Is it Time for a Heroin Maintenance Program? Views of Users and Ex-Users

Abstract

We investigated the feasibility of a trial to provide heroin to dependent users and as part of this sought the views of three groups of users and ex-users. While a majority of each group supported a trial, a greater proportion of people who were currently users of heroin or other illicit opioids were in favour than was the case either for people who had been dependent on heroin in the past or for people who currently used or had used illicit drugs, but who had never used heroin or other opioids. Where possible, we related views about trial outcomes to additional information provided by respondents. This information supported views that a trial might a) increase the number of dependent heroin users and, for trial participants', b) improve health, c) reduce criminal behaviour, especially drug dealing and d) increase the prevalence of driving under the influence of heroin, although this would not necessarily reduce road safety. Difficulties in measuring trial effects on some of these outcome measures are discussed.

Introduction

When drug policy reform is being debated, the views of illicit drug users and ex-users are seldom taken into consideration. Despite the impossibility of drawing representative samples from either population, we believe that users and ex-users of illicit drugs can offer valuable information for drug policy debates and for the evaluation of drug treatment options. Accordingly, in our examination of the feasibility of a trial to provide heroin in a controlled manner to users, we sought input from people who have had experience with illicit drug use. We surveyed three groups: people who were currently users of heroin or other illicit opioids, people who had been dependent on heroin in the past, and people who currently used or had used illicit drugs but who had never used heroin or other opioids. We were interested in their views about a trial of controlled heroin availability as well as in their assessment of likely trial outcomes. We also related their views to their reported behaviours and experiences.

The proposal for an Australian trial of controlled heroin provision was the subject of a four-year feasibility study conducted by the National Centre for Epidemiology and Population Health at the Australian National University and the Australian Institute of Criminology. The study found that the benefits of conducting a trial outweighed the risks and proposed that pilot studies be undertaken (Bammer, 1995). The future of the proposal now awaits political decisions.

The feasibility research covered all relevant facets of a trial-legal and ethical issues, evaluation strategies, community and stakeholder attitudes, risks, lessons from history, clinical protocols, cost, political considerations-and involved all relevant disciplines and interest groups (Bammer, 1993, 1995; National Centre for Epidemiology and Population Health, 1991). Among the latter were the general community, police, service providers and users/ ex-users. A composite picture of the views of the three groups of users and exusers is presented elsewhere, as are the views of the community, police and service providers (Bammer et al., 1995, 1996; Stevens et al., 1995). The aim of this paper is not only to examine differences between the subgroups of users and ex-users, but also to report in more detail on their views.

Methods

In June 1991 illicit drug users and ex-users in the Australian Capital Territory (ACT) were surveyed using self-completion questionnaires. Questionnaires with reply-paid envelopes were left with groups and organisations which provide treatment and support services to illegal drug users and ex-users. Twenty-five such agencies were identified and over 90% agreed to provide assistance. Between one and two weeks after questionnaires were left with agencies, they were contacted again to encourage distribution of both the questionnaires and of flyers requesting return of questionnaires. Questionnaires were also distributed through four friendship networks of people not connected with treatment agencies.

For the analysis, respondents were divided into three groups: those currently using heroin or illegally using other opioids ('opioid users'), those who had used heroin or other illegal opioids but were no longer doing so ('ex-opioid users') and those who currently used or had used illegal drugs, but had never used heroin or other illegal opioids ('never used opioids').

Respondents were allocated to one of our three categories by assessing their answers to 18 fixed choice questions, supplemented in some cases by answers to open-ended questions. Twenty-one respondents filled in the questions related to current or ex-drug use in contradictory ways. Thus the 18 relevant questions were weighted and assessed by three members of the research team. We were able to reach consensus on the assignment to be given to 20 respondents and this consensus was maintained when the allocations were rechecked by two members of the team some months later. The results for the remaining respondent were discarded.

A subset of the questions was put to a random sample of the Canberra general community in a telephone survey, which took about 15 minutes per respondent. The response rate was 77% (successful interviews as a percentage of contacts with eligible people; see Bammer et al., 1996 for more details).

Results and Discussion

Demographic and Other Characteristics of the Samples

The socio-demographic profile of the people in the three groups is shown in Table 1, along with a comparison with the random sample from the Canberra general community. Illicit drug users who had never used heroin or other opioids were slightly younger and better educated than people who were current or former illegal opioids users. In addition, 43 percent of opioid users, 41 percent of ex-opioid users and 61 percent of the never used opioids group were in full- or part-time employment. Most of the remainder were unemployed (36 percent, 43 percent and 30 percent, respectively) with only small percentages reporting that they were students or undertaking 'home duties. The most common living situations were 'with partner and/or children' (42 percent, 25 percent and 26 percent, respectively) or 'in a group house' (24 percent, 27 percent and 65 percent, respectively). Twenty-one percent of ex-opioid users were living in a therapeutic community at the time of the survey. Five percent of both current and ex-users of opioids were living in refuges and 2 percent of current users had no fixed abode.

Of the current users of heroin or other illegal opioids, during the last month, 5 percent used heroin only, 76 percent used heroin and other illegal drugs and 19 percent did not use heroin but did use other illegal opioids (these people also used other illegal drugs). The other opioids used (calculated as a percentage of the whole subgroup, n = 62) were injectable 'homebake' made from codeine (44 percent), morphine (18 percent), opium (I I percent), pethidine (6 percent), illicitly obtained methadone (8 percent) and palfium (3 percent). Forty-seven percent could be classified as dependent opioid users, 50 percent as non-dependent and 3 percent could not be classified unambiguously. Among the other illicit drugs used in the last month, 82 percent used cannabis, 58 percent amphetamines, and 15 percent cocaine. Fifty percent had also used 'other' drugs in the last month (amyl nitrite, barbiturates, crack, crank, ecstasy, "LSD"/ trips, mushrooms); no single drug in this group was used by more than 15 percent of the sample. Ninety-four percent smoked tobacco in the last month, 73 percent drank alcohol and 44 percent used benzodiazepines.

Among the people who were former users of heroin or other illegal opioids, 47 percent were not using any illegal drugs. Of the illegal drugs used by the remainder, only cannabis use was relatively common (44 percent of the whole subgroup). Eighty-four percent smoked tobacco in the last month and 51 percent drank alcohol.

Most of the illicit drug users rho had never used heroin or other opioids used cannabis only. One third of those who used cannabis in the last month also used other illicit drugs. One person in this group did not use cannabis, but used a range of other drugs (amphetamines, "LSD"/ trips, ecstasy, cocaine and benzodiazepines). One third of this subgroup classified themselves as not currently using any illegal drugs. In the last month, 58 percent smoked tobacco and 71 percent drank alcohol.

Forty percent of current users of heroin or other illegal opioids were currently receiving treatment and more than half were undertaking two or more regimens, for example methadone maintenance and counselling. Twenty-six percent were on a methadone program. Of the people who were former users of heroin or other illegal opioids, 73 percent were currently undertaking treatment, with 39 percent of those in treatment trying more than one form of treatment. Thirty-five percent were in methadone treatment programs. Twenty percent had never undertaken treatment. Of the 24 people who had never used heroin or other opioids, two were currently receiving treatment.

Support for a Trial of Controlled Availability of Heroin

While the majority of respondents in each of the groups favoured a trial (Table 2), a greater proportion of those currently using heroin or other opioids were in favour than is the case for the other two groups. Indeed the support from ex-users and those who had never used opioids was similar to that of the general community in the Australian Capital Territory.

The high degree of support among ex-users was surprising as we had expected them to be predominantly opposed to a trial. A further study using in-depth interviews with a diverse group of 17 ex-users found that they were about equally divided between those who favoured and those who opposed a trial (Bammer and Weekes, 1994).

Assessment of Potential Advantages and Disadvantages of a Trial

The responses of these groups to fixed choice questions about possible outcomes are presented in Table 3. For most questions reflecting potential negative effects of a trial, the views of ex-opioid users and those who had never used opioids were more like the views of the general community than the views of current opioid users. For the questions about potential positive effects of a trial their views were in between the views of current users and those of the general community. Overall there was majority agreement with statements reflecting potential positive trial outcomes and majority disagreement with statements reflecting negative trial outcomes.

Some of these views can be examined in light of responses to other questions and this allows greater insight into likely outcomes from a trial of controlled heroin availability. Such analysis is possible for potential effects on the numbers of heroin users, health, criminal activity and road safety.

Numbers of Dependent Heroin Users

One concern about possible trial effects is that the number of dependent heroin users would increase. Two possible sources of increased dependent users are that non-dependent users would become dependent and that ex-users would start using again. In this survey, around one in six non-dependent current heroin users said they would increase their use if it was necessary to get on the trial. Only one ex-user said they would begin using again to get on the trial, with 8 (19%) being unsure. This suggests that a small increase in the numbers o dependent heroin users might be a consequence of a trial and that ways to minimise this must be examined if a trial goes ahead.

Health

Seventy-seven percent of those currently using heroin or other illegal opioids, 80 percent of ex-users and 50 percent of those who had never used heroin or other illegal opioids had experienced health or other problems which they attributed to their use of illegal drugs.

Five current users of heroin or other illegal opioids and one ex-user reported that they were HIV-positive, but only one attributed this to their illegal drug use. Hepatitis was commonly reported by both current and ex-users; hepatitis B (6 current users, 4 ex-users), hepatitis C (6 current users, 4 ex-users) and unspecified hepatitis (4 current users, 2 exusers). Two current users and four ex-users also reported having overdosed (presumably on heroin).

Current users of heroin or other illegal opioids also mentioned 26 other health problems, which ranged from lethargy (n = 1), constipation (n = 2) and skin sores (n = 1) to malnutrition (n = 6), respiratory problems (n = 7, including pleurisy and collapsed lungs), fractures, cuts and grazes (n = 2) and "stress and depression" (n = 8). The picture for exusers was very similar. On the other hand, people who had never used heroin or other illegal opioids reported fewer and less serious health problems. They mentioned 10 health problems and three of these were specifically associated with 'speed' use.

While these results are limited, they support suggestions that use of illegal heroin and other opioids is associated with significant health problems and that, in the long term, a trial might reduce such problems, especially problems related to illegality rather than heroin per se. Apart from HIV/AIDS, the health problems described above were reported in response to open-ended questions. More problems might be reported in response to fixed choice questions and if symptoms rather than conditions were elicited. However, because of the types of problems reported, it is possible that in the short term a trial would not have easily measurable effects on symptoms of ill-health.

Financing Drug Use, Particularly Through Criminal Activity

Respondents were asked how they financed their illegal drug use and specifically about income generated from supplying illicit drugs.

Legitimate sources of income, that is full- or part-time employment or government benefits (usually unemployment benefits or disability pensions), were reported to play an important role as 'usual' sources of funding for illegal drug use. For current opioid users 38 percent reported that money from employment and 44 percent that money from benefits were usual sources. The corresponding figures for ex-opioid users (when they had been using) were 64 percent and 62 percent, respectively, and for the group who had never used opioids were 66 percent and 33 percent, respectively. Sex work, shop-lifting, other stealing (including break and enter), robbery and fraud were each reported as 'usual' sources by less than 15 percent of current opioid users and the group who had never used opioids. These activities were reported as having been usual sources by between 15 and 41 percent of ex-opioid users. Supplying illegal drugs was reported as a usual source of funding for illegal drug use by 33 percent of current opioid users, 54 percent of ex-users and 24 percent of the group who had never used opioids. Small numbers financed their drug use by selling possessions, using savings, gambling, 'ripping people off', or being given or lent money by friends or family. Illegal activities conducted for other reasons, such as shop-lifting for food, are not included here.

Leaving aside the ex-opioid user group, it can be seen that in this population of current users, criminal activity, apart from drug dealing, was not a major usual source of funding for illicit drug use. This is supported by examination of the frequency in the last 12 months of these supplementary income generating activities for current opioid users (Table 4).

More detailed questions were asked about supplying illegal drugs. Over eighty percent of ex-opioid users and the subgroup who had never used opioids did not currently supply illegal drugs and almost all of those who did supplied marijuana only. In contrast, it was common for current opioid users to supply others with illegal drugs. Mostly this was done to cover the cost of their own illegal drug use (65 percent of the 40 people who reported that they supplied in this question; the responses between different questions were not always consistent), but a few also made a profit from this activity (10 percent of those who supplied). The remaining 25 percent of those who supplied drugs provided them to friends at cost price. Fifty-six percent supplied a range of drugs, 22 percent supplied heroin or other opioids only and 22 percent supplied marijuana only. This suggests that current users of opioids, rather than of other illicit drugs, are the largest suppliers of illicit drugs at the street level and that they generally do this to support their own use.

While there is a widespread view that a trial of controlled availability of opioids might reduce criminal behaviour, the low levels of such behaviour, apart from drug dealing, reported by current opioid users suggest that changes in these behaviours, may be difficult to measure. While the low levels of crime reported here could be a product of sample bias, the potential problem for trial evaluation requires further consideration.

Road Safety

Respondents were also asked about driving under the influence of alcohol or other drugs in the last 12 months. Both were common (Table 5). Many current opioid users report driving under the influence of heroin or other opioids and some do this frequently. However the majority do it less than twice a week. Thus a trial could potentially increase the prevalence of this behaviour.

Additional Comments

At the end of the survey form, respondents were invited to make additional comments.

There were eleven responses relating to the perceived positive effects that a trial would have on the lifestyles of users. Eight of these came from current users who made comments that a trial would, for example, lead to users being:

..... detached from the lifestyle of illegal drug use and naturally more relaxed etc."

"[able] to pursue a productive lifestyle with least disturbance to career and life decisions."

"[able to enjoy] the place without the ever darkening black cloud that society places on its."

One current user personalised his comment by saying

"Haven't worked for a long time 'cos I'm not dependable. This trial will help me do it all right."

Two current users commented on the benefits of a trial to the families of users; it would

"....put a halt to the misery of users' families."

".....improve the lifestyles of addicts' families."

Three current users thought that a trial would make the community safer giving such examples as (a trial would):

"....get all the shit drugs off the streets."

"decrease exposure of heroin and other drugs by addicts to the non-user kids and general population."

A comment of a somewhat different nature came from a current user who believed that the trial

". . . could be a start a process of making heroin a more acceptable social drug and remove the myth that creates a panic in society."

Overall, there were 23 other positive comments from current users, 8 from ex-users and 5 from people who had never used opioids. Most of these were simply of the nature that the trial was a good idea and should go ahead. Three current users alluded to the success of overseas programs. In addition two current users said

"A comprehensive heroin trial, particularly one which is accessible to the majority of IDUs who can't get Methadone, would put the ACT in the commendable position of leading the notion away from the Draconian past."

" Why has this taken so long? Why bury so many friends with overdoses, or shit in dope or AIDS' I hope to see something done in my lifetime."

Some respondents, particularly ex-users, qualified their positive statements.

"[A trial was] not a cure all but [it would have] to make it safer"

"If not abased, [a] trial could have an overall good effect."

"Trial is a reasonably good idea but with no long term solutions."

One respondent who had never used opioids thought that

"[a] trial will help, but never cure."

There were no general negative comments regarding a trial from current users. There were eight from ex-users and one from someone who had never used opioids and who simply pleaded

"Please don't go ahead with the trial."

The comments from ex-users revolved around general fears that a program would be detrimental.

"Have other alternatives been looked at? How many people have to die, if [the trial] does go ahead, before it stops."

"This trial is a negative step and will not help our community " or the using addict. When you're using, or on Methadone, You're insane and don't think straight. Once in recovery the fog lifts and you can see the insanity of your using life"

One respondent worried that drug users would be tied to a medical system

"...which treats addicts with disrespect and even contempt.... If I had an unadulterated guaranteed supply I would be happy in the short term but my soul would be dead and I think that's what we seem to want, to keep addicts quiet by co-opting them.''

Conclusions

The majority of each group-people who were currently users of heroin or other illicit opioids, people who had been dependent on heroin in the past and people who used or had used illicit drugs, but who had never used heroin or other opioids-supported the concept of a trial and thought that the positive effects would outweigh the negative. An investigation of out comes would be a critical component of any 'heroin trial' (Bammer, 1993, 1995), hence we explored some aspects of this issue in detail. A fuller discussion of the range of outcome measures which would be integral to a trial can be found in Bammer (1995).

We examined possible trial effects on numbers of users, health, criminal behaviour and driving under the influence of drugs. This information supported the views that a trial might improve health and reduce criminal behaviour and that it might increase the number of dependent heroin users and the prevalence of driving under the influence of heroin. If a trial eventuates, there may be difficulties in evaluating some of the effects. For example, there are numerous problems in measuring numbers of heroin users (Larson & Banner, 1996), so that studies of changes in numbers will be difficult to conduct. Given that there is little generalisable information about rates of movement between dependent and non-dependent use, or rates of relapse for ex-users, there are also no reliable baseline measures against which to assess changes in these populations. Changes in health may be difficult to measure in the short-term if illnesses are used as the outcome, so other measures should be developed. This is the focus of current research. If overall levels of criminal behaviour and sex work are as low as this study suggests, these might also be problematic as outcome measures. Changes in drug dealing may, however, be useful measures. Changes in numbers and frequency of driving under the influence of heroin are also potential outcome measures. However, the role of heroin and other opioids in road crashes cannot presently be assessed and it may be minimal, especially when compared with alcohol (Chesher, 1989). Hence overall road safety may not be affected by a trial of heroin prescription. Certainly in terms of trial outcomes, both the prevalence of driving under the influence of heroin and the effects of this on road safety must be assessed.

Overall this research substantiates the notion that illicit drug users and ex-users can offer much valuable information for drug policy debates and for the evaluation of drug treatment options. It also illustrates that any trial of heroin prescription is likely to carry risks as well as benefits. For sound policy decisions to be made about the long-term integration of heroin prescription into treatment options for heroin dependence, both the risks and the benefits must be assessed as rigorously as current methodologies allow. The controversial nature of such a trial may also be a catalyst for the development of new measures and methodologies.

Acknowledgements

We are grateful to the study participants and to the individuals and groups who distributed the questionnaires. The paper arises from a large study to which many people contributed and they are acknowledged in National Centre for Epidemiology and Population Health (1991). Jodie Rickett and Deborah Tunnicliff provided valuable assistance in the production of this paper and useful comments on an earlier draft were received from Dorothy Broom, "Roger Mitchum" and Ros Woodward.

References

Bammer, G. (1993). Should the controlled provision of heroin be a treatment option? Australian feasibility considerations. Addiction, 88, 467-475.

Bammer, G. (1995). Report and Recommendations of Stage 2 Feasibility Research into the Controlled Availability of Opioids Canberra, ACT: National Centre for Epidemiology and Population Health, the Australian National University and the Australian Institute of Criminology.

Bammer, G. and Weekes, S. (1994). Becoming an ex-user: insights into the process and implications for treatment and policy Drug and Alcohol Review, 13, 285-292. Also Bammer, G. and Weekes, S. (1993) Becoming an exuser -would the controlled availability of heroin make a difference? Feasibility Research into the Controlled Availability of Opioids Stage 2 Working Paper Number 4. Canberra, ACT: National Centre for Epidemiology and Population Health, the Australian National University and the Australian Institute of Criminology.

Bammer, G., Stevens, A., Dance, P., Ostini, R, and Crawford, D. A. (1995). Controlled heroin availability in Australia'? How and to what end? International Journal of the Addictions, 30, 991-1007.

Bammer, G., Dance, P., Stevens, A., Mugford, S., Ostini, R. and Crawford, D. A. (1996). Attitudes to a proposal for controlled availability of heroin in Australia. Is it time for a trial? Addiction Research, 4, 45-55.

Chesher, G. B. (1989). Understanding the opioid analgesics and their effects on skills performance Alcohol, Drugs and Driving, 5,(2) 111-138.

Larson, A. and Bammer, G. (1996). Why? Who? How? Estimating numbers of illicit drug users. Lessons from an ACT case study Australian Journal of Public Health, 20, 493-499.

National Centre for Epidemiology and Population Health. (1991). Feasibility Research into the Controlled Availability of Opioids Volume 1. Report and Recommendations, Volume 2. Background Papers. Canberra, ACT:NCEPH.

Stevens, A., Ostini, R., Dance, P., Burns, M., Crawford, D. A. and Bammer, G. (1995). Police opinions of a proposal for controlled availability of heroin in Australia Policing and Society, 5, 303-312.

Notes

a. "National Centre for Epidemiology and Population Health, The Australian National University, Canberra ACT 0200

b. School of Human Movement Science, Faculty of Health and Behavioral Sciences, Deakin University, Burwood, Victoria 3125

c. Department of Psychology, University of Minnesota, Minneapolis MN 55455, USA

d. Women's Studies Program, The Australian National University, Canberra ACT 0200, Australia

Corresponding author. Dr Gabriele Bammer, National Centre for Epidemiology and Population Health, The Australian National University, Canberra ACT 0200, Australia.