Illicit drug policy based on punitive measures has failed, and it is time to seek a healthcare approach
MJA 1998; 168: 590-591
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The worsening global problem of illicit drugs will have been under discussion at the United Nations General Assembly Special Session on Drugs (UNGASS) in New York this month (8-10 June), just a few days before this issue of the Journal is published. The international crisis to which the United Nations is responding reflects decades of preferring to view the world as we would like it to be rather than as it is. Despite decades of alarming deterioration in outcomes associated with illicit drugs, the International Day Against Drug Abuse and Illicit Trafficking (26 June) is likely to be marked by yet more grandiloquent pronouncements of unachievable goals. In another editorial in this issue, Manderson describes the evolution of the complex drug control web in which we are now caught.1 Whenever new evidence has emerged of increasing illicit drug production and poorer outcomes, the reflex response of the international community has been to attempt to even more vigorously reduce supply. Genuine efforts to develop evidence-based alternative approaches, such as the proposed Australian Capital Territory heroin trial in 1997, have all too often been resisted by politicians. Senior Australian law enforcement officers have recently begun to question the traditional reliance on efforts to control illicit drug supply, with some calling for greater emphasis on treatment.2 After a recent meeting, Australian police commissioners "formally agreed to consider a range of strategies focusing on rehabilitation and avoiding the criminal justice system".2 Victorian Police Chief Commissioner, Mr Neil Comrie, said commissioners had decided to "almost wipe the slate clean" on current strategies.2 Australian criminal intelligence experts have stated that "law enforcement efforts are having only a limited effect on the amount of heroin offered at street level", and concluded that "it is obvious that current policies are not working".3 Some health interventions against illicit drugs, such as methadone treatment and needle exchange programs, have proved remarkably effective. Pharmacological treatments, of which methadone is by far the most important, attract and retain a substantial proportion of drug users and are strongly supported by evidence of safety and effectiveness.4 As both drug users and the broader community benefit substantially by recruitment and retention of users in treatment, the allocation of additional funding for monitoring and evaluation of trials of new pharmacological treatments in the recent "tough on drugs" statements by the Prime Minister should be warmly welcomed. These treatments include the partial opioid agonist buprenorphine, two opioid agonists (sustained-release oral morphine [SROM] and l-a-acetyl-methadol [LAAM]) and the opioid antagonist naltrexone. Each of these agents has particular advantages compared with methadone: buprenorphine and LAAM are safer and offer less costly alternate-day dispensing; SROM does not accumulate; and naltrexone avoids euphoria or dependence. However, there is no current evidence that these agents are more attractive or effective than methadone. By contrast, some trials have found that treatment retention, which often correlates well with other outcomes, was better for prescribed heroin than for methadone.5-7 There is a long history of pharmacological therapy for illicit drug users. More than 40 government clinics prescribed injectable morphine in the United States between 1919 and 1923.8 Heroin prescribing to treat heroin dependence commenced in the United Kingdom in 1926 and continues today,8 although this practice has been uncommon and rarely evaluated. A surprisingly extensive practice of prescribing amphetamine to amphetamine-dependent patients exists in the United Kingdom (Philip Fleming, Consultant Psychiatrist, Portsmouth Drug and Alcohol Service, Southsea, Hampshire, UK, 1998, personal communication), but is poorly documented and insufficiently evaluated. In this issue of the Journal, Metrebian and colleagues present the results of a UK study of relatively intractable patients allowed to choose treatment with either injectable heroin or injectable methadone.9 This study provides further support for the feasibility of prescribing heroin. The fact that more than one-third of patients chose injectable methadone should reassure those who assume that heroin prescription will prove irresistible to heroin injectors. Diversion of prescribed heroin to others was apparently not a problem, even though some prescriptions were dispensed weekly. Retention in treatment was unimpressive, but these patients had previously proved refractory to multiple treatment modalities. Illicit drug use, injecting risk behaviour, criminal activity, social functioning, health status and psychological adjustment all improved. Although the authors did not compare prescription of injectable drugs with other treatments, this study provides further support for conducting rigorously designed heroin trials. Whether prescribed heroin is suitable only for a heroin-dependent subgroup who do not respond to oral methadone or could be extended successfully to selected treatment-naive heroin users is a question that may also need to be answered one day. Right now, the study by Metrebian et al is also of interest in Australia because the harmful practice of methadone syrup injection is becoming increasingly common, and it is conceivable that parenteral methadone prescription might prove less harmful. The rationale for evaluation of medical prescription of heroin is based mainly on the need for dramatically improved treatment outcomes. The results of the recently completed heroin trial in Switzerland showed impressive health, social and economic gains,7 although the lack of a control arm inevitably limits any conclusions. Patients all had extensive histories of previous unsuccessful attempts at treatment (including methadone treatment). Retention on heroin prescription was considerably better than contemporary national retention rates for oral methadone treatment (although better staffing of the experimental program makes such comparisons problematic). After the Swiss heroin trial, 71% of voters in a national referendum supported continuation of this treatment, with majorities in all 26 cantons. It is hard to think of any new intervention in the illicit drug area in the last quarter-century that has shown such promise. On 6 June this year, the New York Academy of Medicine hosted the first international scientific meeting on heroin trials, reflecting growing international interest. A heroin trial will commence soon in the Netherlands, with trials under consideration in the UK, Germany, Spain, Austria and Canada.10 Interestingly, police chiefs in 10 of the 12 largest cities in Germany have been pressing for such a trial.10 The increasing interest in heroin trials is partly the result of authorities' growing acknowledgement of the failure of current policy. Were responses to illicit drugs to be decided entirely on the basis of evidence rather than fear and rhetoric, Australia would now be awaiting the results of the pilot stage of the ACT heroin trial. Demand for heroin is currently met by adulterated supplies of unknown concentration obtained from criminals. It seems probable that drug users and the general community would be better off if at least part of this demand were met by sterile heroin of known concentration prescribed by medical practitioners. Most doctors faced with a complex, chronic, relapsing-remitting disorder would prefer to choose from a range of effective treatments rather than rely on a single agent. The trials of new pharmacological agents are likely to extend and improve our therapeutic repertoire for treating heroin dependence. And there is still a compelling case for proceeding with a scientifically rigorous Australian heroin trial when political factors allow. Alex Wodak
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