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Not such a bad treatment after all

Problematic heroin users in the UK are thought to number about 200 000 (Home Affairs Committee 2002). Estimates of the number in treatment range from 30 000 (Hickman et al. 1997) to over 100 000 (Department of Health 2002). Either way treatment uptake is disappointing, since treatment has been clearly shown to reduce mortality and crime. There is enough money in the system to fund comprehensive healthcare without plundering the National Health Service (NHS). A Select Committee report advised that a moderate shift in spending from enforcement to healthcare would be sufficient (Home Affairs Committee 2002). In 2001/2002, £3.5 billion was spent on the direct and indirect costs of drug misuse, but only £217 million was spent on treatment (Audit Commission 2002). Moreover, treatment actually saves money: in the UK it is calculated to save £3 for every £1 spent (Gossop et al. 1998). The heroin trials in Switzerland saved £7000 per patient per year, even when their expensive system of supervision was taken into account (Uchtenhagen et al. 1999). Methadone maintenance is the gold standard treatment for established opiate users. There is strong evidence for its effectiveness in terms of retention, reduction in illicit opioid use, reduced imprisonment and prevention of HIV infection (Ward et al. 1998). The National Treatment Agency plans to double the number of treatment slots and to reduce waiting time to 2 weeks. This is clearly a priority. However, comprehensive treatment means more than just methadone. Counselling, detoxification, rehabilitation, occupational advice and housing support must all be available. There must also be treatment for those who fail to respond to methadone or to other oral replacement treatments, such as buprenorphine. In spite of best treatment, there remains a small group of patients whose condition continues to deteriorate. Some have tried methadone and found that they did not like its properties, or that it did not work for them. Some injectors are unable or unwilling to give up injecting. Switzerland has a well-equipped and diversified system of treatment for dependent heroin users, but they still found that a large group of dependent heroin users were either not in contact with drug services or had tried and failed. It was this observation that led to them mounting their well-publicized heroin trials (Uchtenhagen et al. 1999). In a cohort of 800 subjects receiving heroin treatment, there were significant reductions in illicit drug use and criminal behaviour, and improvements in physical and psychological health and in social functioning. Criminal behaviour reduced from 69% reporting income from illicit sources to 10%. Police records and official crime statistics verified self-reported criminal activity. Health improvements included general and nutritional status, and injection-related skin diseases. In a further study in Geneva, 46 long-term users were randomized to a prescription for heroin, or to a waiting list where most received oral methadone (Perneger et al. 1998) After 6 months, the heroin group showed significant reductions in illicit heroin use, criminal behaviour and significant improvements in psychological health and social functioning. A WHO report (Ali et al. 1999) confirmed that these trials showed that heroin treatment was feasible, but queried whether improvement was due to heroin or to the psychosocial impact of attending a clinic 3 times a day. One response is that it would be hard to imagine these patients attending a clinic 3 times a day if heroin was not available. It is an acknowledged benefit of methadone substitution therapy that it retains people in treatment and brings them into contact with psychosocial support and advice. If heroin is able to perform this function when methadone fails, it is surely an argument in favour rather than against. Another response is to consider the evidence of the recently completed Dutch trials, in which patients taking heroin and methadone were compared with those prescribed heroin alone. Unlike in Switzerland an adequate proper control group was retained. These trials recruited ‘chronic, treatment-resistant heroin addicts’ (van den Brink et al. 2002). The primary