Skip to main content
PMC home page
The BMJ logoLink to The BMJ
. 1998 Oct 10;317(7164):1011.

The Swiss heroin trials

Trial is needed comparing decriminalisation of heroin with existing policy of prohibition

G R Venning 1
PMCID: PMC1114021  PMID: 9765177

Editor—Farrell and Hall seem to have misunderstood the importance of the Swiss trials of heroin on prescription for addicts.1 The call for a clinical trial of heroin versus methadone is irrelevant as these drugs cater for different segments of the addict population; no one suggests stopping methadone clinics. It is self evident that prescribing heroin will attract addicts who need the “buzz” and will not switch to methadone. These include dealers and pushers and those who succeed in obtaining funds through crime. Methadone clinics attract newer rather than hard core addicts. A logical policy for decriminalising heroin under medical supervision would have four steps: giving prescriptions of heroin to all addicts in or out of prison (which would gradually put criminals out of business); providing methadone clinics for those who will switch; weaning the addicts off the drugs; and providing a follow up programme to minimise relapse. The trial that is needed would compare a city region or country adopting this approach with a similar community continuing the existing policy of prohibition. This policy has already failed for the same reason that prohibition failed in the United States: it created an opportunity for the criminal mafias who dominate the drug scene. The end points of a comparative trial should not be narrowly defined as conceived by Farrell and Hall; they should include the numbers of new addicts, mortality and morbidity among addicts and former addicts, the impact on spread of HIV infection and hepatitis B both inside and outside prisons, and statistics for drug related crime (allegedly reduced by 60% in the Swiss trials). The economic gain to the community from heroin clinics will include the street price forgone by the clinics’ clients, which would otherwise be stolen from members of the community. This is a massive gain over and above the similar gain from methadone clinics. The time has come for the medical management of heroin addicts to be submitted to the disciplines of clinical pharmacology and epidemiology, including, ideally, randomised controlled trials.

Apart from the impact on problems caused by hard drugs, the new approach will be essential for resolving issues surrounding soft drugs. Marijuana is safer than alcohol or tobacco, but legalisation is inhibited by the fear that pushers of hard drugs can recruit users of soft drugs.

References

  • 1.Farrell M, Hall W. The Swiss heroin trials: testing alternative approaches. BMJ. 1998;316:639. doi: 10.1136/bmj.316.7132.639. . (28 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1998 Oct 10;317(7164):1011.

Further studies of heroin treatment are needed

Alex Wodak 1

Editor—On the basis of a trial in Switzerland,1-1 Farrell and Hall conclude that medically prescribed heroin is likely to have only a limited role in the future.1-2 It is hard to know how any judgment can be made about this approach after only one randomised control trial,1-3 one case-control study,1-4 and the large but uncontrolled study that the authors commented on.1-1

Farrell and Hall are right to emphasise the difficulty of disentangling the contribution of comprehensive social and psychological inventions in the impressive results obtained in this population.1-1 After more than three decades of research evaluating the effectiveness of methadone maintenance treatment it is safe to conclude that such interventions improve outcomes but difficult to be much more precise than this. Social and psychological interventions probably improve results of virtually all interactions between patients and the healthcare system.

The authors say that the proposal to conduct a heroin trial in Australia damaged support for harm reduction. This is arguable. The mood in Australia has generally been more conservative over the past two years. The controversy over the heroin trial in Australia probably contributed to major improvements in a local methadone programme and certainly led directly to a commitment and funding for research on an expanded range of pharmacological treatments for heroin dependence.

The authors question whether Australia is in the middle of a national heroin crisis. If a sixfold increase in mortality from drug overdose during the past 16 years1-5 is not a crisis it is hard to know what would be.

The Swiss heroin trial may have been more expensive than routine prescription methadone. But trials of new treatment are invariably more costly than providing well established treatments as a routine. Heroin and methadone are both cheap to produce. The cost of methadone represents under 5% of the costs of methadone maintenance treatment. There is no good reason to believe that heroin treatment will be considerably more expensive than methadone treatment.

Most important, Farrell and Hall endorse studies that will determine the comparative usefulness and cost effectiveness of injectable heroin and methadone maintenance treatment. The 71% support for heroin maintenance shown in a referendum in Switzerland in September 1997 (with majorities in all 26 cantons) suggests that the Swiss were not confused about these issues.

Rigorously conducted trials of medically prescribed heroin must be conducted soon lest we repeat the history of methadone maintenance treatment: the failure to conduct such studies when they were still possible proved costly.

References

  • 1-1.Uchtenhagen A, Gutzwiller F, Dobler-Mikola A, editors. Programme for a medical prescription of narcotics: final report of the research representatives. Summary of the synthesis report. Zurich: University of Zurich; 1997. [Google Scholar]
  • 1-2.Farrell M, Hall W. The Swiss heroin trials: testing alternative approaches. BMJ. 1998;316:639. doi: 10.1136/bmj.316.7132.639. . (28 February.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Hartnoll R, Mitcheson M, Battersby A, Brown G, Ellis M, Fleming P, et al. Evaluation of heroin maintenance in controlled trial. Arch Gen Psychiatry. 1980;37:877–884. doi: 10.1001/archpsyc.1980.01780210035003. [DOI] [PubMed] [Google Scholar]
  • 1-4.McCusker C, Davies M. Prescribing drug of choice to illicit heroin users: the experience of a UK community drug team. J Subst Abuse Treatment. 1996;13:521–531. doi: 10.1016/s0740-5472(96)00155-9. [DOI] [PubMed] [Google Scholar]
  • 1-5.Hall W, Darke S. Trends in opiate overdose deaths in Australia 1979-1995. Sydney: University of New South Wales; 1997. (NDARC technical report.) [Google Scholar]
BMJ. 1998 Oct 10;317(7164):1011.

Authors’ reply

Wayne Hall 1,2, Michael Farrell 1,2

Editor—We used the Swiss trial of prescribing heroin to counter the unrealistic expectations of its impact exemplified by Venning, who asserts that heroin prescribing will eliminate the black market, drug related crime, and the recruitment of new users of heroin.

Venning’s letter is lacking in supporting evidence, relying on appeals to “self evident” facts and “lessons” from the history of alcohol prohibition that are uninformed by recent scholarship (for example, the article by Tyrell).2-1 A confusion between heroin prescribing as a therapeutic option of last resort and the repeal of prohibition of heroin2-2 was one of the reasons why Australia did not proceed with a trial of heroin prescribing.

Wodak contests our assertion that the Swiss model of on-site heroin prescribing is likely to be an expensive, minority treatment option. It is costly to ensure that heroin is not diverted between manufacture and administration, and for staff clinics to provide extended hours to supervise self treatment with heroin. The costs are calculated to be between five and 10 times those of oral methadone treatment. The high level of supervision that was necessary to address public anxieties about heroin prescribing and the risks of diversion was an interesting aspect of the trial.

The increased rate of deaths in people taking heroin in Australia certainly presents a major public health problem, but we doubt that “crisis” is the best way to describe it. The increase has occurred over two decades, and most deaths are now among people who started using heroin a decade or more ago. “Heroin crises,” like “drug wars,” tend to prompt ill considered and disproportionate policy responses.

The relation between the debate over a trial of heroin and the trial of alternative pharmacotherapies in Australia is more complex than Wodak suggests. A large trial of buprenorphine predated the debate over trials of heroin, as did plans for trials of other agents. The failure to proceed with the heroin trial did produce a commitment to partially fund these other trials, which would not have happened if the trial had proceeded. But the only trials that have been funded to date (with A$1.4m (£518  500)) have been three small trials of naltrexone maintenance (after accelerated withdrawal under general anaesthesia), a treatment of uncertain efficacy whose prominence in Australia has owed much to the debate about a heroin trial.

References

  • 2-1.Tyrell I. The US prohibition experiment: myth, history and implications. Addiction. 1997;92:1405–1409. [PubMed] [Google Scholar]
  • 2-2.Farrell M, Strang J. Confusion between the drug legalisation and drug prescribing debate. Aust Drug Alcohol Rev. 1990;9:364–368. doi: 10.1080/09595239000185521. [DOI] [PubMed] [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES