It’s not just because I was in Vancouver last week that I have heroin on the brain. Less than a month after a Canadian team found that prescribing heroin to addicts works where other treatments have failed, scientists in the UK reported the same thing. That stacks more evidence in favour of heroin prescription on top of existing good reports from Switzerland, Spain and Germany.
Note the rueful way the Canadian researchers lament the absence of US participation in the North American Opiate Medicate Initiative. In their excellent paper in the New England Journal of Medicine researchers from Vancouver and Montreal thank “the many U.S. scientists who contributed to the early design discussions but ultimately were unable to participate in the trial” because of what they ellipitcally call “financial and logistic barriers”.
This trial was being planned at the same time that the Traditional Values Coalition, defender of all that is Right and Good in America, were sticking the Republican Rottweilers on the National Institutes for Health for funding studies of sexual and drug-taking behaviour. No surprise, then, that US scientists had to drop out of the study. There is no reason in the world to believe that heroin prescription wouldn’t work as well in the US as it does in Canada, the UK or any other country at reducing consumption of street heroin, keeping people in treatment and cutting crime among that hard core of users that have tried and failed to get off smack by using methadone or just saying no. But in the current climate (yes, even with the Obama administration in occupation) there’s really not much point in doing studies in the States — no amount of evidence will lead to a policy change. As Virginia Berridge points out in an interesting editorial in the same issue of NEJM, drug policy is more a matter of history and culture than it is of science. America, founded on puritanism, has always been less tolerant of opiates than the Brits, who used them to fuel an unequal trade with China and some properly great literature.
One finding that surprised the Canadian researchers: while most people in the study obviously knew if they were taking methadone (orally) or heroin (injected) a small number of users were randomly assigned to inject hydromorphone instead of heroin. Neither they nor the study staff knew who was getting the real thing and who was getting the semi-sythetic cough suppressant. Amazingly, not one of the people shooting up cough medicine for a year could tell they weren’t taking smack. As the researchers pointed out in slightly mealy-mouthed research-speak, “the benefits of injectable opiod maintenance might be achievable without the emotional and regulatory barriers often presented by heroin maintenance”. Meaning that we might get away with prescribing drugs to help chronic users stabilise their lives if we could just stay out of the headlines. The “SMACKING UP YOUR TAXES TO SUPPORT JUNKIES!” type headlines.
A finding that didn’t surprise the Canadian researchers: people who were injecting drugs, even on prescription, were much more likely to OD than people on methadone — mostly because the heroin doesn’t mix so well with some of the other drugs they had been taking (crack cocaine use didn’t change for any of the study groups in Canada, although it fell in all groups in the UK). BUT, as the researchers point out, all but one of the overdoses happened in the study clinic, where staff were able to administer nalaxone and provide other support so that users got through the overdose ok. If they’d been out shooting up street smack, the chances are they wouldn’t have been so lucky. Which is one more reason to support supervised injecting facilities such as Vancouver’s impressive Insite.
One thing the Canadian researchers didn’t report was the relative cost of the different approaches. The UK study reported that heroin maintenance cost about £15,000 per person per year, about a third of the cost of a year in jail. But it took a report on the BBC to tell us that we could put three people on methadone for a year for the same amount. The question is: how many of them would still be on treatment at the end of the year?
(The Beeb story has an interesting video interview of one of the users of the programme, but sadly no embed code).