SHORTCOMINGS OF MEDICALLY CONTROLLED HEROIN PRESCRIPTION

by Freek Polak, psychiatrist, Amsterdam*

The m Medically controlled prescription of heroin to people who are chronically dependent on it heroin dependent people is an important step ahead in drug policy advance in the context of m edicalisation framework of medicalis ation. It is a harm reduction measure that was controversial at first, but has since proved effective and has convinced many former opponents of any kind of liberalisation. In the Netherlands there was simultaneously admiration for the Swiss and jealousy.

At this session, the “critical discussion of heroin research: past efforts and new perspectives”, the shortcomings and disadvantages of medicalisation and heroin prescription should not be overlooked just because we are so happy drug policy is moving in the right direction.

Heroin prescription is an artefact of drug prohibition

Despite some of the imperfections extensively discussed today, the Swiss heroin project has been a huge success (I felt tempted to say ´an unmiti­gated success´) and serves an important function in the European and global context of the pursuit of new drug policy strategies. We should nonetheless bear in mind that heroin prescription is an artefact of drug prohibition. If we had a more sensible system for regulating the drug market, there would be no need for medically controlled distribution.

Medical prescription can never fully fill the demand for drugs. Only the most problematic drug users are accepted in the programmes. The demand on the part of less problematic and recreational users will never be met by either their own physicians or the public medical facilities. That part of the drug problem can only be resolved by a coherent drug policy that addresses medical and non-medical use alike.

Lack of repressive policy evaluation

We are discussing the results of the Swiss and other projects and various research designs for new projects, and I would like to point out what I consider a disturbing and unacceptable discrepancy between the demands for the scientific evaluation of repressive and of liberal policies. Of course new harm reduction methods should be judged by the scientific forum if they are to be acceptable to the public, to politicians, and to the international agencies. In practice this means research has to be conducted according to the most rigorous scientific standards. All the while, repressive methods of drug control escape scientific scrutiny altogether. Even if data are available, they are often used in a questionable way. Official reports customarily view the number of drug-related arrests and incarcerations as an indication of the seriousness of the drug problem and not as a consequence of drug prohibition (Stephan Quensel, 1999, personal communication).

At the United Nations Drug Summit in June 1998, an evaluation of the last decade of international drug policy was initially planned, but later dropped from the agenda. One of the few academic evaluations of drug prohibition is Ernest Drucker´s recent study on the public health consequences of drug prohibition which was – quite surprisingly - published in Public Health Reports, the official journal of the US Public Health Service (“Drug Prohibition And Public Health”, Public Health Reports, Jan.-Feb., 1999).

Randomised controlled trial inadequate for drug policy

New repressive measures are introduced regularly without any serious evaluation, but there does seem to be a general consensus that with respect to research on the distribution of heroin, only one design can be applied, i.e. the design for clinical pharmaceutical research, the randomised controlled trial. Now this kind of research – appropriate for the introduction of new therapeutic substances – is of limited value as regards heroin prescription, since heroin is not a new substance. The subjects of the research have been injecting or smoking heroin for years, and in far worse circumstances.

One of the shortcomings of the controlled clinical trial in heroin research is that it creates a new, artificial pattern of usage, and what is subsequently studied is this artificial pattern of use. As a consequence, the findings don´t adequately serve the purpose.

Heroin can be safe

The most important result will probably be that the public-at-large and politicians become accustomed to the idea of providing heroin to the addicts in the poorest physical and mental condition, and that instead of dying, they become healthier and function better.

The consumer perspective

Heroin distribution is discussed here purely in the paradigm of treatment: compulsive heroin use as a manifestation of a chronic or recurrent disorder.

Why not look at it from the users’ perspective? Occasional or frequent use, more problematic or less, with more or less self-control. In any other context, it would be only logical to take the consumers’ point of view into consideration. Since there are no representatives of drug users here today, I would like to point out that the central issue is one of control.

What we really want to know is how the legal restrictions on the drug trade and drug use can best be repealed so as to allow personal, internal control and informal and group norms to replace external control. We want to facilitate and stimulate this process and for the design of new regulatory systems, we need to determine the minimum extent and the nature of external control that will be required in this new situation. (See the report “Drug Control through Legalisation” published by the Netherlands Drug Policy Foundation, online at for a scenario for the first phase of the transition to legal regulation.)

It is obvious that the current heroin projects with their clinical-pharmaceut­ical approach cannot provide this information. For this purpose, research is needed with a social science rather than a medical and pharmaceutical orientation. I hope this kind of research can be carried out in the near future.

Small-scale research and governmental responsibility

The last point I want to make is that no matter how important the Swiss research on heroin-assisted treatment has been, we should also be grateful to the men and women who conducted the numerous small-scale, descriptive studies all across the globe that paved the way for today´s harm reduction projects.

To me the symbol of these researchers is British psychiatrist John Marks. He and many others have done the important work in opiate maintenance that was described and analysed carefully by Annie Mino, Robert Haemmig and others in preparing for the Swiss trial.

John Marks has been accused of not fully coming up to scientific standards in his publications. We should not forget that progress does not solely result from large-scale top quality studies. Simple ones are also needed, but the point is that if the results are promising, that particular line of research should be adopted by larger institutions and, if necessary, instigated by the govern­ment. On this point however, most governments are lax or at best very slow.

As to the Swiss heroin trial, it is a sobering thought that on the basis of results in their own countries and with public health as their main motive, some other governments should have launched this kind of research years earlier. But the Swiss went ahead and did it. I am grateful to them and would like to encourage them to keep up the good fight no matter how irresponsibly aggressive the early reactions to their efforts in some other countries and in some international agencies may have been.

-----

Freek Polak, MD, psychiatrist

Netherlands Drug Policy Foundation

Vossiusstraat 31

1071 AG Amsterdam

the Netherlands

Tel **3120 5555 799

Fax **3120 5555 613

E-mail

--

This text is an edited version of comments made on March 10, 1999 at a session entitled: “Critical Discussion of Heroin Research: Past Efforts and New Perspectives” of the International Symposium “Heroin-Assisted Treatment for Dependent Drug Users: State of the Art and New Research Perspectives: Discussion of Scientific Findings and Political Implications”, Bern, 10-12 March, 1999, organised by the Swiss Federal Office of Public Health, and the Psychiatric Services of the University of Bern.