HEROIN-ASSISTED TREATMENT
TIME FOR A NEW
HAT
Heroin-assisted treatment’ s moment has come, says Mark R Gilman
One hundred years ago, the UK became the first country in the world to prescribe heroin( diamorphine) to heroin users as a treatment for opioid dependency. The‘ British system’ was formally established in 1926 and took a medical approach to opioid dependency – heroin users could be prescribed diamorphine as their drug of choice to stem illicit use and improve health. At that time, most of the users were middle or upper class, and the system was in operation until the 1960s.
The‘ British system’ came under international pressure from the United
Charles Romley Alder Wright, an English lecturer / researcher in chemistry and physics, focused on new opiate compounds. In 1874 he developed synthesised diamorphine. Photo: Wiki Commons
States which viewed heroin use as a moral – rather than medical – issue. There was also concern amongst the British establishment that we were seeing a shift from middle-class‘ iatrogenic’ use( ie the result of medical activity) to dependence that arose because of hedonistic use by young people.
Remember, this was the‘ Swinging Sixties’ – mods and rockers were fighting on the streets and on the beaches. Hippies began to emerge, and working-class teenagers were becoming rebellious and using drugs. Some were using heroin that they got via the prescription pads of a small group of London GPs.
For almost 40 years, middle class heroin users in the UK could receive diamorphine to treat their opioid dependency from their own general practitioners. From 1968 onwards, however, only doctors with a Home Office licence could prescribe heroin via a specialist clinic, usually referred to as a regional drug dependency unit( DDU). From 1968 to 1978, the percentage of people in treatment for opioid dependency prescribed diamorphine dropped to less than 10 per cent.
THE RISE OF METHADONE‘ Brown’ powder heroin began to arrive in the UK in the early 1980s. Unemployed, workingclass young people began to smoke and inject this brown heroin, and those who developed a habit, and went looking for treatment, were offered methadone or methadone. As ever in British drug policy, social class determined who got what. Posh people could get prescriptions from private doctors and pay for expensive residential rehabilitation treatments. The rest of us got what we were given.
Fast forward to 1999, and new Department of Health clinical guidelines are produced which further restrict access to diamorphine. By the year 2000, there were approximately 500 diamorphine patients and by 2019, this number had fallen to less than 300. The vast majority of the approximately 150,000 patients in medication assisted treatment( MAT) in the UK receive methadone or buprenorphine.
Despite the decline in diamorphine prescribing for the treatment of opioid use disorder in the UK, the case for its efficacy and legitimacy remains. In recent years, there have been clinical trials of heroin-assisted treatment( HAT). These trials require patients to come into a medically supervised clinic space, usually twice a day, to inject diamorphine under conditions that dictate the route, dose and frequency of administration. These clinical trials have consistently shown
that HAT works for people who are not responding to methadone or buprenorphine. HAT is effective in health gains, crime reduction and prosocial behaviour. The evidence jury has decided that HAT works. So, why is HAT not on offer?
For almost 40 years, middle class heroin users in the UK could receive diamorphine to treat their opioid dependency from their own general practitioners.
BARRIERS TO HAT The most often cited barrier to further expansions of HAT is cost. That is, the cost of the medication itself, the cost of nursing staff to supervise injections and the opportunity cost – money spent on HAT could be spent elsewhere in the treatment system. After all, you can’ t have enough recovery navigators, recovery coaches and recovery whatevers … or can you?
The price of another signposting team could provide a safe supply of diamorphine to keep marginalised users alive. A difficult choice for commissioners and providers – offer HAT or further expand the workforce. The expanded
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