The current issue of the New England Journal of Medicine, probably the world’s most prestigious medical journal, details the results of a recent Canadian trial comparing injectable heroin with oral methadone as a treatment for heroin injectors.

Like the four previous European trials comparing these two treatments during the past 15 years, the Canadian researchers found that injectable heroin was more effective than oral methadone.

As in the previous trials in Switzerland, the Netherlands, Spain and Germany, the Canadians recruited a group of severely dependent heroin injectors who had not benefited from multiple previous attempts at drug treatment (including several previous episodes of oral methadone treatment).

The average age of the 251 people in this study was almost 40. Males accounted for more than 60%. Almost a quarter were of Aboriginal descent and almost three quarters were homeless, living in shelter or a single-occupancy hotel room.

The average duration of injecting drug use was 16.5 years; 94% had been charged during their lifetime for any crime and almost three quarters had committed illegal activities (other than illicit-drug use) in the previous month. More than half had a chronic medical problem and almost 10% were HIV-positive.

The average number of previous drug treatments was 11.1 (including 3.2 previous attempts at methadone treatment). The group used illicit drugs on most days of the month before entering the study (heroin 26.9, cocaine powder 5.0, crack cocaine 13.4). Median expenditure on drugs in the month before entering the study was $A1470).

Both groups in the study did well but 88% of the injectable heroin group were retained in addiction treatment compared with 54% in the methadone group.

Illicit-drug use or other illegal activity declined in 67% of the heroin group, compared to 48% in the methadone group. There results were all statistically significant.

Serious adverse events were more common in the heroin group but the only death in the study occurred in a subject receiving methadone. The results in the (optimised) methadone group in this study were better than had been achieved previously in routine treatment.

The heroin group recorded significant improvement in six of the seven subscales while the methadone group improved in two subscales. After adjusting for baseline values, the heroin group improved more than the methadone group in four of the scores (including drug use).

The average number of days in the previous month illicit heroin was used decreased by 80% in the heroin group compared to 56% in the methadone group. Cocaine use remained the same in both groups.

All five trials considered the same variables (drug use, illegal activities, health, and social adjustment) and showed greater benefit from injectable heroin than oral methadone. The heroin group in the Canadian study showed greater improvements in medical and psychiatric status, economic status, employment and family and social relations.

The authors (rightly) recommended that methadone should remain the mainstay of treatment for the majority of patients. However, for a minority of heroin users with very severe problems who have not benefitted from a range of previous treatments (including high quality methadone maintenance), injectable heroin appears to be a safe and more effective treatment.

The Canadian study was published 12 years and one day after federal Cabinet (at the behest of then Prime Minister John Howard) aborted an Australian heroin trial because this would have “sent the wrong message”.

Since then 68% of Swiss voters in a national referendum and 63% of federal politicians in the German parliament have voted in support of heroin treatment as an option for the “worst of the worst”. A stable 5% of patients undergoing heroin treatment in Switzerland have required injectable heroin.

Although more expensive than other treatments, economic savings (mainly from reduced crime) are twice the cost of the treatment. No doubt the gnomes of Zurich fully understand that it is more important to invest in cost-effective treatments than to cancel scientific research in order to “send a message to the electorate”.

The small minority of severely dependent heroin users who require treatment with injectable heroin account for something like 30% of the crime associated with heroin. It is better for these individuals, their families and communities that they are attracted, retained and benefit from injectable heroin treatment rather than be allowed to continue to create major problems in the community or to be made even worse at great expense to taxpayers in prison.

Should Australia conduct a heroin trial? There will be insufficient political support for an Australian heroin trial as long as the heroin shortage continues (bringing with it lower numbers of heroin overdose deaths and lower crime rates).

Denmark has decided that the research evidence is strong enough to start this treatment without conducting additional research. That is what Australia should also do, 29 years after this was first officially recommended in Australia (to Premier Neville Wran).

Heroin shortages do not last forever.

Peter Fray

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