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Miller P., McKenzie S., Lintzeris N. et al.
Mental Health and Substance Use: Dual Diagnosis: 2010, 3(3), p. 248–259.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Miller at email@example.com.
Addicts attending a clinic twice a day to take prescribed heroin seems like a recipe for an unwelcome increase in local drug-related disorder and nuisance, but given (as there usually will be) small numbers, experience in London was that not much changed.
Summary This report concerns the impact on the neighbourhood of a clinic in London which from 2005 began prescribing injectable heroin and methadone in the treatment of heroin addiction. Especially because they demand frequent attendance (up to twice a day in the featured study), heroin prescribing clinics have the potential to aggravate drug-related nuisance and distress caused to the local community. Despite this potential, the international literature suggests such clinics are unlikely to affect either the number of drug users in the area or levels of crime or public disorder. Whether this was also the case in London was the subject of the featured study.
The London clinic opened as part of the RIOTT trial of injectable heroin and methadone versus oral methadone in the treatment of heroin addiction. Other clinics in the study were in Darlington and Brighton. The study recruited heroin addicts who had been injecting the drug for at least three years, had been in conventional oral maintenance treatment for at least the past six months, yet who had continued to inject street heroin on at least half the days over the preceding three months. They were required not to be dependent on alcohol or regularly misusing benzodiazepine drugs.
As described by this Findings analysis, the main questions posed by the study were whether patients who remained wedded to street heroin despite extensive treatment were simply beyond available treatments, whether it was just that their current oral treatment programmes were sub-optimal, or whether they would only do well if prescribed injectable medications. Each of these three propositions was true for some of the patients. A third did seem beyond current treatments even as extended and optimised by the study. For a fifth, 'all' it took was to individualise and optimise dosing and perhaps also psychosocial support and treatment planning in a continuing oral methadone programme. But nearly half the patients only did well if prescribed injectable medications, with heroin by far the better option than methadone for suppressing illegal heroin use. As defined by the study, two-thirds of these seemingly intractable patients responded well to this option.
Among the study's patients were the 35 treated in London by the time in 2007 when data collection ended for the featured study, some of the roughly 300 at any one time in a range of addiction treatments at the clinic.
The neighbourhood impact of this extension to the clinic's work was assessed by interviewing local residents and workers whose occupational or community roles were related to street amenity or social order, plus elected representatives from the local council and residents' groups. The 22 interviewed before the RIOTT clinic started operating were among the 40 (re-)interviewed in 2007, from 18 to 22 months after the clinic had recruited its first patients.
Beforehand few foresaw any benefits for the community. Instead, commonly they were concerned that twice-daily visits by RIOTT patients would increase the number of drug users coming to the area, and that crime would increase. But after nearly two years, few had noticed any impacts attributable to the RIOTT clinic, whether positive or negative. Since the start of the trial, most had not noticed any changes in levels of crime, drug use and trading, street drinking, public intoxication, street cleanliness or local trade, while others who did notice such changes did not link them to the RIOTT clinic.
Their impressions were reinforced by police records of crimes committed in the immediate area of the clinic and in the London borough of which this formed a part. Either overall or for particular categories of crimes, these revealed no substantial changes from before to after the clinic started work. In particular this was true for offences of theft and handling stolen property in the vicinity of the clinic, the non-drug offences most commonly linked to drug users.
The model of service provision used in the RIOTT trial – relatively small numbers prescribed injectables in the context of a larger prescribing and treatment clinic – had no adverse effects on the community as assessed by crime and feedback from key informants including local law enforcement officials and representatives of residents' organisations.
The study also illustrated the importance of developing communication strategies with local communities before implementing new interventions, rather than later having to engage in damage control after adverse publicity. Lack of pre-trial information and the perceived secrecy of its launch allowed misinformation to fuel residents' understandable fears.
commentary The featured study usefully reviewed relevant evidence from other heroin prescribing trials and from studies of drug consumption rooms in which people take their own drugs rather than these being prescribed. Generally studies either did not scientifically assess local impacts or found these neutral or positive. That there was also no impact in London might be expected at a clinic where patients in the RIOTT trial formed at most 1 in 8 of the caseload, and where these patients, despite their continuing use of illicit heroin, were selected to be free of serious problems with alcohol or benzodiazepine tranquillisers and sleeping pills, and were prepared to at least try to comply with the stringent attendance requirements of the clinic. Spearheading an experimental treatment from which they and their peers might benefit, they had much to lose from visibly upsetting the local community. With its history of deprivation and hard drinking, people in the area are unlikely to be shocked by the sight of marginal and socially disadvantaged people. Nevertheless, these conditions can also be expected to apply to other injectable prescribing services opened at existing addiction treatment clinics which prescribe oral methadone, offering some reassurance that there too the local community should not suffer.
The fact that few informants attributed any impacts to the RIOTT clinic is encouraging, but it is unclear how they could have known whether any drug users or drug-related incidents they witnessed involved RIOTT patients as opposed to other patients at the clinic or drug users not in treatment at the clinic at all.
A companion study found that in respect of troublesome street drinking, more of a concern locally than drug-related nuisance, the injectables clinic may in fact have been beneficial. Clinic patients recorded among street drinkers causing some nuisance at the start of the study relatively rapidly disappeared from the records.
Though in any given locality the numbers may be too small for a noticeable impact, heroin prescribing clinics have generally been associated with greater reductions in crime among their patients than among patients in the same studies randomly allocated to oral methadone. In an analysis published in 2011 of the findings of relevant trials, based on the patients' own accounts, all but two of seven studies recorded significantly greater reductions in criminal activity among heroin compared to methadone patients, and in another this was a non-significant trend. Just two studies recorded arrests or imprisonment; across these there were significantly fewer such events among patients prescribed heroin. These benefits come on top of the benefits from conventional oral substitute prescribing, promising some respite from acquisitive crime committed locally to fund drug purchases.
For more on substitute prescribing for heroin addiction see this Findings hot topic. For heroin prescribing studies in particular run this search on the Findings site. Especially see this 2011 synthesis of research to date, and these reviews from Drug and Alcohol Findings and a researcher involved in the major UK trial, which paid careful attention to the context of the studies and the details of the treatments.
Thanks for their comments on this entry in draft to Peter Miller of Deakin University in Australia and Anthea Martin of Kings College London in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 15 June 2012
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STUDY 2014 Drugs: international comparators
STUDY 2010 Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial