Editor—Scientific evidence on the effectiveness of interventions for drug dependence is increasingly available and should be used to inform policies. Differences between the approaches of the Netherlands and Italy lead us to doubt that this is happening.
Dutch investigators have recently recommended the prescription of heroin to addicts on the basis of two randomised controlled trials.1 The European Monitoring Centre for Drugs and Drug Addiction (the European Union's drug agency) recently stated that “substitution treatment is a key component of a comprehensive approach to drug treatment and can be effective in reducing the risks of HIV infection, overdose, use of legal and illegal drugs and drug-related crime” (policy briefing No 1/2002).
Recently the Italian government announced a major shift in policy on drug dependence, rejecting harm reduction strategies. The resolution approved by one branch of the Italian parliament states that “the use of methadone and other substitution treatments should be confined within the restrictions of the law; it has to be limited to three months, it has to be linked to a rehabilitation project and it has to be used with low dosages.”
The Italian government states that “too many” patients of public treatment services receive methadone treatment. The opposite is actually true, as under 50% of the 140 000 people who entered public treatment centres in Italy in 2000 were offered methadone treatment and under 30% on a maintenance basis, the average maximum dose being well below the effective dose.2 We believe that the problem is the inappropriate use of methadone treatment rather than its excessive use.
Heroin use in Italy is still a big issue. The estimated prevalence of problem drug use in 1999-2000 and prevalence of HIV infection among drug users are the highest in the European Union3; mortality in heroin addicts is high, particularly among women.4
In the United States in July 1998 Mayor Rudolph Giuliani of New York City introduced a programme requiring the 2100 patients in methadone maintenance programmes in selected clinics to stop using methadone within 90 days. Seven months of debate and controversy ensued. In January 1999 the mayor announced that his programme had been inadequately conceptualised, was not realistic, and was being withdrawn.5 More recent political declarations have confirmed the intention of banning methadone and harm reduction strategies, but no official steps have yet been taken.
We hope that a proper scientific discussion on this issue will prevent politicians from counteracting scientific evidence and interfering with clinical decisions.
Footnotes
Competing interests: AL is an employee of the Università di Modena e Reggio Emilia, Modena, Italy. His views do not imply that the Cochrane Collaboration has an official position on the issues discussed in this letter.
References
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