Heroin Assisted Treatment

Introduction

Hi Guys and welcome to my blog about opiate addiction. Summer is right around the corner and I must say, it feels good. The warm weather is certainly a plus and the combination of free time and nice weather has allowed me, and I'm sure many others, the opportunity to partake in some of our favorite activities, sports, and enjoyments that tend to disappear during the cold winter months. I always thought of summertime as the best time to get off opiates with the warm weather (I absolutely despise the chills associated with withdrawal), time off from school or work (vacation?), and the general sense of mellowness most associate with the summer. I hope my blog can help anyone who is thinking about or currently partaking in a life without opiates.

I also want to alert you guys about a new section of my blog that I have recently created and published. This new section will provide readers with various graphs, photos, charts, figures, and the like that can be used as a reference page for the related post that you are reading. For example, if the post you are reading is about the effectiveness of Suboxone treatment programs, you may read a sentence that says "Suboxone has had various levels of success in relation to specific age groups, which can be seen in Figure 25". You can then check out the new section to view this table, chart, graph, or photo. I will still include these illustrations within the posts themselves as well with the idea of this new section being that users can view these items at later times. The section is simply a normal post created in the usual fashion of my other posts and is labeled as "Tables, Charts, Photos, Figures, and Graphs Reference Page". The section can be found by simply clicking HERE. It can also be found on the homepage of my blog which can be accessed by clicking HERE. This section will be updated constantly and will be effective for any posts published after June 6, 2013.

On that note, I would like to use this post to discuss a topic that I recently came upon that has been meet with much criticism and debate; heroin assisted treatment.

Heroin assisted treatment is a method of treatment that is used to help treat opiate addicts (heroin addicts) by using the drug diamorphine/diacetylmorphine, commonly referred to as heroin. The drug is given to addicts under supervision with dosages being gradually lowered over time to help minimize withdrawal from the drug. I must say, I was really shocked when I first heard of this method and was pretty curious as to how effective this method of treatment really is. A doctor giving heroin to an heroin addict to help combat addiction seemed almost surreal and bizarre when I first came upon this treatment option.



Pharmaceutical Heroin Today
Figure 36

After doing some research on the issue, I began to gain a better understanding of the procedure and started to see the concept behind it. Some within the addiction community see heroin assisted treatment as a means of treating addicts with a drug that is "cleaner" than what they would normally be getting on the street while also having the drug administered in a safer fashion and dosage than what they would otherwise normally be practicing. This method of treatment is somewhat similar to what doctors sometimes do to aid patients who have been prescribed opiates over an extended period of time get off opiates by tapering the patient's dosage over a period of time with the eventual goal of coming off opiates altogether.

Obviously there is a major difference between tapering prescription painkillers with tapering heroin but the overall concept remains, for the most part, quite similar. This method of treatment is without a doubt one of the more lesser preferred methods of treatments but is still nonetheless actively used in some countries. With the methods, beliefs, concepts, medications, and technology constantly changing within the addiction community, it is not that unrealistic to think that this kind of approach (or one similar) of treating those who struggle with opiate addiction reaching other countries or facilities over time. Thus, I would like to go into further detail about this matter by talking about the exact nature of heroin assisted treatment, its history, where it is used, its effectiveness, the risks and benefits, and finally, my opinion on the matter. To make things a little easier on myself and your eyes, I will be using the acronym HAT at times to refer to heroin assisted treatment.

 

What is Heroin Assisted Treatment and How Does It Work?

Heroin assisted treatment (HAT) is the "prescribing of a synthetic heroin, in an injectable or capsule form, to opiate addicts that do not benefit from or cannot tolerate treatment with one of the established drugs used in opiate replacement therapy such as Methadone or Buprenorphine (Suboxone)". Under this method of treatment, heroin is administered under the supervision of a doctor with the dose being gradually lowered over time. Similar to how doctors taper patients off of prescription painkillers, the goal of heroin assisted treatment is to eventually wean the patient off of the drug in an effort to minimize withdrawal. After gradually tapering down to a fairly low dose of heroin, patients will sometimes then be switched over from the heroin to a low dose of Suboxone or Methadone for a brief period of time before jumping off opiates altogether.

The method of treatment allows addicts to identify and learn about their addictions with the hope that these addicts can learn to cope with their addictions and eventually achieve sobriety. By having the heroin administered under medical supervision, the risk of overdose, disease, criminal activity, and costs are lowered or minimized. Heroin assisted treatment is available and practiced in Denmark, Germany, the Netherlands, Switzerland, and the United Kingdom while experimental trials are currently being conducted in Canada and Belgium. Meanwhile, the policy has been heavily criticized and opposed by many within the United States with Methadone, Buprenorphine, and total abstinence being the more preferred and favored methods of treatments for opiate addiction.

The history of heroin assisted treatment began in the United Kingdom during the early 1920s and was commonly referred to as heroin maintenance. The method of treatment was available to a select group of patients, with many ironically being doctors themselves. Due to the close relationship between the United States and the United Kingdom along with the United State's strong anti-drug stance in what would eventually be labeled as the War on Drugs, the use of HAT experienced a sharp decline beginning in the 1960s. However, the method of treatment begun to see somewhat of a resurgence beginning in the mid 1980s and has since found a niche within the addiction community today with the United Kingdom, Netherlands, and Switzerland notably maintaining an active role and voice in the policy today. Germany and the Netherlands actually include the treatment option as a component of their national health care systems.

Bayer Prescription Heroin in 1910

Figure 51

The way in which the heroin is prescribed and administered varies from not only country to country but from clinic to clinic as well. For most patients who are partaking within a treatment program offering heroin assisted therapy, the patients are usually given their dose of heroin under the supervision of a doctor or medical professional. This course of action is preferred as it can help reduce the chance of the heroin being abused or sold on the streets. However, the United Kingdom is unique in that it sometimes allows patients who have demonstrated a sense of trust and responsibility to take home their heroin prescription or to have to only show up to the clinic once a day rather than several times throughout the day due to heroin's short acting half life. It is important to note that while this may seem rather extreme as well as the fact that the United Kingdom is one of just a few countries where HAT is legal, less than 1% of all opiate replacement treatments for heroin in the United Kingdom are heroin assisted treatments.

Clinics in the Netherlands meanwhile often require patients to make at least two visits per day to obtain their doses of the heroin with the option of being able to take home a single dose of methadone each day. Switzerland handles their treatment programs by at first requiring patients to make daily (sometime multiple times per day) visits to obtain their doses with the possibility of patients being able to take home a pill form of heroin after the patient has demonstrated a sense of trust as well as being able to obtain employment.

Patients are sometimes prescribed Methadone in addition to the heroin to help provide relief for withdrawal if the heroin wears off before the patient is able to obtain their next dose. The use of heroin in treating addicts is seen as a way in combating what has been viewed by many as an epidemic that is growing in size and severity each day. Still, there is much fear that this method of treatment can be dangerous, contradicting, and ineffective with many fearing the possibility that the drug can make its way to the streets. Similar to the way in which concerns surrounding Suboxone and Methadone affected programs, this has resulted in tight regulation and supervision of the clinics and doctors who offer this option of treatment.

The Pros and Cons of Heroin Assisted Treatment

As you can probably already gather, there are several pros and cons of heroin assisted treatment. The method has been met with its fair share of intense criticism with many feeling that it is simply a means of providing addicts with their drug of choice, holding little to no value in actually treating their addictions. There is also the issue of the prescription heroin possibly getting out onto the streets. We have already seen just how easy it can be for prescription painkillers to make their way onto the streets and into the hands of addicts each and every day with little disturbance or interruption. With the heroin used for HAT programs most likely purer and with little to no additives (cuts) than most heroin found on the streets, there runs the possibility that drug dealers and addicts may see this as a means of making profits or getting high. Think about how often you hear about a corrupt doctor or pharmacist who wrongfully prescribes, steals, or sells prescription drugs for profits. Well, what would stop these same kinds of people from doing the same exact thing with heroin?

Another cause of concern involves the safety of the patients themselves who are partaking within an heroin assisted treatment. Heroin is a dangerous drug and is certainly one of the more common opiate culprits behind overdoses and opiate-related deaths. Doctors will have to use extreme caution in not only determining how much heroin is safe enough to administer but that there is enough administered to help provide relief from withdrawal. I ask myself, what happens when a patient with an extremely high tolerance to heroin enters treatment? The patient will most likely require a dose of heroin that could be considered dangerous in order to minimize withdrawal. Is the risk really worth it or would the patient be better served with a drug such as Methadone or Suboxone? I'm sure programs offering this type of treatment have thoroughly thought these concerns over but it begs to ask the question, how safe, supervised or not, can administering heroin really be?

The Success of Switzerland's Harm Reduction Programs

Figure 53

The benefits of heroin assisted treatment are a little more difficult to identify and support. A good comparison of HAT would be to the harm reduction programs that several cities across the world run. These programs are created and implemented with the hope that they can reduce and minimize the various risks and negative consequences so often associated with drug use. An example of a harm reduction program would be a needle exchange clinic in which IV users of heroin can drop off dirty or used needles in addition to being able to obtain new and clean needles. The program helps prevent needles from being carelessly tossed on the ground where they could be picked up by an innocent child or accidentally poking someone who unintentionally comes into contact with the  carelessly disregarded needle. Needle exchange programs also discourage needle sharing which can result in the spreading of diseases such as hepatitis or HIV/AIDS. This is critical as diseases such as these are very present within the world of drug and its inhabitants.

I mention the comparison of the needle exchange programs in relation to the heroin assisted treatment option because both concepts are meant to reduce the risks and harm that often come along with using a street drug such as heroin. Supporters of programs such as these see heroin use as a problem that is difficult to stop or even prevent and look to ways to help deal with the problem at hand through harm reduction rather than the difficult and, unfortunately, often unrealistic attempt to eliminate heroin use totally. To sum it up, supporters of these programs feel as through quitting heroin cold turkey or with drugs such as Methadone or Suboxone is too ineffective for some select addicts such that using heroin under a supervised tapering regimen is the next best option. A good saying for this particular scenario is that heroin assisted treatment is the lesser of two evil when compared to heroin use on the streets.

Sign for a Needle Exchange Program

Figure 54

Another benefit that is used to support HAT is that the method of treatment can reduce criminal behavior and costs. Addicts partaking in one of these programs would be obtaining their heroin legally (man that sounds crazy, doesn’t it?) through a doctor’s prescription rather than buying it off the streets from a drug dealer. Addicts will also not have to pay anywhere near as much as it would cost to maintain a habit of buying heroin off of the streets. This would, in theory, reduce the need to commit criminal acts such as theft, drug dealing, prostitution, and violent crimes to support one’s habit. Ultimately, this combination would result in fewer arrests and incarnations. Who would have ever thought that giving heroin to heroin addicts could reduce criminal behavior?

A final benefit that one could associate with HAT is that the method of treatment would be much safer for the addict than if they were purchasing and using heroin from the street. Because individuals within the program would have their doses overseen and administered by a medical professional rather than the addicts themselves, the risk of overdose is greatly decreased. More often than not, heroin is rarely pure, often containing a variety of additives. Occasionally these additives can result in serous illness or death due to the presence of harmful additives, allergic reaction, or the inclusion of more potent drugs (such as Fentanyl). Another factor to consider is the overall nature of the heroin underworld and drug game, which is often filled with dangerous places, acts, scenarios, and people. No one is going to get harmed or killed in a medical facility or treatment program over bag that was shorted or because someone didn’t pay back some money or drugs that they were loaned.

So, Just How Effective is Heroin Assisted Treatment?

Trying to determine the overall effectiveness of heroin assisted treatment in comparison to more traditional methods such as opiate replacement therapy, AA/NA, or total abstinence is, for the most part, quite difficult to determine.

In North America and Europe alone, there are an estimated 2-4 million heroin users with 1-2% of this population prematurely dying each year. The social, economic, and medical costs attributed to heroin use is believed to be in the billions of dollars in addition to the thousands of individuals serving sentences in prisons, jails, hospitals, and institutions each year. In other words, heroin has had a major impact on society and this holds true to not only the addicts themselves, but to everyday people as well. Every day, family members and friends lose loved ones to heroin addiction, be it from incarnation, destroyed relationships, or death. Heroin use is unfortunately a growing problem that looks like it is here to stay. This is all without mentioning the enormous impact prescription painkillers such as Oxycodone, Oxycontin, Dilaudid, and Fentanyl have had on society as well. 

There are a few studies out there that have been conducted over the last 25 years in regards to the effectiveness of heroin assisted treatment. It is a lot of information to digest in these studies to the point that it wouldn't really be appropriate to include all this information in this post. Rather than copying and pasting all this information into this post, I thought it might be a better idea to include the links to these studies below. I will also touch upon some of these findings in my own words below as well as providing you guys with some of the more important results of these studies. The following links below this paragraph will bring you to these studies. The first link is a detailed study conducted by the European Monitoring Centre for Drug and Drug Addiction (EMCDDA) that provides a great insight on the matter. I defiantly recommend checking it out if you have the time even through it unfortunately requires you to download the document after you click on the link (it is, however, free and on a secure site). The articles are as follows:

EMCDDA "New Heroin Assisted Treatment Findings"

Heroin Assisted Treatment, A Decade Later: A Brief Update on Science & Technology

Heroin Assisted Treatment/Heroin Maintenance

Heroin Assisted Treatment for Opiate Addicts: The Swiss Experiment

Heroin Assisted Treatment in Europe: A General Overview

Between 1994-1996 , a study involving the effectiveness of heroin assisted treatment was conducted by an independent research team consisting of members from the Addiction Research Institute and the Institute of Social and Preventive Medicine at the Swiss university, Zurich University. The study demonstrated several positive results in regards to the effectiveness of HAT. The link to the study is the 4th link above this paragraph and can also be accessed by clicking HERE. Some of the findings include (in blue font): 

"The safety of patients and staff could be evidenced (no fatal overdose from prescribed substances, no successful thefts or deviation to the illegal market, few cases of violent behavior). In contrast to expectations, the daily dosages of Diamorphine could not only be stabilized, but were slightly reduced over time. Many patients preferred to combine injectable Diamorphine with oral methadone, in order to have more freedom to resume school attendance or employment"

"The consumption of illegal / non-prescribed substances while being on the program was reduced significantly (especially the daily use of heroin and cocaine, to a lesser degree the regular use of Benzodiazepines). Cannabis use on the other hand remained essentially unchanged, but without noticeable effect on treatment outcome."

"Regarding social integration, it may be mentioned that homelessness was significantly reduced, while reintegration into the regular labor market proved to be more difficult. Most spectacular was the reduction of criminal activities according to self-report and police data (Killias & Rabasa 1998)."

"Retention in treatment was superior to what is observed in other forms of treatment (76% over a 12-month period). 60% of discharged patients could be transferred to a regular treatment program within 18 months (about half of those to drug-free programs)."

In 2000, a second systematic follow-up study was made (Güttinger, Gschwend et al, submitted). The study included 244 patients covering a period of 6 years. At that time in 2000, 46% of patients in the previous study were still in treatment while 48% of discharged patients had entered a regular program. The study also provided a comparison of those still in treatment with those who were discharged showing the following information (again, in blue font):  

 

- a significant reduction in illegal heroin, cocaine and Benzodiazepine use in both groups

- no reduction in cannabis use in both groups

- a significant reduction of homelessness in both groups

- no reduction in unemployment in both groups

- a highly significant reduction in living from illegal income and in new court cases.

The results of the Swiss study clearly illustrated mostly positive outcomes for patients involved in the heroin assisted treatment trials. Despite these results, the study stresses that it is not recommending heroin assisted treatment as a first line of defense in the battle against opiate addiction. Rather, the method of treatment should be reserved for a select few individuals, focusing on those who are 1) using heroin and 2) have been unsuccessful with other lines of treatment in the past such as Methadone or Suboxone. In other words, someone with an addiction to prescription painkillers shouldn't attempt to go this route as it geared more towards heroin addicts as a last resort. Using heroin, whether in a program or not, can at times be like playing a game of Russian roulette as the potential risks, addictive nature, and reputation of the drug are all well documented. Heroin assisted treatment should thus be reserved for those heroin addicts who have exhausted nearly all other possible options (with little to no success) such as abstinence, Methadone, or Suboxone before looking into a HAT program.

 

Now lets take a look at a study conducted in the Netherlands in which injectable Diamorphine (heroin) was administered to patients. The group receiving the injectable heroin was compared with a group receiving Methadone. The Dutch study showed that after twelve months, client retention rates were higher for the Methadone group compared to the heroin assisted treatment group. However, patients in the heroin assisted treatment group responded better than those in the Methadone group in regards to aspects such as comfort level, side effects/reactions, and overall cost effectiveness of program. The overall findings of this study demonstrated that the group receiving the heroin assisted treatment was usually nearly equal to or greater than (although not by substantial margins) in most factors of the study than the group in which members were administered Methadone.  

A quick summary, conveniently in the form of a table, of a few of the studies conducted that focused on the effectiveness of heroin assisted treatment can be found by clicking HERE.

 

A final aspect to look at when determining the effectiveness of heroin assisted treatment is the availability of the program. As I mentioned earlier in my post, HAT is quite limited in that it is only legal and available in a select few (five to be exact) countries and even in those countries, the number of heroin assisted treatment programs is small. I bring this issue up because what good is a treatment option when it is close to impossible to find or partake in. To demonstrate to you guys just how few HAT programs there are worldwide, take a look at the number of HAT programs in each of the five countries where the method of treatment is legally available.

Country                                   Number of HAT Programs

Denmark                                             3

Germany                                             7

Netherlands                                        17

Switzerland                                        23

United Kingdom                                3

 

 

My Final Thoughts and Opinion on Heroin Assisted Treatment

Over the past decade, the world (especially the United States) has seen what appears to be an epidemic in regards to the abuse of prescription painkillers and opiates. Thus, we must learn new ways to deal with this growing and demanding problem. Is heroin assisted treatment the perfect solution to this problem? Of course not, but neither are drugs such as Suboxone or Methadone. For some, these methods of treatment work wonders while for others they are ineffective. Rather than praise one method while bashing another, we should give each method a fair and efficient evaluation determining what works and what doesn’t. Would I consider HAT a solid solution to opiate abuse or something I would try myself? My answer is probably not, but I believe that if it truly works for some people, then it has its place within the addiction community.

What I’m trying to say is that if it works for some people, is proven to be relatively safe and effective, and is used the right way, then who am I to say it does or doesn’t have its place within the addiction community. For example, I am currently on less than 1 mg of Suboxone a day after being addicted to over 200 mg Oxycodone for roughly two years. I have been on the Suboxone for a little over a year and through a supervised taper regimen, have found the drug to be a total godsend. However, there are some people who feel Suboxone just doesn’t work well enough for them and would prefer other means such as Methadone maintenance, AA/NA meetings, or total abstinence to treat their addictions. If those routes work for you, than all the power to you with the most important thing at the end of the day being whether or not you are clean off of opiates or are, at the very least, heading into that direction through your method of treatment.

Typical Outpatient Clinic

Figure 55

I look at heroin assisted treatment as a more untraditional means of tapering just like how someone would be tapered off of a prescription painkiller. I think a lot of criticism surrounding HAT programs is due to the stigma that revolves around heroin. Most people, rightfully so at times, see heroin as an evil, dangerous drug that has no place in the medical community. Yet when you get down to the main ingredients in most prescription painkillers, they are almost the same ones usually found in heroin, often coming from the same kind of plant. Because these prescription painkillers are made in a factory or lab, there is often a sense of false security that comes with them. Well guess what, at the end of the day both heroin and prescription painkillers can cause addiction and both result in similar withdrawal. To provide you guys with a metaphorical example, think about marijuana. There is a difference between some high grade marijuana and some low grade mids. Yet, at the end of the day, they are both kinds of marijuana.

The best way that I can describe how I feel about HAT is to tell someone to try to look at the relationship and similarities between heroin and prescription painkillers in the big picture. By big picture, I am referring to looking at where both come from, the similarities in the highs between the two, the withdrawals that can accompany both, and the devastating consequences that both can have on people and those around them. Is it really that insane to think and see the similar nature between both beasts? Sadly, I think it is not that crazy to think and see such as thing.

To reiterate and summarize my final thoughts on heroin assisted treatment, I say that while it is something I would never consider partaking in myself (if it were legal in the U.S.), I think that the method of treatment is deserving of further attention. As of right now, I feel this method of treating addicts leaves far too much opportunity for it to be misused or abused. I admit that I could certainly use more information or firsthand accounts of the process that one undergoes when getting into one of these programs as well as more information as to how they usually operate.

Under the proper supervision and environment, I feel there is potential and promise for this concept. However, the idea of giving someone with an addiction to heroin the opportunity to take home doses of the drug seems a little absurd to me in that I feel the potential for abuse or misuse is too great to allow someone to take home and administer the drug themselves without the supervision of a medical professional. I have met and seen firsthand several addicts with prescriptions to Suboxone and Methadone who do not take their medications as prescribed or even sell them as a means of supporting their habits. Thus, I don’t believe it is too farfetched to see something like this occurring in a program that offers heroin assisted treatment.

Conclusion

Well, I think this post might take the icing on the cake for the longest post that I have written thus far. If you read it all, especially in one sitting, I would like to thank you for taking the time to do so. I hope you found this post interesting and if you are someone in a country where heroin assisted treatment is legal and are considering this method of treatment, that you found this post was helpful. I would love to hear what you guys think of this topic under the comment section so please don’t hesitate to drop a comment. If you have any firsthand experience with HAT, I would greatly appreciate your input on the matter.

As always, thanks for reading Guys. Don’t forget about the new section in my blog that allows readers the opportunity to view the various pictures, graphs, charts, figures, and tables used throughout my blog. I think this section will be especially helpful for referencing items as well as allowing readers the opportunity to look something up that they may have read in one of my previous posts. I can only hope that my next post is as exciting and interesting as this one as I must admit, it is at times getting more and more challenging to find and write about fresh and interesting topics. I guess that's part of the fun as well. I have certainly learned a lot since I wrote my first post roughly a year ago.

Well, my time is now up and I thank you for yours. Take care my friends and remember…in even the darkest places and times, there is always light so don't hesitate look around a little bit to keep seeing that light! It’s there somewhere, I promise.

Be safe, be healthy, and most importantly, be happy.

-Seeingthelight