One hundred years ago, the UK became the first country in the world to prescribe heroin (diamorphine) to heroin users as a treatment for opioid dependency. The ‘British system’ was formally established in 1926 and took a medical approach to opioid dependency – heroin users could be prescribed diamorphine as their drug of choice to stem illicit use and improve health. At that time, most of the users were middle or upper class, and the system was in operation until the 1960s.
The ‘British system’ came under international pressure from the United States which viewed heroin use as a moral – rather than medical – issue. There was also concern amongst the British establishment that we were seeing a shift from middle-class ‘iatrogenic’ use (ie the result of medical activity) to dependence that arose because of hedonistic use by young people.
Remember, this was the ‘Swinging Sixties’ – mods and rockers were fighting on the streets and on the beaches. Hippies began to emerge, and working-class teenagers were becoming rebellious and using drugs. Some were using heroin that they got via the prescription pads of a small group of London GPs.
For almost 40 years, middle class heroin users in the UK could receive diamorphine to treat their opioid dependency from their own general practitioners. From 1968 onwards, however, only doctors with a Home Office licence could prescribe heroin via a specialist clinic, usually referred to as a regional drug dependency unit (DDU). From 1968 to 1978, the percentage of people in treatment for opioid dependency prescribed diamorphine dropped to less than 10 per cent.
THE RISE OF METHADONE
‘Brown’ powder heroin began to arrive in the UK in the early 1980s. Unemployed, working-class young people began to smoke and inject this brown heroin, and those who developed a habit, and went looking for treatment, were offered methadone or methadone. As ever in British drug policy, social class determined who got what. Posh people could get prescriptions from private doctors and pay for expensive residential rehabilitation treatments. The rest of us got what we were given.
Fast forward to 1999, and new Department of Health clinical guidelines are produced which further restrict access to diamorphine. By the year 2000, there were approximately 500 diamorphine patients and by 2019, this number had fallen to less than 300. The vast majority of the approximately 150,000 patients in medication assisted treatment (MAT) in the UK receive methadone or buprenorphine.
Despite the decline in diamorphine prescribing for the treatment of opioid use disorder in the UK, the case for its efficacy and legitimacy remains. In recent years, there have been clinical trials of heroin-assisted treatment (HAT). These trials require patients to come into a medically supervised clinic space, usually twice a day, to inject diamorphine under conditions that dictate the route, dose and frequency of administration. These clinical trials have consistently shown that HAT works for people who are not responding to methadone or buprenorphine. HAT is effective in health gains, crime reduction and prosocial behaviour. The evidence jury has decided that HAT works. So, why is HAT not on offer?
BARRIERS TO HAT
The most often cited barrier to further expansions of HAT is cost. That is, the cost of the medication itself, the cost of nursing staff to supervise injections and the opportunity cost – money spent on HAT could be spent elsewhere in the treatment system. After all, you can’t have enough recovery navigators, recovery coaches and recovery whatevers… or can you?
The price of another signposting team could provide a safe supply of diamorphine to keep marginalised users alive. A difficult choice for commissioners and providers – offer HAT or further expand the workforce. The expanded workforce can then reach out to the most marginalised and disenfranchised users and be reminded that they have nothing to offer… bye bye.
Funding for HAT expansion has been precarious. For example, the Middlesbrough heroin assisted treatment (MHAT) programme ran for three years until closing on the grounds of cost in 2022. There are currently HAT programmes in Scotland and the West Midlands, and there are also some ‘legacy’ patients scattered around who have managed to hold on to their diamorphine prescriptions.
It’s tempting for advocates of HAT to argue the case primarily on the grounds of crime reduction. However, the UK is currently facing an epidemic of drug-related deaths. HAT can reduce these deaths, lengthen lives and improve the quality of those lives. We can now access regular supplies of diamorphine in different formats that expand the offer and may reduce cost. As well as injectable diamorphine, there are 200mg tablets and a nasal spray.
HIGH RISK GROUPS
One of the features of those at highest risk of premature death is recycling in and out of opioid substitution treatment (OST). For this group, methadone does not hold enough attraction to ensure retention and buprenorphine does not provide enough of an anxiolytic effect to treat a lifetime of trauma. Heroin is very effective at suppressing trauma-related feelings of being exposed, anxious and vulnerable.
This means that the most marginalised people who use drugs are not being offered suitable opioid agonist maintenance treatment (OAMT) options that would support them to move off street opioids. Harm reduction is undergoing a renaissance in the UK as we see the limits and dangers of forcing people out of treatment and into unwanted states of abstinence.
If we’re serious about addressing drug related deaths, it’s time for a new HAT.
Mark R Gilman is a consultant on substance use at Harm Reduction Research, Policy & Practice