Heroin-assisted treatment as a response to the public health problem of opiate dependence.

Abstract

Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries. Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its application varies internationally with respect to treatment regulations and delivery modes. In order to effectively treat those patients who have previously been resistant to methadone maintenance treatment, several countries have been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence problem internationally, the current opiate dependence treatment landscape in several countries, and the status of ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.

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Heroin-assisted treatment as a response to
the public health problem of opiate dependence
BENEDIKT FISCHER, JÜRGEN REHM, MARITT KIRST, MIGUEL CASAS, WAYNE HALL, MICHAEL KRAUSZ,
NICKY METREBIAN, JEAN REGGERS, AMBROS UCHTENHAGEN, WIM VAN DEN BRINK, JAN M. VAN REE *
Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries.
Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis
B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the
most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its
application varies internationally with respect to treatment regulations and delivery modes. In order to effectively
treat those patients who have previously been resistant to methadone maintenance treatment, several countries have
been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy
treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence
problem internationally, the current opiate dependence treatment landscape in several countries, and the status of
ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.
Keywords: clinical trials, heroin-assisted treatment, opiate dependence, opiate pharmacotherapy treatment,
public health
ILLICIT OPIATE USE AS A PUBLIC HEALTH ISSUE
Illicit opiate use is a considerable public health problem
in established market economies (EMEs). Due to the
nature of illicit drug use behaviour, exact prevalence and
incidence estimates are difficult to obtain. However,
based on advanced epidemiological methods and
monitoring techniques, it is suggested that in the majority
of EMEs, 0.1 to 0.5% of the total population are illicit
opiate users.1 More specifically, Farrell et al.2 estimate
that European Union countries feature opiate-dependent
populations in a range of 94 to 400 persons per 100,000
adult population aged 15 to 64, and that therefore ‘despite
some variation, each [EU] country now has a sizable and
comparable long-term opiate dependent population’
following the ‘epidemic growth of heroin addiction’ in the
1970s and 1980s. The illicit opiate using population is
estimated to be around 600,000 in the United States and
60,000–90,000 in Canada, or around 330 (US) and 290–
430 (Canada) per 100,000 adult population aged 15 to 64
respectively.3,4 Australia has an estimated 67,000–92,000
illicit heroin users (540–750 per 100,000 population aged
15 to 64), which is a higher rate than in the European
countries (see table 1 for recent illicit opiate user popula-
tion estimates).5,6
While these user population fractions appear relatively
minor, illicit opiate users have considerably higher risks
for morbidity, mortality and disability than the general
population.7 There is also empirical evidence that 1–2%
of illicit opiate users die per annum from drug-related
mortality.5,8,9 In EU countries, the total number of acute
drug-related deaths was estimated to be 7,419 in 1996,
having increased from 6,819 in 1992.10 For North
America, the number of drug-related deaths is estimated
in the 4,000–5,000 range per annum;3,4 and 737 opiate-
related deaths were estimated in Australia in 1998.11
With few notable exceptions, data from most EME coun-
tries suggest that more than two-thirds of illicit opiate
users use their substance of choice intravenously.10 This
goes hand in hand with the fact that an increasing pro-
portion of illicit opiate users in North America and
Europe are also (injection) cocaine users, prompting
numerous injection episodes per day, resulting in extremely
high levels of risk for infectious disease transmission as
well as overdose episodes. In fact, estimates suggest that
in the European Union, HIV prevalence within injection
drug user (IDU) populations in different countries ranges
from 0.5–32%.10 Figures for HIV infection prevalence
among the estimated IDU population in North America
range from 10–40%.12 The proportional connection
between IDU and HIV is less in Australia, where 5% of
EUROPEAN JOURNAL OF PUBLIC HEALTH 2002; 12: 228–234
* B. Fischer1,2, J. Rehm1,2,3, M. Kirst2, M. Casas4, W. Hall5, M. Krausz6,
N. Metrebian7, J. Reggers8, A. Uchtenhagen3, W. van den Brink9,
J.M. van Ree9
1 Department of Public Health Sciences, University of Toronto, Canada
2 Centre for Addiction and Mental Health, Toronto, Canada
3 Addiction Research Institute, Zürich, Switzerland
4 Servicio de Psiquiatria, Hospital Universitari Vall d’Hebron, Barcelona, Spain
5 Institute of Molecular Bioscience, University of Queensland, St. Lucia,
Australia
6 Klinik für Psychiatrie und Psychotherapie, Hamburg, Germany
7 Department of Social Science & Medicine, Imperial College School of
Medicine, London, UK
8 Department of Psychiatry, Centre Hospitalier Universitaire du Sart Tilman,
Liège, Belgium
9 Central Committee Treatment Heroin Addicts, Utrecht, The Netherlands
Correspondence: Benedikt Fischer, PhD, Department of Public Health
Sciences, University of Toronto, McMurrich Bldg., 109C, Toronto, ON,
M5S 1A8, Canada, tel. +416 946 5792, fax +416 260 4156,
e-mail: benedikt.fischer@utoronto.ca
228
at University of Portland on May 23, 2011
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Table 1 Overview of environmental characteristics of selected planned and ongoing heroin-assisted treatment studies
Country
Australia 67,000–
Estimated
heroin
addict
popula-
tion
Pop.
in
1,000
18,751 20–50%
Proportion
of heroin
addicts in
treatment
system
Status of methadone
maintenance and other
treatment
25,000 in MMT; MMT
widely established
through clinics and
GPs; other opiate
pharmacotherapies in
experimental stage
Status of
heroin-assisted
treatment
Extensive
feasibility research
and preparation for
controlled heroin
tx trial since 1991,
but no political
approval
Kind of study
planned/
ongoing
RCT: co-
prescribed
heroin vs.
methadone
alone
Study target
group focus/
remarks
Standard trial
outcomes:
health, crime,
social
functioning.
Full trial only
after successful
pilot
Specific target
on methadone
resistant and
untreated
References
Hall,
Lynskey,
Degenhardt
(1999)5;
Bammer
(1995)6
92,000
Belgium under
40,000
10,204 approx.
20% in
MMT,
but no
coordinated
registry or
control of
MMT
About 7,000 in MMT;
Insufficient number of
MMT spots in north of
country (waiting lists);
in south wide
availability of
methadone including
low threshold
Heroin trial
protocol exists;
approved by
regional medical
authorities as
necessary
condition for
heroin
prescription;
no decision or
timelines on
realization
Trial proposal
submitted for
review for March
2001; proposal
reviewed and
recommended for
funding by
Canadian
institutes of
Health Research;
ethical review not
yet completed in
all study sites;
2003 potential
start date
Protocol for heroin
trial submitted in
1999; no decision
yet nor clear
timelines available
on realization
RCT: heroin-
assisted
treatment plus
methadone vs.
standard
methadone
Reggers
(2001)26;
Farrell et al.
(2001)2
Canada 60,000–
90,000
(IDU)
30,301 25–30%
in MMT
MMT became widely
available after 1995;
regional differences;
low threshold partly
available; places in
abstinence treatment
not clear
RCT: heroin-
assisted
treatment vs.
optimized
methadone
treatment
Outcomes
include
attraction and
retention
Fischer
(2001)27;
Fischer and
Rehm
(1997)28;
Fischer
(2000)29
France160,000 58,874 approx.
60%
About 10,000 in MMT
and 90,000 in
buprenorphine
substitution treatment;
regional and urban/rural
differences in treatment
availability; waiting lists
for MMT;
buprenorphine available
through GPs,
methadone in treatment
clinics
40,000–45,000 MMT
spots; regional
differences; partly
low-threshold MMT;
10,000 codeine
substituted persons;
small number of persons
in buprenorphine
substitution treatment;
majority of opiate
substitution available
through GPs
12,500 in MMT; 4,500
in drug-free treatment;
low threshold available;
small scale studies on
i.v. morphine, i.v.
methadone, oral
dextramoramide
RCT (three
arms): MMT
waiting list vs.
heroin up to 3
times daily with
MMT vs. heroin
once a day and
additional MMT
Comparison
to methadone
which is not
the standard
alternative in
France
Farrell et al.
(2001)2;
Barrau,
Thirion,
Micallef et al.
(2001)30;
Barbier
(2001)31
Germany 150,00082,047 more than
33%
Heroin trial
approved by
government;
trial started
in 2002
RCT: 2∗2∗2;
two randomized
factors (heroin
vs. MMT and
psychosocial tx)
and one factor
self-selection
(not reached by
treatment
system and
failures of
MMT)
Multi-site RCT:
randomized
waiting list
design MMT vs.
heroin-assisted
treatment
including MMT
Randomisation
of psychosocial
treatment
conditions
(case
management &
motivational
interviewing vs.
psychosocial
counseling)
Krausz
(2001)32;
Kalke,
Verthein,
Raschke
(1998)33;
Farrell et al.
20012
Netherlan
ds
26,000
regular
users;
24,000
addicts
15,698 70% in
treatment
system;
50% in
MMT
Heroin trial
ongoing with
separate protocols
for inhalable
and i.v.
administration;
final results in
2002
First results:
recruitment was
successful with
N=600 subjects
and experiences
positive
van den
Brink, van
Ree (2001)34;
van den
Brink,
Hendriks,
van Ree
(1999)35
Table continued
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the reported HIV infections for 1994 were attributed to
injection drug use.13 A great number of local and national
epidemiological surveys also indicate that the majority of
injection drug users are Hepatitis B and Hepatitis C
infected.2,12 In many local populations, Hepatitis B and
C prevalence rates reach up to 90%,14–17 although
considerable differences exist across systems. Also,
recently in some local and regional drug use cultures (i.e.
Netherlands, Southern Spain), the majority (up to
80–90%) of illicit opiate users has switched from injecting
to smoking/inhaling opiates as the dominant route of
administration, and initial evidence suggests that this has
had some impact towards reducing related morbidity as
well as mortality.
The Global Burden of Disease (GBD) study estimated
that in 1990, illicit drugs in the EMEs accounted for
28,800 deaths (=0.4% of total deaths); 717,000 years of
life lost (YLL) due to mortality (1.4% of total YLLs);
1,598,000 years of life lost due to disability (YLD) (3.3%
of total YLDs); 2,315,000 disability adjusted life years
(DALY) (2.3% of total DALY burden in established
market economies).7
Criminological estimates suggest that a considerable
share of property crime, especially in urban areas, occurs
in the form of acquisition crime committed by regular
illicit drug users.2,18–20 Self-report data from illicit opiate
users outside of treatment indicate that their illicit drug
purchasing expenses often accumulate to the equivalent
of $100–200 per day, depending on cultural and environ-
mental contexts.21 Research has also indicated that the
majority of illicit opiate users are unemployed, and use
welfare benefits and illicit activities, in the form of fre-
quent property crime and small-scale drug dealing, as their
major income sources.20–24
A recent cost of illness study on the basis of data from an
untreated illicit opiate user cohort in Toronto (N=114),
Canada found a total social cost burden of Cdn $45,000
per untreated user and year, due to lost productivity,
health and health care, and crime and criminal justice
costs.25 Similarly, Hartwig and Pies23 tabulated the direct
and indirect social costs from illicit heroin use in
Germany in 1992 at approximately US $6.5 billion, or
approximately $45,000 per estimated user/year.
THE OPIATE DEPENDENCE TREATMENT LANDSCAPE
A wide variety of treatment interventions exist for illicit
opiate dependence (including detoxification, residential/
abstinence treatments, behavioural interventions). Over
the past few decades, oral opiate pharmacotherapy – pre-
dominantly in the form of methadone maintenance treat-
ment (MMT) which is estimated to make up 90% of all
currently provided opiate pharmacotherapy (except for
France)2 – has become established as the main treatment
for illicit opiate dependence in EMEs. Current local or
national treatment regulations and delivery models,
driven by social, political and professional determinants,
differ considerably.2,38,42 For example, in some juris-
dictions, MMT is delivered through general practitioners
(GPs) or community pharmacies, while other countries
rely primarily on specialized drug treatment clinics (table
1). Differences also exist in terms of treatment require-
ments, i.e. treatment eligibility, psycho-social treatment
Table 1 continued Overview of environmental characteristics of selected planned and ongoing heroin-assisted treatment studies
Country
Spain
Estimated
heroin
addict
popula-
tion
150,000–
250,000
(mostly
IDU)
Pop.
in
1,000
39,371 40–60%
Proportion
of heroin
addicts in
treatment
system
Status of methadone
maintenance and other
treatment
MMT is widely
available mainly
through specialized
outpatient clinics; plan
for pharmacy delivery
model for MMT for
stable patients
Approx. 16,000 in
MMT; 2,100 in
abstinence-based
treatments; 1,100 in
heroin-assisted
treatment
Status of
heroin-assisted
treatment
Two heroin trial
protocols exist –
approved by
federal authorities
Kind of study
planned/
ongoing
Andalusia:
injectable
heroin-assisted
vs. MMT;
Catalonia: oral
methadone vs
oral heroin
Cohort study:
results positive
with respect to
somatic, mental
health;
criminality;
other indicators
of social
integration;
consumption
Study target
group focus/
remarks
Objective to
‘normalize’
treatment of
heroin
addiction (like
‘diabetes’)
References
Casas
(2001)36;
Farrell et al.
(2001)2
Switzerlan
d
30,0007,106more than
60%
Heroin-assisted
treatment is part of
regular opiate
treatment system
by governmental
decision
Multitude of
additional
studies
Rehm,
Gschwend,
Steffen et al.
(2001)37;
Swiss
Methadone
Report
(1996)38;
Dobler-
Mikola et al.
(1998)39;
Farrell et al.
(2001)2
Metrebian
(2001)40;
Metrebian et
al. (1998)41;
Farrell et al.
(2001)2
United
Kingdom
150,000–
270,000
59,055 35,000
MMT
slots
Oral MMT; injectable
methadone and heroin
available for small
number of patients
Injectable heroin
available for opiate
addiction
treatment since
1920; since 1968
only by doctors
with special licence
Trial planned
but unlikely;
study examining
current heroin
prescription
practices
underway
Which doctors
prescribe heroin
to how many
drug users; why
is treatment so
limited?
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requirements, dosing, length of treatment, and behavi-
oural surveillance.2,38 Research over the last few decades
consistently shows that for those illicit opiate users who
are successfully attracted into and retained in treatment,
methadone maintenance treatment is generally effective
in improving health status and facilitating socio-eco-
nomic stabilization as well as reducing illicit/injection
drug use and criminal activity.3,43,44
However, although a number of countries have made
oral methadone treatment widely available in diverse
modalities, there is evidence that a considerable propor-
tion of illicit opiate users could not be effectively retained
or attracted into methadone treatment. Treatment study
reviews suggest that 30–70% of subjects leave methadone
treatment within the first 12–24 months,44–46 and many
resist methadone treatment altogether. A rather narrow
empirical basis suggests that these methadone treatment
‘failures’ are linked to a variety of reasons, including
pharmacological properties and side effects of methadone,
route of administration, dosing and delivery charac-
teristics, lack of injection and drug-related euphoria.47–51
From a public health perspective, it is predominantly the
most difficult and problematic opiate users (i.e. in terms
of drug use histories and patterns, somatic and psychiatric
health status, injection risks) who cannot be attracted
into or retained in methadone treatment. These apparent
constraints in the desirability and effectiveness of metha-
done treatment have set ‘natural limits’ for the role and
effectiveness of this form of treatment on a population
level. Illustrative case studies are countries like the
Netherlands, Germany, Switzerland and Australia where
methadone treatment is most widely and diversely avail-
able yet ‘only’ 50–60% of illicit opiate user populations
are currently in treatment.2,13
In light of the obvious limitations of conventional metha-
done treatment on the one hand, and the severe public
health consequences of untreated illicit opiate use on the
other hand, much time has been invested in searching for
effective complementary forms of opiate pharmaco-
therapy treatment, especially for treatment-resistant
users. The more conventional pharmacotherapy agents
which are either being tested or, by now, used as standard
medication in various local settings are Buprenorphine
(France, Austria, Denmark, US, UK and Australia),
LAAM (Portugal, Denmark, Spain, Germany, US), slow-
release morphine (Austria) and Dihydrocodeine
(Germany, Belgium, Luxembourg).2,10,52,53
HEROIN-ASSISTED TREATMENT AS A THERAPEUTIC
OPTION
The most controversial modality in complementary
opiate pharmacotherapy treatment comes in the form of
heroin-assisted treatment, in which heroin is used as the
main pharmaco-therapeutic agent.42,54,55 This discussion
has recently been intensified both on a scientific and
political level with the completion of the large-scale Swiss
heroin-assisted treatment study, 1994–1997, aiming to
answer the fundamental questions of whether heroin-
assisted treatment is: i) effective for users who have failed
in other modes of treatment; and ii) effective in producing
improved health and social outcomes.55,56 Based on the
above described constellations with regards to illicit
opiate dependence, and the successes and limitations of
conventional opiate pharmacotherapy treatment, a num-
ber of Western countries (namely: Australia, Belgium,
Canada, France, Germany, the Netherlands, Spain,
Switzerland, United Kingdom) have embarked on im-
plementing or developing scientific studies to explore the
potential benefits of heroin-assisted treatment within
their national boundaries. Although the basic context
and rationale for these studies is similar, the specific
approaches, parameters, design, questions and environ-
ments of these studies differ considerably.
Table 1 provides an overview of countries with a proposal
for a heroin-assisted treatment study officially submitted
or to be submitted to the responsible scientific/political
authorities for approval or funding. In the Netherlands,
a large multi-site clinical heroin-assisted treatment trial
is just completed;35 in Germany a multi-site clinical
heroin-assisted treatment trial started in 2002, and the
proposal for a Canadian heroin-assisted treatment
trial has recently been reviewed and recommended for
funding by the country’s main health research funding
organization. In Switzerland and the UK, heroin-assisted
treatment is currently part of the regular treatment
system. The other countries listed in the table are all at
various stages in the planning phase of a heroin-assisted
treatment study.
The UK is in a distinct situation compared to other
countries, as heroin has been allowed as regular medication
in the treatment of opiate dependence since the 1920s,
although it is limited to a select number of specialized,
licensed doctors. A research application for a study ex-
ploring the effectiveness of heroin-assisted treatment has
been developed, but funding is unlikely. However, a study
to examine the current practice of prescribing heroin in
the UK began in 2000.57,58 The policy priorities in the
area of opiate dependence treatment in the UK seem to
be focused on improving the efficacy of MMT at this
point.
Switzerland has completed the original PROVE cohort
study56 examining the impact of heroin-assisted treat-
ment on treatment non-responders. Results showed sub-
stantial improvements in physical and mental health
status, social integration (including a reduction of drug-
related criminal activity), as well as reductions in illicit
drug use.22,37,56 Furthermore, a cost-benefit analysis in-
dicated that the monetary savings due to the listed bene-
fits from heroin-assisted treatment outweigh the financial
costs of this form of treatment.59 Heroin-assisted treat-
ment is now available as one, yet quantitatively limited,
opiate dependence treatment option in Switzerland,
within a wide range of treatments. Altogether, this treat-
ment system has expanded substantially over the past two
decades, from about 700 MMT spaces in 1979, about
10,000 in 1991, to about 18,000 treatment spaces cur-
rently. Abstinence-based treatment increased from 1,900
spaces in 1993 to 2,100 in 1996, and heroin-assisted
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treatment from 250 treatment spaces in 1994 to 1,100 in
1998.60
The Netherlands had a similar pattern of substantial
opiate treatment expansion as that in Switzerland,
although this expansion began some years earlier. The
Dutch heroin-assisted treatment study was designed as a
randomized controlled clinical trial (RCT) of ‘last resort’
treatment for treatment-resistant subjects, comparing
co-prescribed heroin and methadone treatment with
methadone treatment alone, consisting of separate ex-
perimental ‘inhalation’ and ‘injection’ arms. The trial
began in 1998 with two pilot sites, and then expanded to
six more sites in 2000 with a total of 600 trial subjects.
The final results of the study were just released.61
Germany’s authorities have approved a multi-site heroin-
assisted treatment study that began in 2002. The final
revisions of the design have been negotiated between the
regulatory agency (BfArM) and the study group in Ham-
burg. All study sites have confirmed their participation.
There are two target populations in the trial (methadone
non-responders and opiate addicts currently not in treat-
ment), and the effectiveness of heroin-assisted treatment
will be compared to that of MMT, with an additional
experimental variation of psychosocial care (traditional
drug-counselling vs. case management and motivational
therapy).
In the other countries listed in table 1, the time at which
a systematic heroin-assisted treatment trial will com-
mence is not yet clear. In Australia, a protocol for an RCT
of heroin plus methadone vs methadone alone has been
in development since the early 1990s, based on an extens-
ive feasibility research programme.6 The Australian
heroin treatment trial was approved by the Ministerial
Council on Drug Strategy in 1997,13 but was subsequently
blocked by political decision makers.62,63 At this point,
the history of the trial and its failure is the subject of
scientific investigation,64 but there are no signs that the
project will be revived or implemented soon. However,
an upcoming federal election in Australia that could
cause a change in government, may allow a heroin-
assisted treatment trial to proceed. In Belgium, a heroin-
assisted treatment trial protocol was submitted to the
health authorities in 2000 and is now awaiting approval.
The Belgian trial proposal is also based on an RCT model.
Canada submitted a protocol to the national Canadian
Institutes for Health Research (CIHR) in spring 2001. This
protocol was originally developed in the context of a
multi-centre American study group named the North
American Opiate Medication Initiative (NAOMI),12
and the trial is based on an RCT design with patient
attraction and retention as main outcomes. The CIHR
has scientifically reviewed and recommended the trial for
funding, and has also recently funded an interdisciplinary
opiate-dependence research programme across Canada
including a small-scale heroin-assisted treatment feasibil-
ity study. Optimistically, the larger-scale Canadian
heroin-assisted treatment trial could start in three sites
(Vancouver, Toronto and Montreal) in 2003, ethics
review has been obtained for all study sites.
In France, a protocol was submitted to health authorities
in 1999, and is still awaiting a decision. This protocol uses
an RCT design with three arms dividing heroin-assisted
treatment into two components distinguished by
frequency of delivery (one vs up to three times a day).31
The discussion on substitution in France centres mostly
on the role of buprenorphine vs methadone,65 and a
decision in support of the trial is not expected to be
finalized soon. Finally, Spain has two protocols for
heroin-assisted treatment trials approved by regional
health authorities, and both have recently been approved
by federal authorities. One protocol’s design builds on an
RCT design studying injectable heroin vs MMT (Andalu-
sia), while the other protocol proposes to study oral heroin
vs oral methadone (Catalonia). The Catalonian study
would add significantly to new empirical knowledge, and
if successful has obvious public health relevance as the use
of oral opiate substitution treatment would potentially
reduce the risk of viral infection.
DISCUSSION AND CONCLUSION
Illicit opiate dependence is a major public health problem
in EMEs. Heroin-assisted treatment may help reduce this
problem by attracting new illicit opiates users into therapy
as well as by offering an alternative treatment for users
who have failed in conventional treatment modes. The
Dutch, Swiss, and UK experiences have clearly shown
that such treatment is feasible. Moreover, the Swiss study
has shown overall effectiveness of the combination of
heroin and methadone pharmacotherapy and psycho-
social care, and the Dutch trial provided data on
differential effectiveness of heroin vs methadone, avail-
able as of spring 2002. However, basically all newly pro-
posed trials attempt to re-demonstrate both feasibility and
effectiveness of heroin-assisted treatment in comparison
to methadone treatment as the ‘gold standard’.
Since clinical, injection heroin-assisted treatment trials
are very expensive,66 this replication of similar studies in
national contexts seems a potential waste of resources.
However, different socio-cultural contexts limit the
generalizability of such trials from one country to another,
and the controversy associated with the treatment seems
to require the national reproduction of these trials for
political and symbolic reasons.42 From a public health
point of view, it would likely be a more sensible approach
to consider heroin like any other pharmaceutical agent
for the purposes of treatment and try to answer the
following questions:
Is heroin-assisted treatment as cost-effective as metha-
done treatment? Are there differences in cost-effect-
iveness for different subgroups of users?
What are the differential indications for different forms
of opiate pharmacotherapy?67 Do we really have
evidence-based decision criteria which allow one to
match patient characteristics with form of treatment?
What are the best overall treatment systems for illicit
opiate dependence or, as more and more patients are
poly-drug users at treatment entry, for illicit poly-drug
dependence? Is heroin-assisted treatment a necessary
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component in such treatment systems? Does it make
sense to establish heroin-assisted treatment when
methadone is not widely and diversely available?
While some country systems may insist on having their
‘own’ trials and findings, also with respect to the point of
cultural specificity or to instill some order into rather
unstructured treatment systems, answering the above
questions would likely contribute far more in dealing with
the overall public health challenge of untreated illicit
opiate dependence in EMEs rather than re-hashing the
questions of overall feasibility and effectiveness of heroin
as a pharmaceutical agent. In this sense, it is hoped
that some of the planned or contemplated trials will
fundamentally re-consider directions and objectives.
It has been shown, that harms and costs related to illicit
drug use on system levels can be substantially reduced
with focused policies.68,69 Heroin-assisted treatment may
play a role in these efforts in established market eco-
nomies. To define and shape this role is one of the
challenges of future systematic and policy-relevant re-
search in this area. We hope that such research will be
driven by a meaningful search for relevant evidence from
a public health perspective rather than be primarily based
on ideology or politics.
This article is based on proceedings of the Satellite meeting of the
International Network Conference in Berne, Switzerland, 23–24
February 2001, organized and funded by the Swiss Federal Office of
Public Health (SFOPH; see www.admin.bag.ch for further details).
Financial support for research for this article was in part provided by
the Swiss Federal Office of Public Health, Reference #00.000972,
and the Connaught Fund, University of Toronto, Grant #417623,
and the Canadian Institute of Health Research (CIHR).
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Received 7 May 2001, accepted 3 December 2001
C O M M E N T A R Y
Heroin maintenance and attraction to treatment
ROBIN ROOM *
P rofessor Fischer and his colleagues1 offer a useful and
thoughtful overview of developments and plans for
heroin-assisted treatment studies in a total of NINE
countries. The practical problem from which all the trials
start is that some part of the population of regular users of
illicit heroin and other opiates does not come voluntarily
into treatment either with prevailing forms of opiate
maintenance or in various ‘drug-free’ treatment regimes,
even when the thresholds for entry to these treatment
modalities are lowered. As Fischer et al. note, in France
the prevailing form of opiate maintenance is with bupre-
norphine; elsewhere, it is with methadone.
The proposition that heroin users should be in treatment
rests on a variety of concerns and assumptions: a socio-
* Correspondence: Dr. R. Room, Centre for Social Research on Alcohol and
Drugs - SoRad, Stockholm University, Sveaplan, S 106 91 Stockholm, Sweden,
fax +46 8 674 7686, e-mail: robin.room@sorad.su.se
EUROPEAN JOURNAL OF PUBLIC HEALTH 2002; 12: 234–235
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