They Don't Become Angels: Part II

Dispensing Issues

a. Dispensing Methods
b. Leakage to the Illicit Market
c. Dispensing Frequency
d. Conclusions

a. Dispensing Methods

In England, heroin is a Class A drug and only specially authorised doctors are licensed to prescribe it as a treatment for addiction. Methadone is also a Class A drug which differs from heroin in that it can be prescribed and dispensed to addicts under certain conditions and without a special licence from the Home Office.(85)

The dispensing method for methadone in England is similar to the process in Australia in that the 'take away' method of dispensing has become the norm. That is to say, in most cases the prescription is not administered at the dispensing point, nor is it taken under supervision other than during the initial stages of treatment. What happens is that a prescription is issued by a doctor and the patient can collect the methadone from the nominated chemist at regular intervals, usually from one to three times per week. Methadone is dispensed in the following forms in England:

• Methadone mixture which is in liquid form designed to be taken orally.
• Methadone tablets which are designed to be taken orally, although there are cases where addicts will crush them up so that it can be taken intravenously.
• Methadone injection, which is designed to be taken intramuscularly, although there can be problems because some patients will still take it intravenously.
• Methadone reefers which are cigarettes laced with methadone which are designed to be smoked.(86)

Two explanations have been suggested as to why there is an attraction in injecting methadone intravenously. The first is to satisfy a need which is called 'needle fixation.' "I am supposed to swallow the tablets but I do inject them." (Addict 14) The second is the belief that injecting methadone will give a much stronger 'rush' than will injecting heroin. In Australia, methadone is not prescribed in injectable or smokeable form.

Diamorphine is available as ampoules of a freeze dried powder which is designed to be injected intravenously. Some people on a prescription choose to smoke this form in a procedure where it is heated on tin foil and then the fumes are inhaled. The other form of diamorphine prescribing is as impregnated cigarettes, much the same as the methadone reefers, which are also dispensed from a pharmacy. Dr John Marks has found particular success with the diamorphine reefers. Other clinics, however, have not had the same degree of success and tend to use alternative dispensing methods.

It is the role of the drug clinics to make assessments of the true drug taking habits of the patients in order that the best information possible is made available to the prescribing doctor. After prescribing methadone or diamorphine, the practice is invariably to closely monitor the patient in the initial stages. This often involves watching them take the prescription to ensure the dose is not too large or too small for the individual. For security reasons this is a practical procedure and it also helps to confirm the patient's habit, dosage and need.

You can't get what you need all the time so when drug users come to the clinic they will tell you the most they can use on a good day. They won't tell you what they can get by on, on a bad day .... They always say what they think the doctor wants to hear. (Addict 1)

Most heroin addicts need to administer their drug about four times a day. Even though methadone is longer lasting and does not need to be taken as frequently, it can be easily understood how the practice of watching every addict take every dose would be extremely labour intensive, and therefore cost preventative. No doubt this is why the clinics have had to move to the system of the patients collecting their prescriptions from community pharmacies and taking the drug in private. The usual practice is for the patients to collect their prescriptions from a pharmacy three days per week, usually Monday, Wednesdays and Fridays. Russell Newcombe points out that under the English dispensing procedure, "Little is known about how clients actually consume their prescribed opiates, or how closely they stick to the prescribed regime."(87)

The majority of diamorphine prescribed to addicts is dispensed by chemists, either from hospital or community pharmacies. It should be remembered that heroin is a legitimate drug for other medical purposes in England and it is commonly used for the relief of pain. Hospital pharmacies do carry a ready supply of heroin for this purpose and so the issue of security for these drugs is not something new. The pharmacy at the Cheltenham Hospital has a requirement to regularly order diamorphine which is dispensed both for pain relief and to heroin addicts. The pharmacy has security and administrative procedures in place and has not experienced any problem with theft or leakage.

Nicki Mazey and Graham Hopkins are both chemists who operate separate community pharmacies in Cheltenham. They both dispense diamorphine and methadone from their pharmacies and both participated in interviews in relation to dispensing issues for these drugs. Both of these people indicated that they had not experienced any problems with burglaries. However, they did recognise that the risk of burglary was an occupational hazard for pharmacies whether or not they stocked any particular form of drug. They did have security measures in place and Mazey had taken some extra steps as a result of the requirement to dispense diamorphine from her pharmacy:

One of the addicts who I dispense to gave me a security assessment, and I then employed him to actually do the work he had recommended ... And he did a good job too.(88)

The proposed trial for Australia intends to make diacetylmorphine available only in injectable form. Inhalable diacetylmorphine may be considered, depending on the degree of success that it is credited with by the Swiss, who are presently conducting some evaluation on this form of prescribing. Furthermore, the Australian trial proposes that, "Diacetylmorphine will only be able to be administered at the clinic; there will be no take-away doses."(89)

In England the leakage of methadone and diamorphine appears to have been facilitated largely by the 'take away' dispensing method. That is to say, it has been prescribed and dispensed lawfully, but the lawful recipient has then sold or traded it unlawfully to others. Dispensing the prescription at the clinic and watching the patients administer the drug on site should eliminate most opportunities for leakage through this method.

This practice of supervised drug administration will be implemented for a trial in Australia, but it will not be practical or cost effective on a larger scale. It is then, when the practice goes beyond the trial stage, that the risk of leakage will increase. However, the indications are that even then, the leakage will be minimal and there is also a much greater chance of it being discovered. And in any event, what would be leaked from this system would be a marked dosage which is unadulterated and therefore less likely to cause the same degree of harm as 'street heroin.'

b. Leakage to the Illicit Market

Leakage of licit heroin has been part of the English experience because heroin has always been available as a legitimate drug for the treatment of pain in that country. Controls over drugs of addiction in the UK were introduced in 1920, but these controls did not remove the right of doctors to prescribe certain drugs, such as heroin, cocaine and amphetamine. The original heroin addicts in England, before it became a popular recreational drug, were those who had become addicted as a result of having it lawfully prescribed to them, and doctors who abused their lawful access to the drug. It was not until the 1960s, when the impure, black market heroin became available in England, that a different class of addict appeared.(90) Australia, of course, has not experienced leakage of licit heroin, because it is not legal for any purpose, in any state or territory throughout the country.

A 1990 report of a survey conducted by Fazey of 140 patients from drug dependency clinics found that only three of that sample admitted to giving away, swapping or selling some of their prescription drugs.(91) This information was given greater force by an exercise conducted over a six-month period in 1987 by the Liverpool drug squad. Over this period of time the police examined all arrested drug takers for evidence of clinic prescribed drugs and none were found in possession of drugs to which they were not authorised.(92) Although the survey had low numbers and there was no comparison group, the inference to be drawn was, quite clearly, that there was very little leakage of licit drugs onto the black market via drug clinic prescribing and dispensing.

In relation to methadone prescribing the evidence obtained by this research is that there is significant leakage onto the black market and that a high percentage of those prescribed methadone will continue to use other drugs. Recent research conducted by Parker and Kirby in Merseyside supports this view:

Quite clearly the reports of both the clinic and community sample suggest that a substantial illicit methadone market exists. This is highlighted by the findings from the survey that show that 13% of the treatment sample and 31.1% of the community sample had bought street methadone in the last month.(93)

In relation to diamorphine prescribing this study finds that there is leakage, albeit minimal, to people who were not prescribed the drug or a particular dosage. However, this leakage must be viewed in light of the dispensing practice that presently operates in England for diamorphine, which differs from the process intended for the pilot programs proposed for the ACT.

There was some leakage because there will always be some who will abuse the system. However this leakage was minimal. There was also some lending and borrowing, if one of your mates was short then you would get it back next time.(94)

There is some exchanging between people on the program, but this is more to help each other out. (Addict 7)

The disadvantage is people asking for cigarettes. (Addict 8)

I know that some selling goes on — I've reported one or two myself — but it is a tiny drop in an ocean.(95)

I have seen pharmaceutical heroin that my patients have shown me that they have bought from various other people — that's the nature of the habit ... There will always be people who will want to play the system and get prescriptions and then sell it.(96)

To be honest I get asked a lot for my diamorphine ... There are people who do sell it. I would be lying if I said they didn't. (Addict 16)

Dr John Marks argues from the logical perspective that there would be no financial incentive for those on the heroin maintenance program to sell something that is pure. This is because, if they have a habit but sell their prescribed diamorphine, they will still have to service their addiction. They will, therefore, have to find money to buy heroin from the streets which is adulterated and therefore carries a greater risk. He argues that if they sell it "...because they no longer need it, because they are not using it any more, then urine analysis sooner or later will catch them out."(97)

c. Dispensing Frequency

The general consensus from people interviewed during this study was that heroin addicts needed to service their addiction four times a day. One of the benefits of the 'take away' prescription was that there was no cost involved in supervising the administration of the drug. It appears to be common knowledge that patients will vary their doses and share with other diamorphine patients in contravention of the prescription directions. Although these activities may be strictly illegal, no adverse effects have been documented, and it is probable that similar practices occur with many other prescribed drugs.

The issue for a proposed trial in Australia is that it is only planned to dispense diacetylmorphine three times a day during the pilot programs. This decision has been based on the experience from the Swiss trials. For those patients who suffer withdrawal symptoms overnight it is proposed that "... they win be offered a low dose of methadone to alleviate these symptoms."(98) Considering that the English experience is for a dosage of diamorphine four times a day, the Australian decision to only prescribe for three times a day should be carefully monitored.

d. Conclusions

Much can be learnt from the experiences of methadone prescribing, both in England and Australia. Security for diamorphine has been recognised as a responsibility that must accompany any method of dispensing. The larger the stockpile the greater the risk, and so the greater the need for comprehensive security. This is the situation that already exists for all other forms of controlled licit drugs and so this proposal is only a matter of subscribing to the tried and proven philosophy and practice.

The more diverse the forms of prescribing, the more likelihood there is for abuse, either through improper administering of the drug or leakage. For example, it is much easier and safer to share some reefers than it is to share a needle.

It is clear that professional assessment and monitoring is critical to providing informed treatment. The more comprehensive these processes are, the less is the likelihood of leakage. The greatest threat is seen as the move to 'take away' prescribing of diamorphine. If the pilot programs in Australia were successful then an inevitable result would be the expansion of the service. Such an expansion would be the move towards 'take away' prescribing, but, regulated controls could keep leakage from this process to a minimum.

Social Implications

a. Attraction for Out of Town Addicts
b. Anti-Social Behaviour
c. Participants and Driving
d. Prostitution
e. Conclusions

a. Attraction for Out of Town Addicts

Concerns have been expressed that the establishment of a heroin maintenance clinic may also act as a magnet and draw other unwanted addicts to the location where the clinic is operating. The fear is that there would be an influx of addicts who, because they would not qualify to participate in the program, may choose to stay in the general location and thus cause an increase in associated problems in the area. Similar concerns were expressed in Cheltenham by some people during the course of this study:

We do seem to get a lot of people move to Cheltenham, specifically for the diamorphine scripts. But they don't necessarily stay on our case load. There is concern expressed that if they don't get a script there will be an increase in criminal activity.(99)

There has been a suggestion of more people moving into Cheltenham because of diamorphine and the needle exchange.(100)

When reporting on the early experiences of the Widnes and Warrington Clinics, Mike Lofts indicated that these were genuine concerns because there were previous incidents of crimes and anti-social behaviour:

The publicity attracted addicts from many surrounding areas who came to the clinics because they were unable to receive maintenance in their own area. Intimidation and occasional robberies became the order of the day outside or near to the chemist shops where the addicts picked up their drugs; the addicts were often reluctant to report such offences.(101)

He also reported that out of town addicts did try using false or temporary local addresses with a view to being admitted to one of the maintenance schemes.(102) So from the English experience it appears that some of these fears did eventuate during the early days when the concept was new and the clinics were feeling their way. It should be stressed, however, that the present indications are that these sorts of incidents do not now occur in any measurable quantities. But it is clearly a possible outcome that should not be ignored.

In her Stage 2 Report, Feasibility Research into the Controlled Availability of Opioids, Bammer responded to these concerns by nominating controls, which included residency criteria, that would prevent 'out of town' addicts from gaining a place on the program.(103) It cannot be guaranteed that these controls would prevent all heroin addicts from making a pilgrimage to the ACT with a view to getting on the program.

Bammer suggests that appropriate pre-trial publicity about the residency requirement would be a suitable strategy to avoid this perceived problem of attracting 'out of town' addicts.(104) Publicity alone may not be sufficient to achieve this objective. The publicity might not reach or influence the intended audience; and it is possible that other publicity, such as the grapevine and rumor mill, may work contrary to the official line. The other avenues of defence to deter uninvited addicts are the proposed controls on security and dispensing which should go a long way towards preventing the early English experiences from occurring in Australia. It is an issue that should be prepared for and monitored. The indications are, however, that if the proposed controls and strategies are implemented, then any impact will be minimal.

b. Anti-Social Behaviour

It could be fair to say that heroin addicts are not the most popular members of any community. The general perception is that they are dirty, untidy and unhealthy. Invariably they are unemployed and they have a propensity for criminality. They will cheat and steal to obtain the funds to service their habit. In almost every case they have no honour when the craving starts.

The people we see are not representative of people taking drugs in the community — we have got the most severe end of it, they are really quite disturbed people with major personality problems and emotional problems. They are quite deviate characters.(105)

Society does not want drug problems — it wants to cure people of their drug afflictions, and preferably from a distance. Who would want to live next door to a drug addict, or worse still a drug clinic?

Some of the disadvantages are people injecting in public areas ... Some people just don't give a shit about the public ... I smoke it. I have the pure powder mixed with water and what I do is I put it back onto a plate and dry it out and I scrape it off when it dries and I've got the powder back. I evaporate the water off the powder basically to smoke it ... I do this every two to four hours ... On occasions I have nowhere to go and I have to do it in the car on side streets. (Addict 1)

Heroin addicts are anti-social people in that their behaviour and practices are not approved of by the mainstream of society. They are intimidating to many people simply because of their appearance and demeanour.

Bank holidays are a bit of a problem because they are all climbing the walls outside ... Also they do tend to come together first thing in the morning, and this can be intimidating to other customers.(106)

We do encourage the addicts to come in at times when it isn't a peak time for other patients. We have two windows for them, 9am to 10.30am and 2pm to 3pm. — Monday, 9am to 10.30am is very popular.(107)

It can be understood, therefore, why any program that would bring together heroin addicts in a particular neighbourhood may not be considered the most attractive option to the residents of the area.

Mike Lofts says that, to the best of his knowledge, there have never been any public order incidents as a result of this program in Cheshire. In his opinion, most addicts on a script guard it religiously and use it as prescribed. He believes that they impose on themselves conditions and a code of conduct. He says that diamorphine prescribing is no more of a problem than is methadone "Because the logistics are just the same. "(108) Palombella said it was his experience that, "Sometimes they would turn up to the clinic stoned and there was some graffiti — but never any violence."(109)

In his report, Criminal Liability Issues Associated with a "Heroin Trial," Simon Bronitt echoed concerns expressed by others that "Supplying heroin up to three times daily may encourage loitering outside the treatment centre."(110) The concerns expressed here are that the dispensing process might act as a catalyst for forging links with others involved in the illicit drug scene, as well as creating the possibility for violence and public intoxication.

Chief Inspector David Reid, the Community Involvement Officer for Gloucestershire County, also says that there have been no public order problems at Cheltenham Hospital in relation to the prescribing of diamorphine. However, that is not to say that there are not other issues that have to be addressed and David Samways, the Director of Pharmacy for the Cheltenham Hospital, said that they had experienced some problems. These included the addicts using toilets to inject, even when a room was provided, and people not on the scheme hanging around the hospital. For these reasons they prefer to move patients away from the hospital environment fairly quickly in order to avoid these problems, and what he described as "group mentality."(111)

The community pharmacies in Cheltenham also described some similar experiences, although in both cases they took fairly swift action which resolved the problem.

We had one problem with a fellow going out of here and injecting in the street, so we just said good-bye to him.(112)

We got rid of two that used to pick up the stuff and then go around the back and start injecting, so we told them to stop immediately — they didn't — so we refused to serve them anymore.(113)

Some of the concerns expressed by Bronitt and experienced at different pharmacies were identified by Dr John Marks in his early days of prescribing diamorphine. There the prescriptions were originally dispensed from the District General Hospital pharmacy, but, it was found that:

• The addicts and other hangers-on congregated together, which it was felt, promoted trafficking;
  
• The hospital was difficult to police and objects such as syringes, needles, hospital equipment and staff's personal valuables were stolen; and
  
• The addicts disrupted the smooth running of many departments.(114)

From the information provided it can be seen that heroin addicts, whether undergoing treatment or not, can bring with them a range of anti-social activities. However, these behaviours in those attending treatment can be monitored and controlled, if standards and procedures are put in place and enforced.

c. Participants and Driving

Driving under the influence of a drug is an offence in England, just as it is in Australia. Detecting the offence is somewhat difficult because there is not the same degree of sophisticated equipment to measure the amount, type and effects of drugs in the body as there is for alcohol. There are many licit drugs that people take which could impair their driving. It is also known that a number of people take a whole range of illicit drugs and that many would drive whilst under the effect of these drugs to some degree.

The issue of patients who are undertaking a diamorphine program driving motor vehicles whilst adversely affected by that prescribed drug has not been specifically addressed in England. It could be argued that there are just as many drivers using controlled drugs that can impair driving to a similar degree, and therefore heroin should not be singled out for special consideration in this regard. In an article by Russell Newcombe, he refers to a German government report which estimates that, excluding alcohol, there are 100,000 drugged drivers on the road every day in that country, which causes 4,000 injuries and 150 deaths each year. Newcombe goes on to say that in England over the last three years, several hundred people reported as drug users to the Driver and Vehicle Licensing Centre (DVLC) have been refused driving licences unless they submit to a blood test. Drivers that test positive can lose their licence for six to twelve months. Under guidelines laid down by the General Medical Council there is a mechanism for doctors, in the public interest, to notify drug using patients to the DVLC.(115) These guidelines release the doctor from the duty of confidentiality when "... failure to disclose appropriate information would expose the patient or someone else to a risk of death or serious harm."(116)

I think some are better drivers with the drug than without it ... Many people drive around on benzodiazepines and sleeping tablets which are probably more dangerous and nobody ever checks that.(117)

There was this couple in a car stoned with children. The male was going to drive but he wasn't capable. I persuaded the woman to drive because she was not as stoned as the male. (Addict 1)

Bammer does not support cancellation of drivers' licences for participants in the ACT trial because of the poor public transport system in that city. She acknowledges that participants in the Swiss trials are required to voluntarily surrender their driver's licence. However, her proposal for Australia would be for the individual to take responsibility for their own actions, supported by the provision of facilities at the trial clinic where they could test their human performance skills prior to leaving.(118) She has also adopted the advice provided by Bronnit that,

To be confident that there is no accessory liability, the clinical staff should advise participants that driving while impaired is not only dangerous but is also an offence, and that if they intend to do so, the staff are obliged by law to contact the relevant authorities and can provide no further assistance to the participant.(119)

Dr John Marks makes the observation that the stricter the clinic becomes, the more likely it is to lose people who would patronise it under different circumstances. People driving under the influence of drugs have very real potential to cause accidents and, therefore, place the lives of other innocent people at risk. The issue of people driving after taking prescribed heroin is of concern to police departments in Australia who would want some controls over people registered on the program. There would be a very strong argument for those people selected on such a program to have their licences cancelled. It is strongly recommended that entitlement to a driver's licence should be viewed as a privilege and not a right. It is also recommended that the same philosophy should apply to participants on a diamorphine program.

d. Prostitution

The amount of prostitution in Cheshire was limited and there wasn't very much evidence of it in Gloucestershire either. It is possible that these locations did not fit the socioeconomic environment where prostitution can flourish. However, there are links between heroin addiction and prostitution and a report prepared by Dr Ann Rainford in 1991 addresses some of these issues using 'working girls' from Manchester and Liverpool, both counties which border Cheshire. At the time of this research Dr Rainford was the Senior Lecturer of Applied Psychology at Liverpool Polytechnic. She conducted interviews with 62 prostitutes on a range of issues which included drug use and treatment methods. Only 12 of the research sample were not heroin users, but these women were heavy users of alcohol. Virtually all of the remaining 50 women reported that they were drug users before they became prostitutes, and that they only turned to prostitution after incurring several convictions mainly for dishonesty offences.(120)

In her research Rainford found that 10 of these women were attending the Warrington Clinic which was run by Dr John Marks. At that time the Warrington Clinic had a flexible policy which included the prescribing of diamorphine. The remaining women in the sample were attending different clinics in Manchester and Liverpool, none of which offered diamorphine or the same degree of flexible prescribing as did the Warrington Clinic. Rainford admits that the sample studied was too small to draw any conclusions. However, the evidence she did uncover was very favourable to the clinic which included diamorphine prescribing. She reported that:

Evidence from this research suggests that the prescribing policy adapted by Warrington Clinic was more successful than those adopted by either Manchester or Liverpool. No working girl used the black market in Warrington, and six out of the ten women stopped working.(121)

Rainford suggests that the indications from this limited research is that a more flexible prescribing policy may prevent heroin addicts from becoming prostitutes and trading on the black market.(122) In the absence of further evidence to the contrary it appears that a trial program would not have an adverse affect on addicts turning to prostitution or prostitution increasing in general.

e. Conclusions

It is not easy for a heroin addict to be prescribed diamorphine in England. This is largely because of the controls placed on the practice by the relevant Health Authorities. There have been concerns expressed about 'out of town' addicts being attracted to locations where diamorphine is prescribed. There were problems identified in the early days of diamorphine prescribing, but these are not reported as occurring now to any degree. If this immigration does still occur, it is either minimal or it has not attracted attention as a result of any major problems it is causing.

There are examples of anti-social behaviour in the vicinity of clinics and dispensing chemists. However, these are sufficiently few and far between to not be a major cause for concern. Where they have occurred, a swift and firm response has tended to deal satisfactorily with the problem.

The issue of participants driving has not been adequately addressed. It has, in fact, been ignored. However, the fact that there is no evidence of major accidents involving diamorphine patients means that this issue continues to avoid greater attention. The issue will need to be more adequately addressed before any trial program commences in Australia.

As for prostitution, the limited information available suggests that the clinics are more likely to have a positive influence and outcome from both the individual's and the community's perspective. There appears to be potential for more research to be conducted on this issue.

Conclusion

a. Evaluation and Advice
b. Answers to Questions

a. Evaluation and Advice

The concept of prescribing diamorphine to heroin addicts continues to attract considerable opposition from many sectors of the community, both in England and Australia. Comprehensive evaluation is critical to determining the success of any program or strategy. The practice of prescribing diamorphine to heroin addicts in England has not been the subject of any single, comprehensive evaluation, from either a social or law enforcement perspective. One of the problems for those who advocate diamorphine prescribing in England is that much of the outcome information they can provide is based on limited internal evaluations. Results from internal evaluations may be seen to be lacking in rigour and objectivity, and thus their credibility is more open to challenge. The truth is that very little evaluation has been conducted in England and therefore there is difficulty in marketing the strategy, because what evidence there is, is presented by those who are seen to have a vested interest in the concept.

The fact that there are only approximately 336 addicts throughout England who are prescribed diamorphine makes it very difficult to conduct an evaluation which is both cost effective and efficient. The research conducted for this study was constrained by the size of the sample and the geographical spread of the addicts. At the end of the day, this study provides a 'snap-shot' of the diamorphine prescribing process from the perspective of law enforcement.

Some of the evaluation mechanisms used at different drug clinics, along with some words of advice from professional individuals, are reported here for the information of those who may be involved in setting up a heroin maintenance program.

Dr Sue Ruben has an ongoing audit process every six months, which includes a self reporting tool. She also uses access to police reports and discharging information. Her clients come to the clinic somewhere between every week and every month and some will be seen at their home which provides a secondary reporting process. She points out that urine tests are not used as a punishment.

Psychiatric Nurse, Andy Palombella, says that the initial assessment stage is critical to ensure that diamorphine is being prescribed to people who are psychologically and physically addicted. It is important to establish the level of addiction and tolerance of each patient so that both under- prescribing and over-prescribing are avoided. Because it is not uncommon for addicts on diamorphine to want to kick the habit, they should be guaranteed the return of their prescription if they try detoxification and fail. That is to say, they must not be punished for trying to stop the habit.

Dr John Marks says that everyone he treats is put through an assessment which includes an 87- item questionnaire on their life history and criminal history.

Social Worker, Sue Edwards, from the Clwyd Drug Service says that the grapevine is one of the best mechanisms for information as well as control. The grapevine gave her the opportunity to be pro-active and target dealers which she feels had the effect of reducing dealing and consequently other acquisitive crime associated with heroin addiction.

Most of these suggestions may be of value to the medical staff, but the police also have a very strong interest in many of the facets of drug clinics. It is recognised that there are issues of confidentiality which will prevent the police from having access to certain information. However, they should not be disadvantaged by the establishment of these types of programs. It is clear that there is a strong argument for developing and maintaining close liaison between the police and clinic professionals. Lofts lists the following principles to enhance and protect the interests of both parties, health and police, should a heroin maintenance scheme be undertaken:

• It is essential for mutual aid between both organisations;
• There should be a written set of rules that both organisations agree to;
• It must be agreed that discretion can be exercised, but this does not extend to condoning or ignoring drug dealing;
• Patients on the program should sign a contract accepting the rules and standards laid down by the clinic; and
• There should be regular meetings between clinical staff and police, and there should be some consistency in police representation.

b. Answers to Questions

The English system developed on an ad hoc basis and continues to be poorly received by policy makers. In Australia the proposed trial has been comprehensively planned and there has been a far more structured approach with the establishment of controls and procedures to be implemented from the outset. The main areas of concern to law enforcement have been canvassed by Bammer(l23) and it is predominately those concerns which are the subject of this report. The following summarises the key questions and findings of this study.

Will the program have an effect on the criminality of participants?

The indications are that this is more than likely to be the result for the majority of participants. It does not mean that all participants will cease criminal activities, and for some their criminality might increase, but across the board a decrease in criminal activity is a realistic outcome to expect.

Will the program affect crime rates?

Considering the documented success of methadone programs in Merseyside in reducing acquisitive crime rates, and the indicators from smaller studies of diamorphine prescribing on individual criminality, there is every reason to expect that this will be a resultant outcome. The problem, however, is that it is difficult to measure this outcome when only a small sample is involved.

Is there likely to be leakage, and if so, how will it occur?

It is almost inevitable that there will be some leakage, especially when the programs expand and it becomes necessary to move away from stringently controlled dispensing to 'take away' prescriptions. However, whilst diamorphine remains a privilege to be prescribed and there are controls on dispensing, the amount of leakage will be minimal. It will more than likely occur within a patient's social setting rather than developing into a regularly accessible black market product, The evidence suggests that diamorphine leakage would not be to the same degree as methadone leakage.

Will participants in the program engage in anti-social behaviour?

This may occur, but perhaps no more so, and probably less, than if they were not on the program. The stereo-typed heroin addict can tend to be an intimidating person, especially when that person is not servicing his or her habit. Those addicts prescribed diamorphine have not created any public order incidents and when anti-social behaviour has occurred it has generally been at the lower end of the scale. In most cases a firm response which reinforces the established standards has been all that was needed to deal with these problems.

Will the program attract other unwanted addicts to the area?

This has happened in the past with some adverse results. It does not seem to be occurring in England now to the same degree as was reported to be the case in the early days of diamorphine prescribing. This may be because most of the addicts who want help now know the requirements and restrictions on this form of treatment. In Australia, the planned publicity, coupled with other controls, will have a greater chance of preventing unwanted addicts moving to the ACT if a pilot program commences.

Is dispensing from one location the best option?

Yes, because it helps to prevent the type of problems which will develop with 'take away' prescriptions. However, if the pilot program in Australia is successful and the scheme expands, dispensing from only one location will become financially and logistically difficult to maintain. Strategies need to be considered to control 'take away' prescriptions in the long term.

What policy should be adopted with participants who drive?

This paper recommends that their driver's licence be cancelled. Motor vehicle accidents kill and maim innocent people. Unless the participants can show that they are not adversely affected by the drug, then they should not drive. Consideration of a reverse onus of proof may satisfy the opposing views on this issue.

Diamorphine prescribing should not be seen as a panacea. It is another treatment option for dealing with heroin addicts. From a social and health perspective the arguments in support of diamorphine prescribing remain persuasive. From the law enforcement perspective the concept is worthy of support, so long as control mechanisms remain in place. The process has the potential to save and improve the lives of certain heroin addicts. The evidence is that heroin addiction is a catalyst for increased criminal activity. The evidence is also that treatment for heroin addicts can be the catalyst for decreased criminality. However, we should always guard against unrealistic expectations, because as so many people were at pains to point out during the course of this research, "They don't become angels."