Pubdate: Mon, 21 Jan 2002
Source: Medical Journal of Australia (Australia)
Copyright: 2002 Medical Journal of Australia
Contact:  http://www.mapinc.org/media/259
Website: http://www.mja.com.au/
Authors: Wayne D Hall, Jo Kimber and Richard P Mattick
Note: Office of Public Policy and Ethics, Institute for Molecular 
Bioscience, St Lucia, QLD. Wayne D Hall, PhD, Director.
National Drug and Alcohol Research Centre, University of New South Wales. 
Jo Kimber, BSc (Hons), Senior Research Assistant; Richard P Mattick, PhD, 
Research Director.
Bookmark: http://www.mapinc.org/find?131 (Heroin Maintenance)

BREAKING THE DEADLOCK OVER AN AUSTRALIAN TRIAL OF INJECTABLE OPIOID MAINTENANCE

Injectable heroin maintenance has been advocated as a form of treatment for 
opioid dependence that would attract, and retain in treatment, addicts who 
have either not sought treatment or who have failed at other forms of 
treatment, including methadone maintenance. Advocates of heroin maintenance 
argue that it would increase the proportion of addicts in treatment and 
reduce heroin use, drug-related crime, and deaths due to overdose. [1]

A 1991 proposal by a Select Committee on HIV, Illegal Drugs and 
Prostitution of the ACT Legislative Assembly led to a feasibility study for 
a heroin trial in the ACT. [1] In 1997, the Ministerial Council on Drug 
Strategy voted in favour of a heroin trial, but the trial did not proceed, 
as the Federal Government would not amend legislation to allow heroin to be 
imported for the trial or allocate funds to monitor the use of heroin in 
accordance with international treaties. [2]

Dramatic rises in deaths caused by opioid overdose in the late 1990s 
prompted more calls for a heroin trial. [3] The Federal Government refused 
to countenance a trial, creating a policy deadlock that prevented the 
evaluation of what proponents [2] claimed was a potentially valuable policy 
option.

If we can avoid the fixation on a trial of heroin per se, there is a way 
out of this policy deadlock. The alternative option we are proposing is to 
trial hydromorphone (Dilaudid), an injectable opioid that has similar 
effects to heroin. [4,5] Even if the Federal Government's attitude towards 
a heroin trial were to change, we believe that trialling hydromorphone 
would be a better option than trialling heroin, for a number of reasons:

- - The subjective effects of hydromorphone are very similar to heroin in 
experienced heroin users and both have short durations of action. [5]

- - Hydromorphone is a registered drug (Schedule 8) in Australia, so it can 
be prescribed for medical purposes and used in clinical trials. There would 
be no need to change federal legislation to allow a trial of injectable 
hydromorphone. Nor would there be any need for oversight of heroin 
importation and distribution by the International Narcotics Control Board.

- - The use of hydromorphone can be distinguished from the use of heroin by 
urinalysis, [6] thus allowing detection of any covert use of street heroin 
by trial participants. (A major criticism of the Swiss heroin trials was 
that this could not be done. [4])

- - Hydromorphone lacks the political symbolism of heroin. [5] This would 
allow a clinical trial to be conducted in the absence of the media 
sensationalism that would probably attend a trial of heroin maintenance. A 
protocol for a clinical trial of hydromorphone could be assessed by peer 
review and funded by the National Health and Medical Research Council. (On 
the other hand, a trial of hydromorphone might have the disadvantage of 
discouraging participation of dependent heroin users who only want heroin. 
Assessing the attractiveness of hydromorphone to the patient population 
would therefore be an important part of a feasibility study for a clinical 
trial.)

- - A trial of hydromorphone may reduce the need to inflate the public health 
benefits of heroin maintenance in order to enlist community support for a 
heroin trial. Allowing the prescribing of injectable opioids, whether 
heroin or hydromorphone, would be unlikely to substantially reduce the 
heroin black market or heroin-related crime. The cost of providing this 
form of treatment, and the restrictions that the community would probably 
impose on eligibility for it, mean that too few heroin-dependent people 
would receive this form of treatment to have a substantial effect on heroin 
use and its consequences in the population. [7] Injectable opioid 
maintenance would most likely be a treatment option reserved for dependent 
heroin users who have failed at existing forms of treatment (the model that 
was trialled in Switzerland [8] ).

Any trial of hydromorphone maintenance for opioid dependence should include 
an economic evaluation of the comparative costs and benefits of competing 
forms of maintenance treatment. These could include alternative forms of 
injectable opioid maintenance using longer-acting agonists such as 
methadone and partial agonists such as buprenorphine. Oral methadone 
maintenance should be the comparison condition, as in a recent trial of 
heroin maintenance. [9]

For these reasons, we believe a controlled clinical trial of injectable 
hydromorphone maintenance would break the impasse over a heroin trial and 
enable the Australian community to decide what role injectable opioid 
maintenance has to play in the public health response to dependent opioid use.

Competing Interests

None declared.

Acknowledgements

The authors would like to thank Professor George Bigelow, Professor Jerry 
Jaffe, and Dr Deborah Zador for their comments on an earlier draft of this 
article.

References

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Aust 1996; 164: 690-692.

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3. National Crime Authority. Organised crime in Australia. NCA Commentary 
2001. Canberra: National Crime Authority, 2001.

4. Jaffe J. Injectable opiate maintenance in the United Kingdom: a view 
from the United States. Addiction 2001; 96: 557-560.

5. Bigelow GE, Becker AB, Vernotica E, Liebson IA. Comparison of heroin and 
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6. Meatherall R. Confirmation of codeine, morphine, 6-acetylmorphine, 
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9. Perneger TV, Gina F, Del Rio M, Min A. Randomised trial of heroin 
maintenance program for addicts who fail in conventional drug treatment. 
BMJ 1998; 317: 13-18. 
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