective second-line treatment for this small, and previously unresponsive, group.

Included in the report are the findings of a review on heroin-assisted treatment by the Cochrane Drugs and Alcohol Group, along with the results of a meta-analysis of key studies undertaken. The Cochrane Collaboration is the world’s leading institution in promoting evidence-based healthcare via systematic reviews of evidence.

Supervised injectable heroin (SIH) treatment was first introduced in Switzerland in the mid-1990s in the face of a growing national heroin problem. The new approach was a step on from prescribing heroin to addicts without supervision, practised in the US in the early 20th century and in the UK throughout that century.

Over the last 15 years, six countries, within and beyond Europe, have tried and tested this clinical approach. As a result, SIH treatment is now legally available to long-term, refractory opioid users in Denmark, Germany, the Netherlands, the UK and Switzerland, while in Spain and Canada it is permitted in the context of research trials only. In 2011, some 2 500 clients were enrolled in SIH treatment in the EU and Switzerland (Table 6).

SIH treatment is delivered under direct medical supervision to ensure safety and to prevent diversion of diacetylmorphine (medicinal heroin) to the illicit market. Provided in specialised clinics, open year-round, it aims to reduce patients’ use of ‘street’ heroin and involvement in crime and improve their well-being and social integration.

According to the report, the research trials conducted since the mid-1990s provide ‘strong evidence’ that, for this specific group of long-term heroin users, SIH treatment can be more effective than oral methadone maintenance treatment (MMT). Findings show that SIH treatment can lead to: the ‘substantially improved’ health and well-being of this group; ‘major reductions’ in their continued use of illicit ‘street’ heroin; ‘major disengagement from criminal activities’, such as acquisitive crime to fund their drug use and ‘marked improvements in social functioning’ (e.g. stable housing, higher employment rate).

Regarding clinical practice, the report reveals ‘a strong consistency’ between countries (e.g. use of guidelines) but underlines that ‘clinical precautions remain vital’. Although mortality was found to be similar for the patients in SIH and MMT, the risk of adverse events, such as fatal overdoses, was higher, underlining the need for emergency training for clinical teams.

This type of treatment is not simply a case of offering heroin to heroin users, but is a highly-regulated treatment regime, targeting a particularly difficult-to-treat group of patients. Although the group treated through this method is small, it is one in which the negative consequences of long-term drug use are pronounced. Treating these individuals effectively has the potential to impact positively on the costs associated with drug dependence.

Economic evaluations carried out in three countries (Switzerland, Germany, the Netherlands) report the costs of an SIH maintenance programme to be between EUR 12 700 and EUR 20 400 per patient per year, considerably higher than the cost of MMT (estimated at between EUR 1 600 and EUR 3 500 per patient per year).

But the trials show that the higher cost of SIH treatment in this highly problematic target group is compensated for by ‘significant savings to society’, including less spent on criminal procedures and imprisonment. Societal savings per person per year in SIH treatment were estimated at EUR 15 000 in the Netherlands, EUR 13 000 in Switzerland and EUR 6 000 in Germany. According to the report: ‘If an analysis of cost utility takes into account all relevant parameters, especially related to criminal behaviour, SIH treatment saves money’.

Looking ahead, the report states that the challenge will be to establish a ‘viable operational system’ to offer SIH treatment to severely affected heroin addicts, without undermining the commitment of other patients to more orthodox forms of substitution treatment. Future studies could investigate the longer-term outcome of SIH patients, different routes of administration of diacetylmorphine (intranasal, oral) or other injectable opioid medications.

‘While SIH may be a useful addition to our treatment “toolbox” for opioid users, it is not a solution for the heroin problem’, concludes the report. ‘But for those among whom the benefit is observed, there are major gains for themselves, their families and society’.