BREAKING THE DEADLOCK OVER AN AUSTRALIAN TRIAL OF INJECTABLE OPIOID MAINTENANCE

Injectable heroin maintenance has been advocated as a form of treatment for
opioid dependence that would attract, and retain in treatment, addicts who
have either not sought treatment or who have failed at other forms of
treatment, including methadone maintenance. Advocates of heroin maintenance
argue that it would increase the proportion of addicts in treatment and
reduce heroin use, drug-related crime, and deaths due to overdose. [1]

A 1991 proposal by a Select Committee on HIV, Illegal Drugs and
Prostitution of the ACT Legislative Assembly led to a feasibility study for
a heroin trial in the ACT. [1] In 1997, the Ministerial Council on Drug
Strategy voted in favour of a heroin trial, but the trial did not proceed,
as the Federal Government would not amend legislation to allow heroin to be
imported for the trial or allocate funds to monitor the use of heroin in
accordance with international treaties. [2]

Dramatic rises in deaths caused by opioid overdose in the late 1990s
prompted more calls for a heroin trial. [3] The Federal Government refused
to countenance a trial, creating a policy deadlock that prevented the
evaluation of what proponents [2] claimed was a potentially valuable policy
option.

If we can avoid the fixation on a trial of heroin per se, there is a way
out of this policy deadlock. The alternative option we are proposing is to
trial hydromorphone (Dilaudid), an injectable opioid that has similar
effects to heroin. [4,5] Even if the Federal Government's attitude towards
a heroin trial were to change, we believe that trialling hydromorphone
would be a better option than trialling heroin, for a number of reasons:

- - The subjective effects of hydromorphone are very similar to heroin in
experienced heroin users and both have short durations of action. [5]

- - Hydromorphone is a registered drug (Schedule 8) in Australia, so it can
be prescribed for medical purposes and used in clinical trials. There would
be no need to change federal legislation to allow a trial of injectable
hydromorphone. Nor would there be any need for oversight of heroin
importation and distribution by the International Narcotics Control Board.

- - The use of hydromorphone can be distinguished from the use of heroin by
urinalysis, [6] thus allowing detection of any covert use of street heroin
by trial participants. (A major criticism of the Swiss heroin trials was
that this could not be done. [4])

- - Hydromorphone lacks the political symbolism of heroin. [5] This would
allow a clinical trial to be conducted in the absence of the media
sensationalism that would probably attend a trial of heroin maintenance. A
protocol for a clinical trial of hydromorphone could be assessed by peer
review and funded by the National Health and Medical Research Council. (On
the other hand, a trial of hydromorphone might have the disadvantage of
discouraging participation of dependent heroin users who only want heroin.
Assessing the attractiveness of hydromorphone to the patient population
would therefore be an important part of a feasibility study for a clinical
trial.)

- - A trial of hydromorphone may reduce the need to inflate the public health
benefits of heroin maintenance in order to enlist community support for a
heroin trial. Allowing the prescribing of injectable opioids, whether
heroin or hydromorphone, would be unlikely to substantially reduce the
heroin black market or heroin-related crime. The cost of providing this
form of treatment, and the restrictions that the community would probably
impose on eligibility for it, mean that too few heroin-dependent people
would receive this form of treatment to have a substantial effect on heroin
use and its consequences in the population. [7] Injectable opioid
maintenance would most likely be a treatment option reserved for dependent
heroin users who have failed at existing forms of treatment (the model that
was trialled in Switzerland [8] ).

Any trial of hydromorphone maintenance for opioid dependence should include
an economic evaluation of the comparative costs and benefits of competing
forms of maintenance treatment. These could include alternative forms of
injectable opioid maintenance using longer-acting agonists such as
methadone and partial agonists such as buprenorphine. Oral methadone
maintenance should be the comparison condition, as in a recent trial of
heroin maintenance. [9]

For these reasons, we believe a controlled clinical trial of injectable
hydromorphone maintenance would break the impasse over a heroin trial and
enable the Australian community to decide what role injectable opioid
maintenance has to play in the public health response to dependent opioid use.

Competing Interests

None declared.

Acknowledgements

The authors would like to thank Professor George Bigelow, Professor Jerry
Jaffe, and Dr Deborah Zador for their comments on an earlier draft of this
article.

References

1. Bammer G, Douglas RM. The ACT heroin trial proposal: an overview. Med J
Aust 1996; 164: 690-692.

2. Wodak A. Prescribing heroin: nothing to fear but fear itself? Med J Aust
1998; 168: 590-591.

3. National Crime Authority. Organised crime in Australia. NCA Commentary
2001. Canberra: National Crime Authority, 2001.

4. Jaffe J. Injectable opiate maintenance in the United Kingdom: a view
from the United States. Addiction 2001; 96: 557-560.

5. Bigelow GE, Becker AB, Vernotica E, Liebson IA. Comparison of heroin and
hydromorphone in opiate users [abstract]. Drug Alcohol Depend 2001; 63
(Suppl 1): S14-S15.

6. Meatherall R. Confirmation of codeine, morphine, 6-acetylmorphine,
hydrocodone, hydromorphone, oxycodone, and oxymorphone in urine. J Anal
Toxicol 1999; 23: 177-186.

7. Hall W. Assessing the population-level impact of the Swiss model of
heroin prescribing. Sydney: National Drug and Alcohol Research Centre,
1999. (Technical Report No. 76.)

8. Rehm J, Geshwend P, Steffen T, et al. Feasibility, safety and efficacy
of injectable heroin prescription for refractory opioid addicts: a
follow-up study. Lancet 2001; 358: 1417-1420.

9. Perneger TV, Gina F, Del Rio M, Min A. Randomised trial of heroin
maintenance program for addicts who fail in conventional drug treatment.
BMJ 1998; 317: 13-18.