Feasibility, Safety, and Efficacy of Injectable Heroin Prescription for Refractory Opioid Addicts: A Follow-up Study

The 1980s saw an increase in problems related to heroin use in Switzerland. Partly due to the easy availability of drugs and negative public attitudes, the problem continued to increase into the 1990s. Public health authorities implemented various measures to cut down on the spread of disease due to increased drug use. The main measures focused upon abstinence, reducing opioid-associated health consequences, reducing the stigma associated with drug use, and countering drug-related organized crime. Repression, prevention, treatment and risk reduction are the four "corner-stones of the Swiss drug policy framework," according to the authors.

Many addicts have not been helped by abstinence-oriented and methadone-maintenance treatments. Because a high proportion of addicts have been reached by Swiss programs, a research project was established in 1994 to study the efficacy of different prescription narcotics in the treatment of drug addiction. After some time the study was altered to focus upon a cohort study of heroin-assisted substitution treatment. This article is an overview of 6 years of substitution treatment in Switzerland.

The authors assessed all patients admitted to 21 centers for heroin-assisted treatment between January 1994 and December 2000. A total of 2,166 cases were documented with 1,969 patients. All patients were given opioid-assisted substitution treatment and each received psychosocial counseling. Each had access to medical services, and heroin addicts were given methadone as a replacement drug when needed. The mean dose of intravenous heroin administered was 474mg with administration of an average of 2.6 applications a day. The outcome variables were assessed for 237 patients between Jan. 1, 1994 and March 31, 1995 who stayed at least 18 months. The 128 patients who left before 18 months of treatment were excluded from the study. A team of health-care professionals examined and interviewed patients on admission and after 6, 12 and 18 months. Questionnaires were used to determine data on the use of narcotics and patients' social circumstances.

The number of patients admitted and discharged from the study was 1,969. Of these, 1,418 (72 percent) were men and 551 (28 percent) were women. Nine percent (177) of patients were admitted more than once. Neither sex was admitted more frequently than the other. Patients discharged were treated for a significantly shorter time than those who were not, and the patients who left treatment were slightly younger, more likely to have consumed cocaine on a daily basis, and had higher rates of HIV-1 infection. Treatment retention for heroin-assisted substitution treatment was relatively high, with 1,693 (86 percent) patients continuing with the program for at least 3 months, 70 percent (1,378) for at least a year, 50 percent (985) for a least 2.5 years, and 34 percent (669) for five years or longer. Less than 100 patients left treatment because of lapses in medication or non-compliance. Most left for other treatment modalities. The longer the treatment with heroin-assisted substitution, the more likely patients were to choose abstinence-based treatment when they left the study. Variables of weight gain, mental and psychological distress changed for the better and patients' social situation improved. A reduction of criminality was corroborated by objective judicial data in an independent investigation. Finally, according to the authors, "the proportion of patients needing daily or almost daily doses of street heroin, cocaine, or benzodiazepine was significantly reduced after treatment."

In the view of the results of the study, according to the investigators, "a promising strategy might be to persuade addicts to persevere with heroin-assisted substitution programs for at least 1 year before encouraging abstinence." The findings suggest that patients who give up on their treatment after only a few months do so mostly because of difficulties they encounter with rules and regulations imposed by clinics. These findings contradict previous assumptions that long-term drug substitution has a negative effect on motivation and abstinence.

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