Report from 10th INTERNATIONAL CONFERENCE ON THE REDUCTION OF DRUG RELATED HARM - 21-25 March, 1999

web site address: http://www.ihra.org.uk/geneve/

news service: mcart.org

The International Heroin Trials Debates
To Prescribe or not Prescribe: the State of Heroin Trials Around the World

Session: Thursday, March 25, 1999, 14.30

Rapporteur: Rosa Donahue The following are notes taken from the presentations.

A. Ritter, Australia.

Reported on the background and status of the Clinical Trials project over a five-year period. It must be understood that heroin was only one option among many others drugs in consideration. Despite much interest and determination by members involved in the planning stages of this process, the Minister of Health overturned the decision to go ahead and did not support the heroin trials then.

The current situation, 1999, in Australia: the problem of heroin use has escalated enormously. The death figures for overdose in 1991 was 49. For 1998 it climbed to 268. In 1999, the rate has reached epidemic proportions, one per day, about the same as the rate for road deaths. This situation put pressure on government officials to reconsider the heroin trial issue.

The Prime Minister, Mr. John Howard, still opposes free injection rooms and heroin trials and favors a zero tolerance policy, which is not a national policy. As long as Mr. Howard is in power, she does not see any possibility of an approval needed for the heroin trials.
 

Dobler-Mikola, Zurich, Switzerland

Reported on the Swiss Heroin Trial, a Multicentre Cohort Study in 18 sites, between 1994 and 1996. It took some 10 years of discussions and debates before the trial was started. It compared methadone vs. heroin treatments. One of the objectives was to reach those users who had not been reached successfully by other projects, or those who had failed in other programs. Social, medical, pharmacological, economic and criminal data were collected.

Some findings: patients admitted to the program were more likely to:

• Have an older drug use history be involved in illicit activities use heroin daily use cocaine frequently be on welfare

Upon follow-up, patients in the program were more likely to:

• succeed in the social integration process have some disability pension stop illicit drug use decrease cocaine use decrease contact with drug in general

Future directions of project:
 

• continue treatment recruit more patients do more research with new topics more attention paid to multi drug users address the needs of those with chronicillnesses

V. Hendriks: The Dutch Heroin Trials

A pre-trial survey revealed an estimated 24 to 26 thousand addicts, 74% of them to be in a methadone maintenance program, 36% are in stable condition, 40% having medical and social (personal) problems and 24% having problematic issues with society and the law.

One objective was to evaluate the effectiveness of oral methadone and co-prescribed heroin and another objective was to evaluate the effects of treatment at 6 and 12 months and after stopping treatment.

In the Netherlands, most users are exclusive inhalable heroin consumers. The effect of inhalable heroin vs. injectable heroin was also looked at. Also, the medical and social issues of the patients were evaluated. There were 180 participants. 80 to 90% of them could be reached later for 2-month assessments.

Finding/Conclusions? Prescribed heroin is feasible, possible and safe.

As a result of study, the project obtained support from government officials, some constructive support from the health care system, some mild support from the media, addiction treatment agencies, and also support from international agencies.
 

U. Verthein, Psychiatric Clinic, University of Hamburg, Germany.

He compared the mortality due to drugs in Germany as a whole to that in Hamburg. In Germany there were 2125 deaths in 1991 and 1674 deaths in 1998. In Hamburg, there was an average of only 400. Politicians in Hamburg and Frankfurt introduced the initiative for a heroin prescription law in the early 90's that had great opposition by government officials. However, it now counts with the federal, state and city support from the Ministry of Health.

The project is to start in the year 2000, with 1000 to 2000 patients, for a duration of 36 months. The research will be on Heroin prescription as an important element in completing treatment for opiate addicts. Some issues included in the design of the research: heroin vs. methadone, patient improvement, treatment and care, feasibility and acceptance, and cost benefit.
 

Francisco Carrasco from Spain, presenting for author who was unable to attend.

This Experimental Heroin Prescription Trial has been approved and is to start in a few months. Some issues considered: to significantly improve the quality of life, to help with the social and health integration of the users, to decrease risk behavior, to evaluate the efficacy of prescribed heroin. It will look into oral methadone vs. IV heroin in 150 patients in Granada & Andalusia, 75 on IV heroin and 75 on oral methadone. Recruitment will be: on the streets, from NGOs and from referrals from treatment centers. Patients will be those with a history of at least two failures in other preventive programs.

Premise: In spite of the efficacy of methadone programs over other alternative therapies for drug abusers, a solution for non-responders requires more diversified treatment programs.
 

D. Marsh, Toronto.

Reported on the "A Canadian Heroin Trial?" the Canadian experience. The Heroin prescription issue rose as a response to the use of opium.

Facts: - Deaths from heroin overdose have risen in certain cities, they are also related to HIV infection in some cases. -The social cost exceeds millions of dollars, more going to drug enforcement than to drug treatment. - It is estimated that some 40 thousand dollars per year are spent for every untreated user.

Current rate: it is estimated that 50% of heroin users will be on methadone within 3 years. The Center offers comprehensive services including counseling which makes it more effective in treatment.

The project has drawn growing interest from the public at large, from the media, the government, health care providers and users. However, the issue of prescription heroin still remains an open question for the country with many debates and no solution.
 

David Vlahov, from Baltimore (USA)

As a result of the protocols developed by the North American Trials Protocols Development Team, discussions started for trials in the US and in Canada. The idea of Heroin Treatment in the US was initially a far-fetched idea that slowly changed after the group meetings. However, the policy in the US is still one of zero tolerance and prohibition. The subject of heroin treatment is highly controversial particularly among politicians, even though the idea is not too farfetched among the public.

Some methadone programs have failed to have the expected success. Some recommendations for improvements are to: increase and improve accessibility, increase motivation among users, to remain neutral over political issues, and maintain treatments as a clinical and scientific issue, not political. Access to the political process is important.

Despite all the constraints, Mr. Vlahov is optimistic and thinks approval for heroin prescription trials is possible in the future.