 Heroin as medication?Has treatment of addiction come to an end? The die is cast: heroin should be registered as a medicine and be prescribed to larger numbers of addicts. One more step has been taken towards eventually viewing addiction to be merely a neurobiological condition. Use drugs in the battle against addiction!Mid-March of 2002, former Dutch Minister of Health Els Borst made several recommendations to the Dutch Lower House. These recommendations were based on the results of studies after three new experimental ways of treatment: detoxification under anaesthetic (see framework 1), treatment with high doses of methadone (see framework 2) and the prescription of heroin on medical grounds, which is the most striking experiment. The Minister has recommended that the latter form of treatment be officially included in the addiction care system. In order for that to be possible, however, heroin must be registered as a medicine. Heroin addicts Currently, the Netherlands has a relatively stable number of heroin addicts. During the last decades of the twentieth century, the estimated number of heroin users in the Netherlands increased from 10,000 in 1977 to 20,000 in 1979 and 30,000 in 1983. The current number is estimated to be 25,000. The syringe-using drug users are getting older: their average age is now forty years. The Netherlands has a large number of varied care facilities, from abstinence-based treatment facilities (such as therapeutic centres) to accessible facilities aimed at improving health and psychosocial functioning (such as methadone maintenance programmes, syringe exchange programmes, user rooms and social care facilities). Of the 25,000 heroin users, 13,000 users participate in a methadone programme; of this group, 8,000 individuals still use illicit drugs. This latter category of addicts contains about 1,000 to 2,000 severely degenerated and sometimes seriously ill addicts that are eligible for heroin prescription on medical grounds. Therapy resistance Borst's recommendation to expand the heroin prescription project to include more addicts is the logical consequence of the publication of a report by the Central Committee on the Treatment of Heroin Addicts (CCBH) at the beginning of February this year. This is a positive report about an experiment with heroin prescription on medical grounds to a few hundred addicts. Addicts from Amsterdam, Rotterdam, The Hague, Utrecht, Groningen and Heerlen participated in this scientific experiment that started in 1997. They had to meet certain cri-terions, had to be at least 25 years or older, they had to use heroin primarily via intravenous injection or via smoking and the participants had to have the Dutch nationality. The most important criterion was, however, therapy resistance. The researchers connect the following characteristics with this term: at least five years of heroin addiction, regular participation in methadone programmes, unsuccessful methadone treatment, an (almost) daily use of illicit heroin and a bad physical and/or mental health condition and/or insufficient social functioning/integration. Quality of life According to Borst, this form of prescription provides addicts that meet the above-mentioned criterions with a last chance of improving their quality of life. Therefore, she argues for expanding the project and softening the admission criterions. She wishes to implement heroin prescription programmes nationwide. For this purpose, she has created a Committee for the Implementation Aspects to the Treatment of Heroin Addicts that has to give out an advice in the Autumn of 2002 about the practical implementation of Borst's proposal. Nationwide heroin prescription means that addiction care institutions throughout the Netherlands will be obligated to prescribe heroin. In order for them to be able to do that, they will obtain an exemption from the Dutch Narcotics Act. The addicts that are eligible for heroin prescription will be registered. For this, Borst wishes to use biometrics, i.e. a scan of a finger or hand with which addicts can identify themselves. This way of identification will enable care professionals to exchange information in a faster and better way and it will improve the quality of care. Accessible In her letter to the Dutch Lower House, Borst writes that heroin treatment in accordance with specific guidelines and protocols in principle should be accessible for those patients who have been rendered eligible for this form of treatment. Addicts who benefited from this treatment should continue to be prescribed heroin. Meanwhile, the millions of euros that this will cost have been estimated. However, Borst also wants the admission criterions to be softened. This was also proposed by the CCBH in its report. The admission criterions can only be softened, however, if this does not adversely affect the positive results. Furthermore, Borst wishes to submit an application for the registration of heroin as a medicine. Borst writes: "Such a registration will enable us to organise and execute a systematic monitoring of possible adverse effects on the longer term. Naturally, we should prevent indications for the use of heroin as a medication to shift in the wrong direction. Nevertheless, the threat of abuse of this medication could be best averted by registering heroin as a medicine." Positive results? Then, what exactly are the positive results of the prescription of heroin on medical grounds according to the researchers? Firstly, the researchers indicate that conducting the experi-ment has been successful. The experiment was "feasible, safe and effective in the area of physical and mental health as well as social functioning." More important is, nevertheless, their conclusion that the prescription of heroin (in combination with methadone) is more successful in 23 per cent of the smokers and 25 per cent of the intravenous drug users than treatment without heroin, i.e. with methadone only. Researchers rendered the experiment to be successful if there had been a substantial improvement (that had defined in advance) in the area of physical health, mental health or social functioning without there having been a significant deterioration in one of those areas. The problem addicts gained a better condition and were less involved in criminal activities: the number of days per month during which participants were involved in illegal activities decreased. The CCBH report: "This decrease will have an important influence on the public order and safety in the participating municipalities and the load on the judicial apparatus." Effects Nevertheless, the researchers also indicate that the beneficial effects of the treatment with the combination of methadone and heroin is linked to the continuation of this treatment. The participants' health deteriorated again immediately after the treatment was discontinued. The researchers asked themselves the question whether "offering an additional professional care programme for patients that had already shown some improvement [...] would have prevented the condition of virtually all patients from seriously deteriorating after the experimental treatment was discontinued." This indicates that the prescription of heroin in itself does not seem to have any influence on the solution of the underlying problems. Naturally, you could have seen this one coming. The treatment is only ‘successful' if heroin continues to be prescribed. Prestige "We have said this from the very beginning," general director of De Hoop Teun Storten-beker says. "If you start giving addicts the thing they want most in the world, you cannot just stop doing this. In fact, you condemn a large number of addicts to heroin prescription for the rest of their lives. For them, it will be virtually impossible to develop a life free from addiction." Also, Dutch Lower House member for the Christian Democratic Party (CDA) Wim van de Camp does not consider the prescription of heroin to be a good form of professional care. Van de Camp doubts the success rates that are being mentioned: "Seventy per cent of the addicts have dropped out." Van de Camp calls the heroin experiment a ‘project of prestige' that annually costs 23 million euros "due to expensive prescription offices, stainless steel syringes and gloves." Criticism The main point of criticism remains that a large amount of money is being invested in a form of professional care that enables a majority of the addicts to maintain their addiction. This is being done while a large amount of this money could also be invested in expanding addiction care to include addicts that want to break with their addiction but currently have been put on a waiting list for months before they can be admitted. On the long term, a neurobiological approach to addiction that includes the prescription of drugs and the maintenance of addiction will be the end of addiction care as we know it. NOTE Detoxification under anaesthetic The experiment with detoxification by means of the medicine naltrexon that was started in 1999 shows that it does not make a difference whether or not this detoxification takes place under anaesthetic. Therefore, the Dutch government no longer supports the treatment by means of anaesthetic. However, the experiment with detoxification by means of the medi-cine naltrexon without anaesthetic for now may be continued on a limited scale. At the end of 2003, its results must have become clear and a decision has to be made on whether or not to include this detoxification method in the regular addiction care system. In 1996, De Hoop has made several of its clients detoxify under anaesthetic. However, this detoxification was immediately followed by intramural treatment while the study focused on outpatient treatment following detoxification under anaesthetic. De Hoop's experiences with this method were very positive. For this reason, excluding detoxification under anaesthetic as a form of treatment seems to be very premature. Detoxification by means of higher doses of methadone Research has shown that treatment with high doses of methadone in a methadone maintenance programme on average has a more beneficial effect on drug use, physical condition and mental well-being than treatment with lower doses of methadone. As far as social functioning is concerned, the results are less clear: there is a beneficial effect on the participants' social network but there was no effect on criminal behaviour and the accommodation situation. There was also a lower labour participation. Published in De Hoop Magazine, no. 3, 2002 |
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