Ten years ago, on 19 August 1997, Federal Cabinet at the behest of Prime Minister John Howard aborted a proposed scientific trial to evaluate the effectiveness of prescription heroin as a treatment for heroin dependence. Six years of careful scientific research work was trashed.
Cabinet claimed the heroin trial was abandoned because it would have ”sent the wrong message”. After the meeting, two Cabinet members (Peter Reith, Judith Moylan) breached the Westminster tradition by telling waiting reporters that Cabinet had erred.
Though much less so than a decade ago, heroin injecting is still a significant health, social and crime problem in Australia. A small minority of severely dependent heroin injectors refractory to all existing treatments probably account for much of the heroin-related crime and many of the new heroin recruits. The main reason for conducting prescription heroin trials is to establish whether this could add to the benefits already obtained from existing treatments.
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The community strongly supports bringing all forms of illicit drug use under control aiming to make life healthier and safer. After failing to accept the political challenges of prescription heroin research, the Federal government responded by launching a populist ‘War Against Drugs’ in late 1997. Just a few years later, methamphetamine use and resulting problems started increasing. The community now also has to contend with stimulants like ”ice”, drugs we understand poorly and for which we are ill-prepared therapeutically.
Though the government claims that its Tough on Drugs approach dramatically reduced heroin availability in Australia from 2000, a more credible explanation is the 80-90% fall in heroin production in Burma since 1996. Burma is the source of virtually all the heroin reaching this country but Australia could not have been responsible for Burma’s sharply declining opium cultivation. In June 2001, Mr Keelty, Commissioner of the Australian Federal Police, said there had been ”a business decision by Asian organised crime gangs to switch from heroin production as their major source of income to the making of methamphetamine, or speed, tablets. Their market research tells them that these days people are more prepared to pop a pill than inject themselves.”
Heroin prescription treatment could greatly improve an intractable severe minority among the estimated 120,000 Australian heroin injectors, also benefiting their families and communities. Based on overseas research we could expect improved health and reduced crime with substantial community resources saved.
In 1984, Nick Greiner, then Leader of the NSW Liberal Party, became the first senior politician in Australia to recommend prescription heroin as a treatment
for heroin dependence.
In 1989, a Select Committee of the Legislative Assembly of the ACT was established to inquire into illicit drugs. They asked me, considering the innumerable previous Royal Commissions and parliamentary inquiries into illicit drugs which had made so little difference, what recommendation would make a difference. I suggested a trial of prescription heroin which the Select Committee then took up. The National Centre for Epidemiology and Population Health at the ANU and the Australian Institute of Criminology were invited to evaluate this recommendation and concluded that a trial of heroin prescription was both scientifically and logistically feasible. The ACT Government then established a Heroin Pilot Study Task Force with a diverse membership. The Task Force recommended that a trial proceed (with only one dissenting and pre-ordained vote). One of the strongest supporters of the proposed ACT heroin trial was the then Chief Minister, Liberal politician Ms. Kate Carnell.
The next major step was a meeting of the Ministerial Council on Drugs Strategy in Cairns in July 1997 where six jurisdictions supported and three opposed the heroin trial. Supporters comprised five Coalition governments (Commonwealth, South Australia, ACT, Tasmania and Victoria) and the NSW Labor government while three Coalition governments (Queensland, Western Australian and the Northern Territory) were opposed. Strong support for the heroin trial came from both sides of politics.
At the time the ACT heroin trial was aborted, 45% of national respondents interviewed by Newspoll expressed support, while 47% were opposed. Supporters were younger, better educated, had higher incomes and were more likely to live in a capital city.
Heroin-assisted treatment is only required for about 5% of those seeking treatment with the vast majority managed successfully with methadone or
buprenorphine treatment or abstinence programmes. The evidence in favour of prescription heroin treatment is now much stronger than it was ten
years ago as the results of trials are now available from the Netherlands, Germany and Spain. The Dutch trial involved 430 severely dependent heroin users who had not benefited despite multiple other treatments. The majority (52%) of those treated with prescription heroin improved according to an index reflecting physical health, mental health and social functioning while just over a quarter (28%) of those receiving standard methadone maintenance treatment improved. After 12 months, those who had received prescription heroin treatment were transferred to standard methadone maintenance treatment with 82% of those who had previously improved then substantially deteriorating. The Spanish and German studies also found similar benefits from heroin treatment.
The United Kingdom, Switzerland and the Netherlands now provide heroin assisted treatment but only as a last resort. In Germany, the conservative party in the federal coalition government opposes heroin treatment despite the impressive results of their recent national trial while municipal governments from the same party support implementation.
Heroin trials in several countries have now shown unambiguous and worthwhile health and social benefits. Though more expensive than standard methadone treatment, prescription heroin treatment has proven more cost effective. Concerns about possible risks have not been borne out. Prescription heroin has not been diverted to the black market. More permissive community attitudes to illicit drug use did not develop. Clinics were not inundated by large numbers of inappropriate drug users from neighbouring areas.
In a national referendum in September 1997, 71% of Swiss voters supported retaining prescription heroin treatment. Previous experience of abstinence treatment was a strong predictor of successful outcome from heroin assisted treatment in the Netherlands.
Since heroin availability began declining in Australia in 2000, amphetamine has become the most frequently injected drug. Although the pressure to improve responses to heroin injecting is not as great in Australia in 2007 as it was in 1997, it remains to be seen how long the current situation will prevail. Opium cultivation in Afghanistan increased 49% in 2006 and a further increase is expected in 2007. Afghanistan now produces 92% of the world’s illicit opium. While virtually no heroin from Afghanistan currently reaches Australia, the business concept of ‘market balance’ suggests that this situation may not last indefinitely. If and when heroin from Afghanistan does start arriving in Australia in substantial quantities, it will not be long before calls for a heroin trial begin all over again.
Australia will then have the choice of turning to science in just the same way as science is used to improve treatments for diabetes, breast cancer and heart disease.
The paramount aim of policy should not be just to reduce drug use of all kinds whatever the consequnces, but to get people through the most dangerous phase of their use with least harm to themselves and society. Science can show how this can best be done. Let’s hope that future Australian governments will give science a chance.