|
Despite much thinking and talking about heroin, Australia, like most
countries, has not come close to solving the problems associated with
heroin use. The proposal by researchers at the National Centre for
Epidemiology and Population Health (NCEPH) and the Australian
Institute of Criminology (AIC) to conduct trials of the prescription
of heroin is a welcome attempt to improve the lives of Australians who
use heroin, their families and communities.
The purpose of this article is to argue that the NCEPH/AIC proposal has
prematurely focused on one way of providing heroin which is too narrow
and too restrictive; that some of the criteria for "success" of the
pilot studies seem to be arbitrary; and that some of the criteria for
termination of the project are unreasonable. I also suggest some
alternative approaches to providing heroin on a trial basis.
The proposal is for two pilot studies, each of six months' duration,
followed by a trial of two years. Each stage of the proposal is
contingent on the "success" of the previous stage. The core of the
proposal is to provide heroin for injection to users who attend a
special clinic up to three times a day to receive heroin and/or
methadone under close supervision.
Any radical approaches to opiate dependence (such as providing
heroin) will be constrained by political and practical
considerations. At the outset the investigators associated their
proposal with the prevalent paradigm, which seeks to contain heroin
users by locking them up or treating them. Thus, the report on
feasibility of the trial1 states that the project
"must not be linked with permissive attitudes to illicit drug use and
must be coupled with continuing law enforcement and prevention
activity against illicit drug use". It seems reasonable to ask
whether such views allow adequate exploration of alternative
approaches to providing heroin. If these statements indicate undue
sensitivity to the perceptions of those with negative views about
heroin use, then it follows that any strategy for providing heroin
would tend to be very restrictive.
In stage 2 of the feasibility research into the views of
dependent heroin users, most people questioned were clients of
the ACT methadone program (209) and relatively few had never received
treatment (14) or were treatment "drop-outs" (8).2 There is
little indication that a wide range of heroin users have been
comprehensively questioned about possible methods of providing
heroin or of evaluating the pilots or trial. By concentrating on
clients of the ACT methadone program in which "in both 1993 and 1994,
half the people who entered the program had dropped out within a few
months",2 a premature and limited view
of heroin and methadone provision may have been obtained.
Criteria for success of the pilot studies have been established but
are not necessarily justified. The first pilot study will be
successful if a stable dose of heroin or heroin plus methadone is
"found" for "more than half of the participants".2 These criteria
seem arbitrary and restrictive -- should participants who do not
receive stable doses of heroin but nevertheless have better
lives (improved health, less involvement in crime) be regarded
as unsuccessful? What is the rationale for concluding that
the first pilot project is a success if 51% ("more than half") of
participants achieve a stable dose of heroin? Why not 25% or 75%?
The progression of the second pilot study to the full-scale
trial is contingent on the acceptability to heroin users of being
randomised to receive either their choice of heroin,
methadone or both or, in the control group, to receive methadone
alone. Again, this criterion seems too restrictive in that it gives
preference to the design of a trial over improvements in the lives of
heroin users. In my view, the latter should be given greatest weight as
a criterion at all stages of the project, even if it means redesigning
the full-scale trial.
The relative lack of consideration for the potential variability
in the needs of individual heroin users is taken to a logical
but unreasonable conclusion in the criteria for termination of a
trial. One criterion will be if prescribed heroin "has value for only a
subgroup of dependent heroin users". This is unreasonable because,
for example, if subgroups that were most likely to engage in crime or
experience overdose benefited most, then continuing to prescribe
heroin for them would surely be appropriate.
Another model for provision of heroin in a pilot program might be
decentralised prescription by selected specialist or general
practitioners in a few regions, based primarily on individual
assessment of needs and on potential risks to individuals and
communities.
One seeming advantage of the NCEPH/AIC proposal is the strategy of
proceeding by incremental steps, each dependent on the satisfactory
outcome of the previous one. However, with only a limited initial
model of heroin provision and restricted concepts of
progress or "success", any potential convergence to some "ideal"
model or, indeed, divergence to more than one, is restricted. If there
were several initial models, there would be more opportunity to
select those that are effective. The impetus for the project arose, in
part, from concerns that current approaches to the problems
associated with heroin use "might not be effective".2 It follows that
one focus could be on those for whom current approaches are not
effective.
If we see heroin users as individuals with individual needs, we might
be led to alternative ways of making heroin available and of
evaluating its usefulness. If we focus first on the things that
heroin users and their communities want to change (e.g., crime,
disease risk, cost, overdose) and only later on methods of delivery,
it seems to me we will have a better chance of making a substantive
contribution that will help ameliorate the problems of heroin use.
Arguably, heroin and heroin users are seen as alien by most
Australians. By showing people that heroin users are their fellow
Australians, sometimes with a particular set of difficulties, we
might begin their "acculturation" and not confine them in
prisons and clinics or drive them to extremes of behaviour and
thereby disable them.
In conclusion, I urge the NCEPH/AIC to consider revising its approach
to heroin prescription, and politicians, bureaucrats and others to
support more comprehensive consideration of how to solve the
problems associated with heroin use. The Commonwealth, States and
Territories need to keep this issue on the public health agenda and to
provide mechanisms and resources to enable the discussions and
research to continue.
| 