Heroin and methadone substitution treatments : harm reduction and the effectiveness of 'flexible' prescribing for the treatment of opioid dependency
In the mid 1990's the UK government began to focus on problem heroin use mainly as a drug related crime issue, and so attracting and retaining clients became a treatment priority. The concept of flexible prescribing, matching individual clients to treatment programmes appropriate to their drug using history and circumstances, began to gain support amongst politicians and clinicians. As part of this shift in emphasis, prescribing heroin to heroin addicts re-emerged as a treatment option. Injectable (and smokable) diamorphine (pharmaceutical heroin) began to be prescribed in a small number of drug dependency units under the direction of local psychiatrists, including two in North West England. One hundred and thirty three registered drug users were interviewed between August 1995 and February 1997 using a structured questionnaire. Three key areas and their association with heroin substitution prescribing were addressed; levels of criminal activity, levels of illicit drug use, and a range of client held perceptions and attributions regarding coping/quality of life. The mean age of the sample was 30 years, and 75% were male. 61% had used illicit heroin in the past month, spending on average £638, on a habit of 4g per week. Clients were subdivided on a number of variables and comparisons were made between groups according to (IV) prescription type (which drug), and form (injectable/smokable/oral mixture). Significant differences were found across each of three key variables, including differing levels of illicit drug use according to prescription form, and differing levels of specific criminal activity according to prescription type. Significant effects included; Clients on prescriptions which included ampoules were significantly more likely to report being able to cope with life, and spent significantly less time on drug taking activities, than those clients receiving other prescriptions. Clients on prescriptions which included `reefers' (smokable) reported significantly less shop lifting than clients receiving other prescriptions. It was concluded that the available empirical evidence regarding heroin prescribing is limited, and although some clinicians are yet to be convinced, it seems heroin does have its merits as a viable treatment option. Issues of cost and possible dispersion remain, and are discussed in relation to the continuing development of substitution treatment policy in the UK.