HEROIN MAINTENANCE AND AIDS PREVENTION
GOING THE WHOLE WAY?

Richard Hartnoll co-authored an influential study of heroin maintenance that has often been cited in support of its discontinuation. He re-examines the issue inthe light of HIV and AIDS.

DEFINITIONS OF' HEROIN MAINTENANCE'

Heroin maintenance' is a term that has been used in at least three different senses. The first refers to a treatment or medical management modality, in which heroin is prescribed to addicts within a medical framework. In this sense, it is similar to methadone maintenance as is found in some countries today. The second sense refers to a system of registration, in which addicts who meet given criteria are entitled to possess and use a certain amount. Unlike the first meaning, this does not refer to a treatment modality but to a designated status that confers certain rights on specified categories of people. The nearest example in the drug field was perhaps the arrangement in Iran, following the general prohibition of opium, that allowed male opium smokers over the age of 60 a continued legal supply of opium. A third sense in which heroin maintenance is sometimes used refers to a form of decriminalisation, i.e. to proposals to shift the control of heroin away from the criminal law towards alternative mechanisms for regulating the supply and use of heroin. In this chapter,'heroin maintenance' is used in the first of these senses. The other two concepts are better described by the terms'registration'and'decriminalisation'.

HISTORICAL CONCEPTS OF HEROIN MAINTENANCE

During the twentieth century, heroin maintenance has been suggested as a'solution'to various heroin-related problems. Over this time, the arguments for it have changed, reflecting different historical contexts and changing perceptions of'the problem'. Originally, in the United Kingdom (1920s to early 1960s) it was deemed bona fide medical practice to maintain addicts on their drug of addiction if other treatments had failed and if they were able to live 'normal and useful lives' when given a regular, stable dose but were unable to do so when the supply was withdrawn (Departmental Committee on Heroin and Morphine, 1926). Most addicts at the time were either of therapeutic origin (i.e. had become addicted during treatment for organic disease) or were drawn from the medical and paramedical professions who had access to opiates. There was little evidence of a drug subculture. In that context, heroin maintenance (in fact, often morphine maintenance) was a clinical approach to the management of individual patients who were seen in terms of having a chronic, relapsing nervous disorder.

During the late 1960s and 1970s, non-medical drug subcultures emerged and expanded in Britain, as in many other countries. Within this broader context, younger addicts appeared whose drug use was perceived interms of a hedonistic and socially deviant subculture. The rationale for heroin maintenance changed from managing individual addicts to containing the spread of an'epidemic' (Edwards, 1969). Over the late 1970s and 1980s, this approach to addiction fell out of favour among clinicians and therapists who increasingly saw their job as one of challenging their clients' drug use. Drug policy moved away from maintenance and towards abstinence. Containment of the drug subculture and the illicit market was seen as a task for other social agents such as the police.

Meanwhile, in the USA in the 1970s, heroin maintenance was proposed by some as a way of reducing drug-related crime and 'taking the profits out of the illicit market' (see Danaceau, 1977). These proposals did not bear fruit. In Amsterdam in the early 198OsYlthe CityCouncil discussed the free distribution of heroin to addicts as a development of its policy of 'normalising' drug use and reducing the unwanted social costs of the illicit heroin subculture. This too failed to materialise, partly due to strong opposition from central governmerit and from certain other countries. The outcome was a limited experimental project to provide 50'extraproblematic addicts'with injectable morphine (Derks, 1990). More recently, options including heroin maintenance are being examined in Hamburg, Switzerland and Canberra.

HEROIN MAINTENANCE AS AIDS PREVENTION

In recent years, heroin maintenance has been proposed within a harm-reductionist framework as a response to the emergence of HIV and AIDS among drug-inj ecting populations. The rationale for this is that heroin maintenance programmes would:

Attract and retain a higher proportion of injecting drug users than existing services (including methadone programmes).

Stabilise drug use and reduce involvement in the drug scene and in illicit drug use.

Shift the context of heroin use into a medically supervised framework that offers more support and greater possibilities of health promotion and social integration.

This rationale is based on a model of intravenous drug use and HIV transmission which posits that:

It is the illicit drug scene, the associated lifestyles and the unpredictable circumstances of scoring and using drugs that provide the high-risk context for sharing and HIV transmission.

Some or many injecting opiate users do not wish or are unable to stop at the moment, and do not use existing services effectively (including methadone).

The remainder of this chapter examines the objectives ofheroin maintenance vis a vis AIDS prevention in terms of

Evidence on the possible consequences of heroin maintenance in the context of HIV and the 1990s.

How heroin maintenance would need to be implemented if it were to have a chance o achieving its objectives.

Issues that arise concerning the relationship between the goals of heroin maintenance and different underlying strands of broader policy objectives.

The evidence is drawn largely from the UK, the only country with recent and well-documented experience of heroin maintenance. In particular, this chapter draws on a clinical trial that compared heroin maintenance with the offer of oral methadone (Hartnoll et al., 1980). It must be emphasised that the study took place at a time (1972-76) when many addicts believed they had a right to expect to be prescribed heroin (unlike today) and when the life-threatening phenomenon o AIDS was not an issue. It is also possible that the sample of addicts in that study manifested higher levels of previous pathology than would be found in treatment populations today. This might have an important bearing on projections from that study, because in many situations, the best predictors of outcome tend to be the personal and social variables of the subjects involved.

OBJECTIVE 1: TO IMPROVE 'CAPTURE 'RATES

Improving the 'capture' rate of services means: (1) attracting into treatment intravenous drug users (lVDUs) who are not attracted by existing services, and (2) retaining them in treatment. The broad conclusion, based on past evidence, is that heroin maintenance can increase attraction and retention rates. Thus, in the early 1970s, when heroin (or injectable methadone) was prescribed by many drug dependence units (DDUs) it was estimated that at least 50% of opiate addicts sought treatment. By contrast, in the 1980s, when drug policy was more abstinence-oriented, and when heroin maintenance was no longer offered to new clients, estimates of the treated population ranged from one in four to one in ten (e.g. Hartnoll et al., 1985; Parker et al., 1988). In the controlled trial mentioned above, 74% of those offered heroin were still in treatment 12 months later, compared to only 29% of those refused heroin maintenance and offered oral methadone instead. The question of how to translate that evidence into the context of the 1990s involves consideration of other factors; for example, there isnow a much wider range of treatment and harm-reduction services than was the case 20 years ago. Despite this caveat, however, it is argued here that the ioclusion of heroin maintenance would increase service uptake and contribute to better retention rates, as long as two important conditions were met:

1. One is clear about the target populations for whom heroin maintenance is intended, and the goals it is hoped to achieve.

2. One is willing to put into practice whatever is needed to achieve those goals.

These two apparently non-controversial conditions conceal important constraints on the effective implementation of heroin maintenance, and introduce a major theme of this chapter. Anxiety about anticipated reactions to proposals for heroin maintenance (e.g. concerns that it will lead to increases in addiction, moral objections that it condones heroin use, or sheer disbelief that it is feasible to make heroin available legally and safely) leads to the inclusion, or imposition, of a variety of restrictions, criteria and safeguards which have the effect of negating the purposes for which heroin maintenance was proposed in the first place. If one is serious about introducing heroin maintenance, then it is necessary to 'go the whole way' in terms of implementing what the objectives of heroi maintenance demand. This becomes clear if we loo more closely at whom heroin maintenance is meant t attract, and why.

Heroin maintenance can be seen as an attempt t attract and retain two general categories of opiate users The first covers a broad range of people who are consid ered 'hardto-reach' (but also i mportant- to- reach) These include:

Socially marginalised groups and individuals wh avoid and mistrust official programmes and services.

Younger users, with a shorter history of dru use/drug injecting, including individuals who ar not necessarily dependent but who intend to con tinue using and injecting (but who are more likel to be HIV antibody negative).

More controlled, less problematic users whose drug use and lifestyles are relatively stable and who See little need for help (but who may nevertheless still share injecting equipment as much, or even more, than those who are seen at services).

For these 'hard- to-reach' groups, heroin maintenance can be seen as an alternative strategy to outreach, with heroin as a bait to lure people into a programme, rather than going to the trouble of trying to locate them in the community. In other circumstances, heroin maintenance would not necessarily be considered the most appropriate treatment or management strategy for some or perhaps many of the individuals concerned. Thus some people would stop without intervention; others would seek help later when the need arose. However, within an agenda dominated by HIV and AIDS, the need to 'catch'people as soon as possible, before seroconversion or before they transmit the virus to others, has become paramount.

Proposals to make heroin maintenance attractive and readily available to hard-to-reach populations need, by definition, to contain a minimum of the controls, checks and barriers that are believed to deter those populations. To achieve this objective, heroin has to be prescribed or dispensed on a low threshold basis to almost anyone who asks for it, throughchannels that are easily accessible, confidential and non-stigmatising, and on terms that are acceptable and convenient to the target populations. If not, heroin maintenance cannot be expected to reach the hard-to-reach users that other programmes (including methadone) cannot reach.

It is then that the fears arise and the objections are voiced - young and/or experimental users would be confirmed as 'addicts', other treatment programmes would see their clients tempted away, and so on. There would be very strong pressure to develop criteria that defined eligibility forheroin maintenance, for example some sort of assessment to confirm heroin use/dependence (e.g. urine screening), a minimum number of treatment failures, a minimum age or length of drug history.

These pressures would be understandable. However, their effect would be that the eligible population, in reality, starts to change from the first, broad category described above towards a second, narrower category longer-term addicts who have dropped out of or failed other programmes. This category would also be more likely to include users who were already HIV seropositive.

This second category may well be a valid target population from a clinical and individual perspective. But (1) they are no longer the hard-to-reach but the already reached or even the over-reached who have not responded to other treatments; and (2) the first category, the wary and the hard-to-reach, are unlikely to go to a heroin maintenance programme that is seen as being the last resort for 'hopeless junkies'. Ifonewants to use heroin maintenance to attract and retaln the original target groups - the hard-to-reach and the reallyhard-to-reach, then one has to go the whole way andmake heroin truly accessible. Only then can it be HIV prevention in the intended sense and not a safety net.

The other two objectives of heroin maintenance as an AIDS prevention strategy are considered more briefly.

OBJECTIVE 2: TO STABILISE DRUG USE AND REDUCE DRUG SCENE INVOLVEMENT

The broad conclusion here, based on previous experience, is that a significant reduction in illicit heroin use and involvement in the drug scene could be expected among those recruited into heroin maintenance programmes. Thus in the controlled trial, the reported average daily consumption of illicit heroin among those prescribed heroin decreased from about 75 mg to about 20 mg (doses converted to 100% pure equivalents). More generous prescribing would most probably have reduced illicit use even more. More importantly, it is also probable that heroin maintenance would reduce the uncertainty associated with scoring and using illicit heroin and minimise the sense of urgency and desperation that can be linked to sharing injecting equipment, even among those who try to avoid such high-risk behaviour. However, this conclusion must be put into perspective.

The reduction in illicit use of heroin is likely only to be partial and relative, unless sufficient doses are prescribed and unless one is willing to allow some increases in dose as tolerance increases (Parry, 1992). Although the use of heroin may stabilise after a time, the use of other drugs, notably central nervous stimulants and perhaps some sedatives, may not change very much. From the point ofview of AIDS prevention, continued use of drugs other than the prescribed heroin does not matter as long as it does not affect the occurrence of risk behaviours such as sharing syringes or unsafe sex. One should have pragmatic rather than unrealistically ideal expectations of changes in drug use and risk behaviours that are likely to follow from heroin maintenance.

Several other issues arise here. Heroin has a shorter duration of action than, for example, methadone. This means that dependent users are likely to use heroin several times a day. The provision of heroin also means that users are injecting rather than taking the drug orally (ignoring for the moment the possibility of heroin maintenance involving heroin in smokable or other non-injectable forms). The implications for both staff and clients is that on-site consumption is very much more difficult than for oral methadone programmes. This would be true both in terms of the number of visits per day that might be involved, and in terms of the ambience and dynamics of a service where substantial numbers of clients were all supposed to inject on the premises. It would be unappealing both to staff and to clients. The provision of some oral methadone along with the heroin might alleviate some of these difficulties and reduce the number of visits per day, but the core of the problem remains.

Traditionally, heroin maintenance in Britain involved take-home heroin, in which a weekly prescription was mailed to a retail pharmacist near the clients' homes. The clients then collected the heroin on a daily basis and used it as and when they wanted. They were also provided with ample supplies of disposable syringes, needles, sterile water, cleansing swabs etc., often on a weekly basis. It is likely that heroin maintenance as a programme that was intended to reach a wider population of opiate users and injectors would have to include either some form of take-home or other arrangements to allow dispersed and off-thepremises consumption. For heroin maintenance to attract and retain clients long enough to achieve the objective of stabilising their drug use, programmes would have to (1) allow clients a considerable degree of control regarding both the amount of heroin they received and how and when they used it, and (2) accept the risk that some heroin might be diverted.

Once again, anxieties and reactions to the implications of a wholehearted implementation of heroin maintenance are liable to lead to demands for constraints and regulation which will render the programmes unattractive and intrusive to important parts of the target populations. There is the possibility that they would be left trying to attract only those drug users who have no options remaining. Even they may not find it attractive, as the Amsterdam experimental morphine project for 'extra-problematic drug users' suggests.

OBJECTIVE 3: TO SHIFT CONTEXT OF USE TO A MEDICALLY SUPERVISED FRAMEWORK

The final goal of heroin maintenance in the context of AIDS and harm reduction is to providp the opportunity for more effective health promotioln among otherwise hard-to-reach target groups, and to increase the possibilities for better social integration and social functioning.

The overall impression from the experience of heroin maintenance in Britain is that it was reasonably effective in the pre- 1960s era for 'therapeutic' addicts and medical professionals who became addicted, i.e. for individuals or groups who were already well integrated, or who at least could function relatively well (Schur, 1962). In the subsequent period, however, the evidence suggested that improvements in health and social functioning were observed only among a minority of maintained addicts (Hartnoll et al., 1980; Stimson and Oppenheimer, 1982), and that for many heroin maintenance did not, of itself, lead to improved social integration, better health or other desired outcomes in the area of social functioning.

As with other conclusions based on past experience, these conclusions should be placed in context. Thus, in the late 1960s and 1970s, an immediately lifethreatening phenomenon such as AIDS was not an issue. There is sufficient evidence to suggest that it is realistic to expect changes in risk behaviour, albeit incomplete, onthe partof significant proportions of the still- injecting population (e.g. Stimsonet al., 1988; van den Hock et al., 1989). In this respect, heroin maintenance can be viewed conceptually in similar terms to needle exchanges - as an intervention that facilitates positive changes in health behaviour among drug injectors who are unwilling or unable to stop injecting. However, as with syringe exchanges, although heroin maintenance may reduce the prominence of some of the circumstantial factors that encourage risky behaviours, it is unlikely that it would, per se, produce some of the more dramatic changes, either in individual behaviour or in social integration, that some of its more uncritical proponents have claimed. For that to occur, more imaginative and concerted educational strategies are needed and, above all, support for developing constructive alternatives, practical training opportunities, realistic pathways out of drug-centred lifestyles, and so on. These are not incompatible with heroin maintenance, but they go far beyond it.

CONCLUSION

The evidence of the early years of the 'drug clinics' in Britain suggests that it is feasible to implement heroin maintenance, though it is probably only a practical proposition on a large-scale basis if off-the -premises consumption, and the risks that this entails, are considered.

It is likely that heroin maintenance could achieve some of its objectives in terms of AIDS and harm reduction. In particular it would most probably increase attraction and retention rates; diminish, though not eliminate, illicit heroin use, drug scene involvement and HIV-related risk behaviours; and encourage stabilisation of lifestyle, though probably only in a minority of clients who alreadyhad access to appropriate personal or social resources. It has not been, nor is it likely to be, a dramatic or utopian solution. Other complementary strategies and services remain essential. It will only reach the really-hard -to- reach if one is willing to take the necessary steps outlined above to achieve that goal - and that may well conflict with other policy objectives. Similar considerations apply to registration schemes. Although they would avoid some of the tensions between treatment and prevention, they would still be associated with some sort of assessment process, eligibility criteria, monitoring etc., and would involve official confirmation as a recognised, registered heroin user which in all probability would be perceived as a 'confirmed addict', a label that perhaps only a minority of the target populations outlined above would be willing to acquire. The decriminalisation debate is perhaps a more relevant area for discussing the problems of effectively reaching the hard-to-reach and for reducing, in the longer term, the costs and damage that arise from hidden and illicit drug use. That debate, however, falls outside the brief for this chapter. In the meantime, it is important to make clear distinctions between decriminalisation, registration and maintenance. In the case of heroin maintenance, the purpose of this chapter has been to emphasise that its objectives can only be achieved to the extent that one is willing to follow the logic of what those objectives imply.

Richard Hartnoll, Institut Municipal d'Investigacio Medica, Barcelona, Spain

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