Treatment with Heroin

Introduction

It probably does not eliminate the nuisance aspect. Nor is it cheap. But an experiment with 300 to 500 addicts at 3 to 5 sites is worth the trouble. At any rate if the treatment is part of a total range of care facilities. In principle, prescription heroin might very well be effective for about 8,000 addicts. This was what the Health Council told Health Minister Borst.

The Health Council's Committee on Medicinal Intervention in Drug Addiction has advised Ms Borst, the Dutch Minister of Health, on providing heroin by prescription. Prof. Wim van den Brink, the committee chairman, would like to clearly state that this does not entail large-scale distribution of heroin to addicts. For the sake of clarity the Health Council has called its recommendations: advice on prescription heroin for addicts. "We are talking about a solution to a health problem." This does not solve a social problem, even though the Committee does realize that the experiment might some day be a step in that directions."

"The nuisance aspect is a complex problem. The links between addiction, criminality and the nuisance factor are not as clear as they are assumed to be."

These recommendations are not about the "free" distribution or legalization of heroin. "That was not what we were asked. What is more, there is still too little to be said about the effects of legalization."

Isn't it odd to make recommendations about distributing heroin now that it is less popular and coke is the trend? "We don't know much about what the trends are. Heroin addicts are still coming to the addiction care facilities for help. These are not final recommendations. We will continue meeting with the request for advice that we received at the first stage, pertaining to the use of medication in the treatment of drug addiction in general. And the Committee feels the wording of the request for advice puts too much emphasis on prescribing heroin. At a later stage, we will say more about the distribution of palfium, for example, in a small, interesting test launched in Amsterdam."

Street Heroin

Based on the international literature and accounts of earlier experiments, the Health Council hopes to be able to stipulate the conditions under which the medical distribution of heroin could take place. "Of course another question would have to be answered first: should this kind of distribution take place at all?" In the report the Health Council submitted to the Minister last week. the experiences up to now were described.

In the Netherlands, experiments were conducted in the past with morphine distribution. Fifteen years ago, England experimented with heroin distribution. An experiment with heroin in Liverpool, which was not part of a wider help programme, was stopped last month because the distribution was not taking place in a systematic fashion. In Switzerland, a two-year experiment with heroin distribution has been in operation since last year. A first provisional evaluation is expected soon. Australia wants to start a similar expertment. "The aim there is to minimize the drug-related nuisance aspect."

The information the Health Council hoped to uncover is barely in existence, says Van den Brink. "All kinds of things have been done. But no reliable evaluations have been drawn up." From the experiences, it can be concluded that the medical distribution of heroin is not pariicularly harmful. "There have not been any fatalities." And heroin does appear to be what attracts addicts. In the Swiss experiment where use was made of heroin produced in France, there were addicts who said they still preferred the doctored street heroin because it gives the best flash, "But okay, they still keep coming.

Stabilization

All things considered, the Health Council concluded that a medical experiment would not be unwarranted but that very little is known about the negative and positive effects. As Van den Brink says, "With an experiment of its own, the Netherlands would be able to add something to what little knowledge there is."

It can be assumed that giving heroin to addicts will make for stabilization. That would have to be the primary aim of any system of medical distribution.

"They don't have to hustle anymore and if the distribution is part of a wider care programme, the addict comes into contact with facilities that can help him work to improve his social integration, housing situation and the way he spends his time. At any rate it can be concluded from the experiments conducted elsewhere that people do come to the care facilities for heroin. Heroin is what keeps them coming." Whether the assumed stabilization can actually be put into effect by distributing heroin still remains to be seen. That is why the Health Council proposes starting an experiment. Prescribing heroin with no strings attached does not solve anything or so the Health Council notes. "it is just as effective as methadon with no strings attached."

8,000 Addicts

0f the estimated 20,000 to 25,000 heroin addicts in the Netherlands, in principle a larger percentage is eligible for medical distribution than has been suggested in the past. The Health Council is focused on addicts who "have tumed to addiction care facilities a numher of times to no avail." This group includes the approximately 3,000 "extremely problematic drug users" and a maximum of 5,000 people who do not react well to methadon, the replacement substance the addiction care system has been providing for years. "For them," Van den Brink says, "in principle the medical distribution of heroin might prove to be effective." For the rest, the Health Council Committee has been wondering whether it would not be wise to even consider heroin distribution at a much earlier stage.

"Because why should people first have to hit rock bottom?" The Committee does not expect that in the long run, launching the experiment will lead to an enormous demand. "I don't expect all the addicts to come rushing to the heroin. And you do hear people say they are not so far gone they are willing to give up the idea of stopping with heroin altogether. What is more, the Swiss example showed that only a third of the addicts had the energy to get through the whole intake process that was needed before they were eligible for the medical distribution."

Cigarettes and Pills

The further elaboration of the experiment into a protocol has yet to come. The question there is which conditions should be set for the addicts who take part in it. "You might stipulate that they have to be people you already know from the addiction care system who have a fixed address. And in individual treatment contracts, it has to be clearly stated that they are getting the heroin for the duration of the experiment. As the morphine experiment demonstrated, one thing that definitely should be avoided is that when the experiment stops, care givers are threatened or coerced with talk of suicide. Of course it goes without saying that in the event of threats or aggression, the individual care contract is terminated. The supply of heroin is not the problem. "it can be made easily and cheaply by the pharmaceutical industry." It is not the substance itself but the ampules that make it expensive. And the organization of the experiment: the premises, the selection process, the personnel, the care facilities around the project, the registration and the evaluation study. "No one should think it is cheap." The way of administering the heroin is still a problem. "For addicts who shoot heroin, you can use injectable heroin. But of course you don't want to he the one to introduce the other users to the needle. In Switzerland they use cigarettes made of wild thyme, because tobacco would be against the law. There are ways to provide it in inhalators or heroin 'puffs.' Pills under the tongue are another possibility, or suppositories."

Large Cities

To keep the whole project manageable, the Health Council proposes starting at three to five sites, not only in the large cities, at existing facilities that supply methadone, Municipal Health Services (GGDS) and Alcohol and Drug Counselling Centres (CADs), with 300 to 500 addicts. The minimum duration of this experiment is one year. The various projects in the country should be coordinated and evaluated by a research committee. In the end, Minister Borst is the one to decide what she wants to do with what Van den Brink calls "general recommendations with a very cautious first step." Van den Brink does not know what the outcome will be. "There might be economic or political reasons not to take the advice. If for example it is considered wiser to spend money reducing the nuisance aspect." At any rate, all the Minister has to go on is the observation that there is a good chance that via an experiment like this, a number of people might function better despite and with heroin. "We can only do what is within our reach. But if we thought that treating heroin addicts with heroin was nonsensical and dangerous, we would not make these recommendations. From a purely scientific point of view, this is an interesting thing to do. Absolutely."