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Heroin Maintenance

Just recently, David Raynes was telling us about the failures of the British programs in heroin maintenance.

Now the results of a new study are out. It’s the Randomised Injectable Opioid Treatment Trial (RIOTT), which not only tried heroin maintenance, but compared it to other options in a randomized controlled trial. It was for a group of hard core street heroin users and they received either supervised injectable heroin, supervised injectable methadone or optimised oral methadone.

No surprise that the injectable heroin group had, by far, the best results, and showed dramatically positive response in: retention, abstinence from street heroin, reduction of crime, reduction in crack use, and improved physical, mental health and social functioning.

Danny at Transform provides some perspective:

That should not be news to anyone. I realised during my third or fourth interview yesterday, that the feigned shock from radio presenters that the Great British Public would be funding heroin users ‘addiction’, should be as nothing compared to their real shock that we are all funding the prohibition that leads users to steal and compromises their health in the first place.

Whilst the presumed roll out is to be welcomed, one has to ask why it has taken so long to come to this conclusion. Evidence has existed for years that, for those assessed as having a clinical need, heroin prescribing will keep them alive, improve their health and wellbeing and reduce the collateral damage of their use to wider society.

Danny also pointed out some disturbing facts:

The substantially increased cost of prescribing injectable heroin, compared with oral methadone, must also be seen in the context of the Macfarlane Smith monopoly on the UK opiates market that the Department of Health buys from. That means that the UK pays well over the odds for our diamorphine (£12,000 a year per user), compared to the Dutch (£2000 a year for the same product). This artificial cost barrier has been a major political obstacle.

How stupid is that? We have a massive, dirt-cheap supply of poppies available just a short distance away in Afghanistan. Why do business with a drug cartel that has forced out all competition?

Note: I really don’t know how a heroin maintenance program would work as the full model for legalization (because it’s never been tried in that way – it’s always been limited to the hard core user), but it’s clear that heroin maintenance is an effective and valuable tool in drug policy, and should be included as part of any legalization or decriminalization plan.

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5 comments to Heroin Maintenance

  • this trial was for supervised use of prescribed heroin, the criteria for this form of access being long term relapsing users who have repeatedly failed on other programs such as methadone, or residential rehab. To that extent it is clearly only appropriate for a small fraction of users, indeed only a small fraction of heroin users. That said, it has not been tried more widely – with less stringent criteria for other heroin injectors – so the jury is out on that front although i think it is reasonable to posit that use of clean drugs and equipment in a clean supervised setting, combined with decriminalisation/destigmaticsation, removal of the need to offend to maintain use and other support and access to services would be useful for a larger % of users.

    In the short term this is a good model for a certain type of problematic user. More broadly opiate use needs to be regulated with a more flexible range of models depending on the nature of the idividual user and the issues they face and patterns of use they have. These will include licensed user/pharmacy sales of certain non injectable pharmaceutical opiates (in pill form), and licensed membership based premises for consumption (either smoking or tea form) opium. These are probably better than a ne size fits all methadone approach, which users don’t seem to like much (methadone is not associated with the level of subjective pleasure of many opiates so is very functional) so doesn’t have great retention rates – and is often supplemented with illicits.

    Differential control of availability over a wider range of options could be used, over time, to encourage patterns of use towards safer products and preparations, safe using behaviours and methods of administration, and use in safer environments. There is some good literature on ‘route transitions’ – ie how the nature of the market shapes the nature of use – and risk associated with it. Control of the market offers the opportunity to reverse the trend of the last few decades towards increasingly dnagerousn products and behaviours.

    IN the longer term – given that opiate use, perhaps more than most drugs, reflects a need to escape from personal pain and low wellbeing of one form or another – the only solution is to address the underlying causes of why people seek solace in opiate use (or anything else). this is a challenge for wider social policy – but the resource drain and practical and political obstacles created by prohibition and criminalisation of users and markets certainly doesn’t help.

  • daksya

    Steve: given that opiate use, perhaps more than most drugs, reflects a need to escape from personal pain and low wellbeing of one form or another – the only solution is to address the underlying causes of why people seek solace in opiate use

    That’s a non-answer. Two points:
    1)one of the merits of our camp is the acknowledgement of the bare economic truth i.e. where there’s demand, there’s dealers. Talking about social prophylaxis is fine, but there will be continuing demand for opiates, from both addicts and non-addicts alike, and there will have to be a legal access facility for all aspiring adult users in the post-prohibition era. The maintenance model is of limited value there.
    2)the “underlying causes” will never be more than modestly engaged. The continuing prevalence of organized religion in human societies is a testament to that. So, treating opiate use as inherently malignant is a notion that belongs to the last century. Informing people of the nature of opiate use & providing the tools and the environment for prudent use, and having an acceptably efficient mechanism to help those who lose the way is the most suitable outcome.

  • Servetus

    Terrible when the alleged problem turns out to be the solution, eh?

    The pod people who make up American drug enforcement are probably spazzing out right about now as once again their fantasy world gets dragged out and stomped on. Or maybe they’re just not paying attention. Denial probably wins out.

    Damn, it must suck to be a drug warrior. Or maybe they’re all just alcoholics. Only their abused children and pets know for sure.

  • @Steve who wrote: “To that extent it is clearly only appropriate for a small fraction of users, indeed only a small fraction of heroin users.”

    Yet it also strikes me that what we’re doing here is a bit of “an insane solution in an insane world”. We have this Broken Existence Factory that seems to be grinding out completely broken individuals that qualify for heroin maintenance. Fewer individuals would actually need this maintenance were opiods legal & regulated.

    Now there’s a free fall into oblivion, and only a razor’s edge from total annihilation we decide to stretch out the security net and put them on life saving heroin maintenance.

    Safe injection sites would be a lot less in demand if the huge economic incentive to inject wasn’t there. People would largely prefer the weaker preparations in oral or smoked form.

    Even the maintenance demand would diminish, because earlier interventions wouldn’t be dealing with completely broken individuals. Milder disease, if you’ll allow the comparison, demands less severe medicine.

    Have you ever tried to score some pills with, say, codeine or morphine? That’s actually HARD compared to the extreme ease with which you can score heroin in either smokeable or injectable form.

    Again demand is interesting, and I wonder if we’ll soon see a book called “Morphine & Codeine are safer! So why are we driving people to do Heroin?”

  • ourcellardoor

    drugs
    , particularly heroin, has been a major problem in the United States for many years. I believe that a regulated, legal distribution maintenance program would work and do wonders for this ever increasing problem. This will never happen in the U.S. though because too many politicians, corporations and businesses profit from addiction and the drug trade/war….after all it’s our government who is bringing in and allowing this to happen…Like it or not they truly do control the black market and if you don’t see it that way you need to follow the paper trail…