THE SWISS HEROIN TRIALS: TESTING ALTERNATIVE APPROACHES

Prescribed heroin is likely to have a limited role

Over half a million heroin misusers receive oral methadone maintenance
treatment world-wide(1) but the maintenance prescription of injectable
opioid drugs, like heroin, remains controversial.

In 1992 Switzerland began a large scale evaluation of heroin and other
injectable opiate prescribing that eventually involved 1,035 misusers.(2,3)
The results of the evaluation have recently been reported.(4) These show
that it was feasible to provide heroin by intravenous injection at a
clinic, up to three times a day, for seven days a week. This was done while
maintaining good drug control, good order, client safety, and staff morale.
Patients were stabilised on 500 to 600 mg heroin daily without evidence of
increasing tolerance. Retention in treatment was 89% at six months and 69%
at 18 months.(4)

The self reported use of non-prescribed heroin fell signifianctly, but
other drug use was minimally affected. The death rate was 1% per year, and
there were no deaths from overdose among participants while they were
receiving treatment. There were limited reports of problems in the local
neighbourhood, despite the high frequency of daily attendance. Heroin
diversion was not a major problem, although some trial participants were
expelled for attempting to remove heroin from the clinic or to smuggle
cocaine into the clinic.(4)

The Swiss trials have encouraged proposals for similar trials in other
countries, including Australia,(5) and, more recently, Denmark, Luxemburg,
and the Netherlands. Any country that contemplates a trial of heroin
prescription will need to address several problems that arose in the Swiss
trials. Firstly, the participants' preference for heroin over any
alternative opioid undermined the randomised controlled design that was
originally planned and resulted finally in a descriptive outcome study.
Secondly, in the Swiss trials heroin was prescribed as part of a
comprehensive social and psychological intervention. In the absence of any
comparison treatment it was impossible to disentangle the pharmacological
effects of heroin from the effects of providing treatment in well resourced
clinics with highly motivated staff. An assessment of this issue requires
an appropriate comparison treatment. Thirdly, the unique social and
political context of the Swiss trials makes it uncertain how to generalise
their findings to other countries. Switzerland is a wealthy society that
has a comprehensive healthcare system that includes a well developed drug
treatment system whose staff have substantial experience with opioid
substitution treatment. Even so, heroin prescription in Switzerland has
been an addition to existing treatment approaches: it has not replaced the
methadone maintenance still prescribed for 15,000 Swiss heroin misusers but
has been an expensive option for a minority of severely dependent misusers
who have not responded to existing treatments.

Given this limited role, the controversy surrounding heroin prescription in
Switzerland and elsewhere has been out of all proportion to its likely role
as a treatment option. A recent debate about heroin prescription in
Australia, for example, dominated public discussion of drug policy for
nearly a month before the government decided against proceeding with the
trial. The debate also had other untoward effects: supporters of the trial
argued that something radical was needed, thereby encouraging the view that
Australia was in the midst of a national heroin crisis. Their opponents
agreed but countered that this was evidence that the national policy of
harm minimisation, which sanctions methadone maintenance and needle and
syringe exchange, had failed.

These issues have not been resolved by the Swiss trial. There are clearly
still questions that remain unanswered. The most important is what is the
comparative usefulness and cost effectiveness of injectable heroin and oral
methadone maintenance? A convincing answer to this question would
substantially improve our understanding of the role of this controversial
treatment.

Michael Farrell Senior lecturer National Addiction Centre, Institute of
Psychiatry, London SE5 8AF

Wayne Hall Executive director National Drug and Alcohol Research Centre,
Sydney, Australia

References

1 Farrell M, Neeleman J, Gossop M, Griffiths P, Buning E, Finch E, et al.
The legislation, organisation and delivery of methadone in 12 EU member
states. Brussels: European Commission, 1996.

2 Rihs-Middel M. The Swiss Federal Office of Public Health's research
strategy and the prescription of narcotics. In: Rihs-Middel M, ed. The
medical prescription of narcotics. Scientific foundations of practical
experiences. Berne: Hogrefe and Huber, 1994.

3 Uchlenhagen A, Dobler-Mikola A, Gutzwiller F. Medically controlled
prescription of narcotics: fundamentals, research plan, first experiences.
In: Rihs-Middel M, ed. The medical prescription of narcotics. Scientific
foundations of practical experiences. Berne: Hogrefe and Huber, 1994.

4 Uchlenhagen A, Gutzwiller F, Dobler-Mikola A, eds. Programme for a
medical prescription of narcotics: final report of the research
representatives. Summary of the synthesis report. Zurich: University of
Zurich, 1997.

5 Bammer G. The feasibility of the controlled supply of heroin to opiate
addicts.