Is There Any Hope for the future of Heroin Assisted Treatment in the UK?

Heroin assisted treatment (HAT) has a proven track record in helping those resistant to more typical forms of treatment for opioid dependency. With HAT programs cautiously being adopted at a local level in the UK, is there any hope they could become commonplace in this country in the future?

Prescribing diamorphine -- the medical term for heroin -- to people suffering from problematic use has been legal in the UK since 1926, though was later restricted to doctors who received special licensing to do so from the Home Office. Such prescriptions aim to help dependents who have historically failed to respond to conventional treatments such as opioid substitution therapy (OST) under which methadone falls.

The surprised response of many to a 2011 BBC investigation which highlighted how 120 heroin dependents were being prescribed diamorphine on the NHS in London is illustrative of the secrecy surrounding this type of treatment. Pauline Holcroft, the mother of Rachel Whitear who died at the age of 21 from a heroin overdose, stated she "had no idea" that heroin could even be prescribed, believing instead that only synthetic opiates such as methadone could.

Efforts to roll this out on a wider scale are being made. The successful results of a UK Randomised Injectable Opioid Treatment Trial (RIOTT) published in 2010, prompted the Department of Health into further action, awarding three-year contracts to South London and Maudsley NHS Foundation Trust (SlaM) in 2010 and two mental health trusts in 2012 to provide supervised heroin treatment in London, Darlington and Brighton. 

So what did RIOTT show? Starting in 2005, it treated 127 chronic heroin users for whom conventional types of treatment had failed. This follows a number of similar trials conducted globally since the 1990s, the results of which led to the legalization of HAT in four countries -- the Netherlands, Germany, Switzerland and Denmark -- while Spain and Canada permitted it in further research trials.

RIOTT, like other HAT trials and current practices, aimed to get dependents to quit using “street” heroin, improve well-being and disengage from criminal activity by providing supervised heroin treatment, complemented by a program of social and medical care.

A third of the patients were given methadone orally and another third injected methadone. The remainder were treated with injectable diamorphine. Researchers monitored the outcomes for six months to compare the physical and financial effectiveness of the three treatments.

Results showed that supervised heroin treatment produced larger reductions in street heroin use with the proportion of patients achieving 50 percent or more negative samples for street heroin being highest in the injectable heroin group (66 percent). This was followed by injectable methadone (30 percent) and oral methadone (19 percent).

The trial also confirmed the potential for HAT to substantially reduce criminal activity. In the month before the scheme started, patients in the heroin injecting group reported carrying out 1,731 crimes in the 30 days prior to the start of the program. After six months, this fell to 547 offenses - a reduction of more than two-thirds.

Furthermore, analysis showed that the related savings from legal, prison and health service costs would more than cover the cost of treatment; supervised heroin treatment costs around £15,000 per patient per year, while the typical cost of prison is £44,000 per year per person.

These results prompted Professor John Strang, who led the trial, to conclude that supervised injectable heroin should be provided “for carefully selected chronic heroin addicts in the UK”.  It was estimated in 2010 that around 5-10 percent of 265,000 heroin users in England were resistant to methadone, and according to Professor Strang, are “responsible for the vast majority of drug-related criminal behaviour”. 

The success of RIOTT is heavily backed by previous HAT trials which produced similar promising outcomes. Evidence from six such programs collated in the 2012 report “New heroin-assisted treatment,” found in comparison to oral methadone treatment, heroin assisted treatment performed relatively better in bringing about “a major reduction in the extent … of ‘street’ heroin’ [use], improvements in general health, psychological well-being and social functioning, as well as major disengagement from criminal activities” across all trials.

So what does this ultimately mean for harm reduction in the UK?  To start, it is important to be clear that this does not mean that the value and effectiveness of methadone treatment is redundant, since HAT is for a very specific group among problematic heroin users who have a history of being non-responsive to methadone maintenance treatment (MMT).

The fact that patients who had an established history of injecting street heroin while receiving opioid substitution treatment started achieving 50 percent or more negative samples for street heroin during RIOTT after only six months illustrates the dramatic power of HAT in turning around lives.

Yet, despite the positive results of RIOTT there is still an incredibly long way to go before this becomes accessible to those who need it most. The fact that the official NHS page on treating heroin misuse does not even state that this form of treatment exists is illustrative of the difficulty in getting access. Most help centers for heroin users offer treatments that are either abstinence, methadone or subutex-based. Worryingly, when calling up three main local rehabilitation centers in the London borough of Tower Hamlets, along with calling the FRANK helpline, the service and information providers either did not know that HAT existed as an alternative or could not give any information on how to obtain access to this treatment.

The second question it raises is whether there is the political will to actually listen and engage with the evidence to change the approach to problematic heroin use.

The government shouldn’t be nervous about expanding HAT. A DrugScope survey found that 88 percent of people they asked either strongly agreed or agreed with the statement that “drug treatment should be available to anyone with an addiction to drugs who is prepared to address it." Furthermore, public figures such as Dr Clive Froggatt, a former advisor to Margaret Thatcher, along with former Chief Constable Tom Lloyd and Durham Chief Constable Mike Barton argue that HAT is vital in “beating the drugs problem that costs this country billions of pounds every year." Indeed, according to the government's own estimate, crimes related to drugs alone cost the UK £13.3 billion every year.

Although the UK Government’s 2008 Drug Strategy promised to roll out the prescription of injectable heroin and methadone to clients who do not respond to other forms of treatment subject to the results from RIOTT, this intention is not mentioned at all in the 2010 UK Drugs Strategy paper, illustrating the uncertainty of the future of HAT.

Some signs of minimal progress on the harm reduction front have emerged recently, as illustrated by the government's (albeit tame) recent announcement to provide free foil to heroin users in a bid to divert intravenous use to smoking and therefore reduce cases of HIV/AIDS and Hepatitis C. Furthermore, it is commendable that Nick Clegg, the deputy prime minister, has come out stating that drug users should not go to jail but instead be provided with treatment, highlighting that drug misuse is first and foremost a health problem.

Yet, it is disappointing to see that swathes of the media have branded his announcement as "controversial" when the growing body of rigorous evidence illustrates it is anything but. Indeed, HAT is now an established and successful part of the drugs strategy for a handful of countries similar to the UK. The UK's public thinking and action needs to go much further to catch up with its more advanced European neighbors if it is to actually tackle the problem of heroin misuse on all fronts.