A number of countries – including Switzerland, the UK, Germany, the Netherlands, and Canada – prescribe heroin for use under medical supervision, as part of successful programmes to treat long-term users of illicit opioids. Recently Glasgow and Durham, UK, have put forward proposals for Heroin-assisted treatment (HAT) aimed to combat public health risks caused by street use.
HAT is significantly less common than opioid substitution treatment (OST). This is because HAT is typically reserved for opioid users who have proven unresponsive to other forms of treatment, and because it is considered more politically controversial. But despite its relatively limited availability, there is now a substantial body of evidence demonstrating the effectiveness of HAT. This evidence provides useful lessons for managing one of the most risky and problematic forms of drug use as a public health challenge, rather than a criminal justice one.
Legally recognised as a medical intervention and therefore not prohibited by the UN drug conventions, HAT shows the wider potential benefits – locally, nationally and internationally – of moving the supply and use of an illicit drug into a completely legal, strictly regulated market. The experience of Switzerland, which became a pioneer of HAT in the 1990s, represents the most comprehensive source of empirical evidence on the outcomes of such a transition. It suggests that if this form of treatment were rolled out widely – particularly in major consumer countries – it could have major benefits for many people dependent on heroin, and a significant impact on the scale of illicit drug markets.
The prescribing of medical-grade heroin as a treatment for heroin dependence has a long history, having been firmly established in UK medical practice by the 1926 Rolleston Committee,1 after which it operated in parallel with the criminalisation of non-prescribed heroin under both domestic and international law.2 Coming to be known as the ‘British system’, it remained in place until concerns around rising heroin use among young people, overprescribing, and the risk of the drug being diverted to the illicit market, led to heavy restrictions being introduced in 1967. Despite an exponential rise in use since then, today less than 200 of the UK’s more than 200,000 users receive heroin on prescription.
Switzerland, like much of Europe, experienced a rapid rise in injecting heroin use during the 1970s and 1980s, but ultimately adopted a very different policy model to the UK. By the 1980s, heroin use had graduated into a full-blown public health crisis, as it became clear that illicit injecting – and particularly high-risk behaviours such as the sharing of needles – was associated with high rates of HIV transmission. In 1986, Switzerland had approximately 500 HIV cases per million people, the highest proportion in Western Europe at the time.3 By 1989, half of all new cases of HIV transmission were linked to illicit drug injection.4 By 1990, HIV prevalence was over 40% among those who reported having used drugs for more than 10 years, and in the era before effective treatments for HIV/AIDS, mortality rates among this population were correspondingly high. Added to this, there were growing fears about sexual contact with injecting drug users leading to a rise in HIV infection rates among the wider population.
As this challenge grew, initial responses consisted mostly of traditional law enforcement crackdowns. Switzerland’s federal drug law was revised in 1975, to include a greater focus on abstinence, which led to significantly increased arrests, and mandated registration of illicit drug users and sellers by the police – rejecting harm reduction measures such as needle and syringe programmes (NSP), and imposing onerous licensing requirements on methadone prescribing. The response failed, with illicit drug injection and related health problems continuing to increase sharply. Zurich became a particular focus, with the number of people who inject drugs growing from less than 4,000 at the time of the 1975 law revision, to an estimated 10,000 in 1985, 20,000 in 1988, and 30,000 in 1992.5
As Zurich’s street drug scenes became an increasingly visible, problematic and politically charged manifestation of the injecting phenomenon, new approaches were demanded. In 1987, the city authorities made a pragmatic decision, attempting to contain and manage the problem by establishing a tolerance zone – the Platzspitz park – where people were allowed to use drugs. The space soon became known as ‘Needle Park’, and it did enable the injecting scene to be contained and managed to some degree, as well as facilitating the targeted provision of health services. Between 1988 and 1992, the ZIPP-AIDS project based in the park responded to 6,700 overdose episodes, vaccinated thousands for hepatitis B, and distributed 10 million sterile syringes.6
The ongoing health and crime problems linked with needle park, particularly those that spilled into neighbouring areas, ultimately led to its abrupt closure in 1992. In an example of the so-called ‘balloon effect’,7 the drug scene simply shifted elsewhere, and problems continued. However, the way in which the intervention prioritised health over enforcement helped shape the discussions around policy responses to drug injection that followed. Once again, it became clear that new thinking was needed.
In 1991, at the request of municipal authorities and state (canton) governments, a new national programme was established within the Federal Office of Public Health to reconsider the problems. Reflecting previous experiences, the recommendations that emerged were public health-led, including a combination of established harm reduction interventions (OST and NSP), treatment and social support provision, and a new call to explore HAT. In 1992, a change in the law enabled such an exploration.
The Swiss HAT model differed from the old British System in that rather than being given ‘takeaway’ prescriptions, patients were required to attend a clinic once or twice a day and to use their prescriptions on site under medical supervision. The idea was to combine the benefits of prescribed supply (heroin of known strength and purity, free from contaminants and adulterants, and used with clean injecting equipment) with the benefits of regular access to services and supervised use in a safe and hygienic venue (as found in the more common supervised injection facilities such as Canada’s Insite facility8), while also preventing the diversion of prescribed heroin to the illicit market.
The first HAT clinics opened in 1994 as part of a three-year national trial. In late 1997, the federal government approved a large-scale expansion of the trial, aimed at accommodating 15% of the nation’s estimated 30,000 heroin users, specifically those long-term users who had not succeeded with other treatments.
The programmes were explicitly designed and implemented as an empirical investigation. They were rigorously documented and evaluated, and evolved in line with the results generated, following public consultation and debate. In this way, it was possible for the policy model to grow from a scientific experiment into a more formalised policy framework that enjoyed growing public support – a process helped by overwhelmingly positive outcomes.
Summary of Impacts
- Health outcomes for HAT participants improved significantly
- Heroin dosages stabilised, usually in two or three months, rather than increasing as some had feared
- Illicit heroin (and illicit cocaine) consumption was significantly reduced
- A large reduction in fundraising-related criminal activity among HAT participants. (This benefit alone exceeded the cost of the treatment9)
- Heroin from the trials was not diverted to illicit markets
- Initiation of new heroin use fell (the medicalisation of heroin making it less attractive), and, in turn, there were reductions in street dealing and recruitment by ‘user-dealers’10 11
- Uptake of treatments other than HAT, especially methadone, increased rather than declined (as some had feared it might)