"Acculturating" heroin use

The purpose of this article is to argue that the NCEPH/AIC proposal has prematurely focused on one way of providing heroin which is too narrow and too restrictive; that some of the criteria for "success" of the pilot studies seem to be arbitrary; and that some of the criteria for termination of the project are unreasonable. I also suggest some alternative approaches to providing heroin on a trial basis.

The proposal is for two pilot studies, each of six months' duration, followed by a trial of two years. Each stage of the proposal is contingent on the "success" of the previous stage. The core of the proposal is to provide heroin for injection to users who attend a special clinic up to three times a day to receive heroin and/or methadone under close supervision.

Any radical approaches to opiate dependence (such as providing heroin) will be constrained by political and practical considerations. At the outset the investigators associated their proposal with the prevalent paradigm, which seeks to contain heroin users by locking them up or treating them. Thus, the report on feasibility of the trial¹ states that the project "must not be linked with permissive attitudes to illicit drug use and must be coupled with continuing law enforcement and prevention activity against illicit drug use". It seems reasonable to ask whether such views allow adequate exploration of alternative approaches to providing heroin. If these statements indicate undue sensitivity to the perceptions of those with negative views about heroin use, then it follows that any strategy for providing heroin would tend to be very restrictive.

In stage 2 of the feasibility research into the views of dependent heroin users, most people questioned were clients of the ACT methadone program (209) and relatively few had never received treatment (14) or were treatment "drop-outs" (8).²There is little indication that a wide range of heroin users have been comprehensively questioned about possible methods of providing heroin or of evaluating the pilots or trial. By concentrating on clients of the ACT methadone program in which "in both 1993 and 1994, half the people who entered the program had dropped out within a few months",² a premature and limited view of heroin and methadone provision may have been obtained.

Criteria for success of the pilot studies have been established but are not necessarily justified. The first pilot study will be successful if a stable dose of heroin or heroin plus methadone is "found" for "more than half of the participants".² These criteria seem arbitrary and restrictive -- should participants who do not receive stable doses of heroin but nevertheless have better lives (improved health, less involvement in crime) be regarded as unsuccessful? What is the rationale for concluding that the first pilot project is a success if 51% ("more than half") of participants achieve a stable dose of heroin? Why not 25% or 75%?

The progression of the second pilot study to the full-scale trial is contingent on the acceptability to heroin users of being randomised to receive either their choice of heroin, methadone or both or, in the control group, to receive methadone alone. Again, this criterion seems too restrictive in that it gives preference to the design of a trial over improvements in the lives of heroin users. In my view, the latter should be given greatest weight as a criterion at all stages of the project, even if it means redesigning the full-scale trial.

The relative lack of consideration for the potential variability in the needs of individual heroin users is taken to a logical but unreasonable conclusion in the criteria for termination of a trial. One criterion will be if prescribed heroin "has value for only a subgroup of dependent heroin users". This is unreasonable because, for example, if subgroups that were most likely to engage in crime or experience overdose benefited most, then continuing to prescribe heroin for them would surely be appropriate.

Another model for provision of heroin in a pilot program might be decentralised prescription by selected specialist or general practitioners in a few regions, based primarily on individual assessment of needs and on potential risks to individuals and communities.

One seeming advantage of the NCEPH/AIC proposal is the strategy of proceeding by incremental steps, each dependent on the satisfactory outcome of the previous one. However, with only a limited initial model of heroin provision and restricted concepts of progress or "success", any potential convergence to some "ideal" model or, indeed, divergence to more than one, is restricted. If there were several initial models, there would be more opportunity to select those that are effective. The impetus for the project arose, in part, from concerns that current approaches to the problems associated with heroin use "might not be effective".² It follows that one focus could be on those for whom current approaches are not effective.

If we see heroin users as individuals with individual needs, we might be led to alternative ways of making heroin available and of evaluating its usefulness. If we focus first on the things that heroin users and their communities want to change (e.g., crime, disease risk, cost, overdose) and only later on methods of delivery, it seems to me we will have a better chance of making a substantive contribution that will help ameliorate the problems of heroin use.

Arguably, heroin and heroin users are seen as alien by most Australians. By showing people that heroin users are their fellow Australians, sometimes with a particular set of difficulties, we might begin their "acculturation" and not confine them in prisons and clinics or drive them to extremes of behaviour and thereby disable them.

In conclusion, I urge the NCEPH/AIC to consider revising its approach to heroin prescription, and politicians, bureaucrats and others to support more comprehensive consideration of how to solve the problems associated with heroin use. The Commonwealth, States and Territories need to keep this issue on the public health agenda and to provide mechanisms and resources to enable the discussions and research to continue.

1. Burchfield R W, editor. A Supplement to the Oxford English Dictionary. Oxford, Oxford University Press, 1972.
2. Bammer G. Report and recommendations of stage 2 feasibility research into the controlled availability of opioids. Canberra: National Centre for Epidemiology and Population Health, Australian National University and the Australian Institute of Criminology, 1995.

Correspondence: Dr M D Gaughwin, Drugs and Alcohol Resource Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000.