Benefits of heroin treatment for drug users

Drug users who do not benefit from conventional treatments for heroin addiction should be able to access the drug through the health system, urges a Canadian expert in The BMJ today.

Standard treatments for heroin drug addiction include detoxification, abstinence programmes and methadone maintenance, but there is a subgroup of patients for whom these do not work.

As doctors can provide no effective treatments for these patients, many will remain "outside the healthcare system" and there is "overwhelming" evidence that they will relapse into using illicit heroin and "suffer immeasurably" while costing society a "fortune," explains Martin T Schechter, Professor, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada.

Illicit heroin is a dangerous street drug because its dose and purity are unknown and users face the risk of overdose and death. Because the drug is illegal, many users engage in unsafe practices, for example, using contaminated syringes that increase the risk of life threatening infections such as HIV and hepatitis, and its use often leads to crime and sex work.

Many users are often in and out of hospitals and prisons for these reasons, he explains, adding that they can be "deeply affected by the illness of the addiction and its consequences."

But heroin assisted treatments should be offered to this vulnerable group of patients, he argues, because they have been shown to improve outcomes, reduce harm, lower societal cost and make savings for the healthcare system.

Currently, this type of treatment is not offered following regulations put in place by the Canadian government in 2014 although a small group of participants are being given the drug after benefiting from it in a successful clinical trial.

Schechter notes six randomised controlled trials that found heroin assisted treatment to be more effective than standard treatments for such patients, and the recent Cochrane Collaboration review that concluded that it can help to decrease illicit substance use, criminal activity, incarceration and possibly reduce mortality and increase compliance with treatment.

In addition, he explains that while the direct cost of heroin assisted treatment is four times that of traditional treatments, it still works out to be cheaper when accounting for all associated costs when compared to other interventions.

For example, a trial in the Netherlands showed that heroin assisted therapy made overall savings of around € 13,000 (£9530; $14,100) per patient per year when compared to methadone, even when taking into account the direct cost of treatment.

Other research carried out by Schechter demonstrated better outcomes at a lower societal cost compared to methadone maintenance while British researchers found that heroin assisted therapy was more cost effective than oral methadone.

"Treatments like this represent the holy grail of medical research seeking to support a sustainable health system: they achieve better outcomes at lower overall cost," he argues.

And such savings could be used in addiction prevention programmes and other important priorities, he notes, adding that "the key question is not whether we can afford this new treatment, but whether we can afford the status quo."

Conventional treatments should remain the first preference for patients with heroin addiction, but if these do not work, diamorphine should be prescribed to patients by doctors at specialized clinics to ensure safety, he concludes.