The Heroin Trial Failure

A report of a recent heroin prescription trial in Britain published in the Lancet (29th May 2010) was widely promoted as a success. The fact is that for a very costly intervention a surprisingly small minority got off street heroin.
Of the 43 clients that received a heroin dosage of 450mg twice a day plus a nightly oral methadone supplement over a 26 week period, just 5 of them managed to get off street heroin. Hardly a measure of success.
That means that the remaining 38 although they decreased their consumption of street heroin (hardly surprising) are still involved in the illegal heroin market, and still involved in the crime, harm and misery related to it.
Regardless of the at best mixed results, the authors make the following recommendation based on their study: “UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts.” This is not the way policy making should be informed.
It would be a surprise if a free handout of 900 mg a day of heroin would not decrease street heroin consumption to some extent. What is a significan and surprise finding is that even when offering free heroin, the program has such a limited impact on the use of street heroin.
The cost of heroin prescription per client is estimated to be about €18.000 a year, far more than for other treatment options. The UK government has spent about €700.000 on two heroin trials last year.

Misleading media reports

Reports in the press pretend that the project kept people “off street drugs”. That is stretching the truth quite a bit. This is how Reuters (Reuters Health) quote the researchers: “Prescribing heroin to addicts who can’t kick their habit helps them stay off street drugs, British researchers said Friday”, under the headline “Prescription heroin helps addicts off street drugs”. This is clearly misleading, and it reflects badly on the researchers that are clearly unable or unwilling to present a correct picture of their results.
The clients were measured on their reduction of street heroin, not other drugs. They were in fact not even tested for other drugs. For a specialist in drug treatment and for health politicians this is not very helpful. Drug addiction must be seen as a whole and not as unrelated consumption of various substances.
Associated Press reports that “Some heroin addicts who got the drug under medical supervision had a better chance of kicking the habit than those who got methadone, a new study says”, under the title “Study: heroin better than methadone to kick habit”.
First of all, to “kick the habit” means to get off the addiction. But the aim of the trial was not to get people off addiction. It did not even measure that. Second, the study does not say that treatment with heroin is better than methadone, it suggests that for some hard to treat/reach clients (5-10% of the heroin addicts) heroine may give better results. For the vast majority of problem heroin users methadone would be more suitable.
To see such inaccurate and misleading reporting by the world’s two most serious news agencies should worry everyone who is interested in how science is translated. Much of the responsibility should however lie on the researchers since they presumably were given the text for verification before release. In any case one would expect the researchers to immediately ensure that the grossly misleading reports were corrected.

“A ripple of excitement”?

The journalists’ reports lack precision and insight; the researchers however seem to have engaged in pure spin.
Professor Strang is quoted by The Independent in an article from September last year that the “the findings have sent a ripple of excitement through the addiction treatment community, which is unused to seeing progress with hard core addicts.” The researchers claim they have uncovered “”major benefits” in cutting crime and reducing street sales of drugs”.
See Kathy Gyngells blog at Centre for Policy Studies from September last year where she reports on some of the spin behind this affair while searching for the facts behind the “excitement”.
How is it possible to be positively surprised about these results, one may ask. Anyone would understand that if you give addicts heroin they will not have to buy it. The surprise is that so many of them continue to buy street heroin nevertheless.

Moralism, determinism and a bit of science

The biased approach of the researchers gets even more evident by reading the quote by Thomas Kerr, one of the researchers. He is director of the Urban Health Research Initiative at the University of British Columbia in Vancouver. He says to Reuters “I would argue it’s completely immoral and unethical to fail to treat those individuals and to allow them to suffer and allow the community around them to suffer”.
The first question to consider is if this is at all treatment. Treatment per definition should address the addiction and the health problems. This does not. If anything, it is primarily crime prevention. If treatment was paramount then why are treatment outcome indicators not measured? Their findings of psychosocial benefits are only anecdotal.
Second, the term, “allow them to suffer” assumes that their suffering is caused by “street” heroin and relieved by prescribed heroin. This represents a very narrow and simplistic understanding of the harm and problems related to addiction and drug use.
The researcher seems wedded to the myth of the demon drug. A basic social profile of the 43 clients would show that a host of social and psychosocial problems was well established before the drug problem and the addiction became the dominant issue.
Kerr question may therefore be turned around: Is it not equally “immoral and unethical” to fail to treat those individuals’ underlying problems and “allow them to suffer and allow the community around them to suffer”?
Why is it apparently more moral and ethical to substitute street heroin with prescription heroin and thereby reducing crime levels than actually treating their addiction and underlying social problems?
Do they know what addiction is?
The researchers seem to display a profound lack of understanding of what addiction is. Strang says the results shows they have “turned around” the users drug problem. “Turned around”? What happened with the few people that started to use less street heroin and more prescribed heroin cannot be called a turnaround. Some of them would commit somewhat less crime and spend a bit less time running for the next fix. Some contact is established. But where is exactly the “turnaround” in terms of the addiction and health problems? Their drug problem is not turned around and certainly not the addiction.
What this trial illustrates is the limitations of such harm reduction measures rather than its strengths. It also illustrates how scientific results may be distorted and misleading, possibly intentionally. Heroin prescription may have some benefits for some people, but they appear to be very limited, very costly and we know too little about it to make a judgement anywhere near what the researchers did in this case.
The simple question remains: what exactly is the treatment objective? What is the health related benefit? And where is the continuum of care and treatment? The programme has managed reach this very difficult group that is hard to reach and hard to treat. A politician would ask: OK, you’ve reached some of them, so what do you do?

Source: Report by Anders Ulstein, Updated 12.06.10 , published by Drug-Watch International
The study is called “Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial”, written by John Strang and colleagues.

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