To Give Or Not To Give Heroin To Addicts
Featured ArticleMain Category: Alcohol / Addiction / Illegal Drugs
Article Date: 13 Jan 2008 - 0:00 PDT
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Should heroin addicts who are hard to treat be given heroin? A head-to-head (debate) looks at this topic in this week's issue of the British Medical Journal (BMJ).
Yes
Jurgen Rehm, Centre for Addiction and Mental Health, Toronto, and Benedikt Fischer, University of Victoria, British Columbia explain that maintenance treatment with heroin is appropriate for heroin addicts under specific circumstances.
Trials carried out in Germany, the Netherlands, and Switzerland have found heroin assisted maintenance treatment to be practicable and effective for people who are resistant to treatment - it was also found to be more cost-effective than methadone maintenance treatment. In the United Kingdom, where heroin treatment has been an option for many decades, the practice is still controversial.
They ask why heroin should not be used as one such pharmacological agent if maintenance treatment is generally justifiable.
Safety for both the patient and the general public has been cited as one reason. However, according to the Swiss study, mortality of patients in heroin assisted maintenance programs is low, and less than for patients in other maintenance programs.
Rehm and Fischer see no compelling reason why heroin assisted maintenance treatment should not be included as part of a comprehensive treatment system for heroin dependence.
No
Neil McKeganey, Professor of Drug Misuse Research, University of Glasgow, says that prescribing heroin to a heroin addict is not treating the addiction, rather it is treating the effects of misuse. He adds that the evidence regarding heroin prescribing is not conclusive at all. It may cost three to four times more to treat an addict with heroin than with methadone.
There is also a risk that doctors end up prescribing increasing quantities of the drug.
McKeganey explains that research has indicated that with the right services in place it is possible to achieve more than just stabilizing the addicts' continued drug use through the prescribing route. He cites a Scottish study that found that 29.4% of addicts who receive residential rehabilitation did not take heroin for at least 90 days, compared to just 3.4% of those on methadone maintenance.
According to other studies, the addict really does want a service that helps him/her become drug free. It is the duty of health services to make sure they are supporting the addict's attempts to become free of the drug. Services have to be extremely cautious about any addition to a policy that may be seen as a path to maintaining instead of reducing an addict's dependence, he concludes.
"Should heroin be prescribed to heroin misusers? Yes"
Jürgen Rehm, Benedikt Fischer
BMJ 2008;336:70 (12 January), doi:10.1136/bmj.39421.593692.94
Click here to read it online
"Should heroin be prescribed to heroin misusers? No"
Neil McKeganey
BMJ 2008;336:71 (12 January), doi:10.1136/bmj.39422.503241.AD
Click here to read it online
Written by - Christian Nordqvist
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Visitor Opinions In Chronological Order (6)
To Give Or Not To Give Heroin To Addicts
posted by Bob Thorn on 14 Jan 2008 at 2:41 amNeil McKeganey misses the point of supplying heroin as a substitute. Jurgen Rehm does not state, nor does anyone else state, that substitute treatment should be the only option available. Heroin is only prescribed when all else has failed, including abstinence types of treatment. Relapse after abstinence treatment like residential rehab is not only extremely common but extremely dangerous, with higher mortality after relapse than substitute treatment programmes. The only failing of heroin substitute (and any substitute treatment) is the lack of additional psychosocial support.
Neil McKeganey misses the point that substitute treatment decreases harm by encouraging the addict out of a criminal way of life. His endless moralising of the subject does nothing but encourage a judgmental and demonising attitude to prevade the debate. He is a sociologist not a clinical prescriber and tends to make sweeping judgements on prescribing practices he knows little about.
To Give Or Not To Give Heroin To Heroin Addicts
posted by Peter O'Loughlin on 15 Jan 2008 at 6:08 am"For every complex problem there is an answer that is clear, simple, and wrong." (H.L. Mencken.)
Addiction as we know is a complex, chronic condition, and whilst it is true that relapse is more common than recovery, we also know that many do recover. We also know that the vast majority of addicts would like to be drug free, but all too often they have come to believe that they are beyond hope. A belief that has been drummed into them simply because they've had a couple or more relapses, and, or someone has told them they're 'not ready'.
Yes psycho social intervention is essential,. Of equal importance is the addressing of the grave emotional and mental disorders suffered by addicts, because unless they are treated in parralel, relapse is more likely than not. Unfortunately, here in the UK both are in short supply with the bulk of intervention being substitute treatment, which in no way reduces the harm caused by blood born diseases' ; on the contrary Both hepatitis C and HIV increase year on year, as do drug related deaths, which for 2005 are six percent up on the previous year. It is difficult to see how that can be classed as 'harm reduction'
This writer does no agree that Prof. McKeganey has missed the point, nor can he see that he is moralising. Telling someone they are 'not ready', and keeping them locked into addiction is both moralisng and judgemental. The inescapable fact is that the ongoing ingestion of psycho active drugs increases the severity of the addiction to the point that the addict's self will is eroded, at that stage any hope of lasting recovery has gone.
the principal reason for drug related deaths occuring at relapse either after a period of a abstinence or methadone maintainence is that the addicts tolerance for heroin has diminished considerably, consequently in relapsing to similar quantities of heroin used prior to abstinence, 'overdose' occurs.
We should also not overlook the deaths arising from the misuse of methadone, nor for that matter the fact that most of those on methadone continue to use other psycho active drugs, for the simple reason that the methadone is not giving them the high, or release they feel they so desperatly need.Once again the severity of the addiction is increased.
This writer has no quarrel with substitute treatment, providing it is not regarded as an end in itself, but a stepping stone to abstinence based recovery, whch again, here in the UK does not seem to be the case with 135,000 thousand addicts in treatment in 2005, 109,000 of which were on substitue, treatment the bulk of whch is methadone, in itself a highly addictive drug. (Methinks Menckel had a point.)
Prof McKegany also points us to the recovery rate in Australia, which is a standard to which we should all aspire, rather than just taking the least line of resistance and keeping addicts locked into addiction.
And Also
posted by kerry wolf on 16 Jan 2008 at 8:41 pmI want to add that it is decidedly untrue that "most of those on methadone continue to use psychoactive drugs". This is absolutely false. In the USA, where adequate dosing is the norm, the percentage of patients NOT using illicit drugs is anywhere from 65% (at poorly run clinics) to 90% (at well run ones). The UK is sadly guilty of ignoring studies that show that almost all methadone patients need a minimum of 80-120mg in order to stabilize and control withdrawal symptoms, and the average dose in the UK is 40mg--far below the minimum recommended dose. So, it may be in the UK that more people use illicit drugs with methadone, but that is not the fault of the drug, but the fault of the inadequate dosing.
The goal of methadone treatment is not, and never has been, to be a bridge to abstinence. The founders of MMT, Drs Dole and Nyswander, realized this, and Dr Dole stated that it was immaterial whether or not they EVER got off methadone, as long as the patient was restored to normal functioning and a normal place in society. Stats show that those who remain in treatment do much better than those who taper off.
The US System Was A Total Mess
posted by Jim Solwer on 16 Jan 2008 at 10:26 pmI am American, but also hold a British passport. I was a heroin addict and was treated in the USA several times in several centers. I was eventually taken to England by my aunt and received treatment there (here), all free. The difference was huge. In England I was treated like a human being - in the USA I was treated like a self-indulgent, sinful, leper, in ALL the places.
My one treatment England was successful, and I have not taken anything for four years.
Kerry lives in cloud-cuckoo-land.
My American Experience Was Shocking
posted by Yayoi Kumira on 16 Jan 2008 at 10:33 pmI was treated in the USA for heroin addiction. It was barbaric!! I still get angry about it. It was not until a went back to Canada, after being away for 15 years that I managed to get proper treatment.
The way Americans treat drug addicts is a disgrace - a waste of money with arrogant people who never listen.
Cloud Cuckoo Land
posted by kerry wolf on 17 Jan 2008 at 5:36 amWell, sir, I do agree with you that the UK in general has a much better system of caring for it's citizens, and the US is indeed barbaric in its treatment of addicts and everyone else for that matter, no argument there. I was only saying that the UK system does not, as a rule, use an adequate amount of medication to control the symptoms for most people.
As an advocate for methadone patients, I talk to many people from the UK, as well as keeping abreast of any studies, articles, etc, and I can assure you that a great many people from the UK are vastly underdosed and desperate for relief. A simple dose increase would make all the difference to these folks. That is my ONLY argument with the UK system. Otherwise, I agree with you that it is far superior to the USA system.
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