Miller P., McKenzie S., Walker J. et al.
Drugs and Alcohol Today: 2011, 11(4) , p. 204–209.
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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 in London the effect was to remove rather than add people to the troubling street-drinking population.
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 through the records of a community forum which met fortnightly to (amongst other things) monitor street drinking and other anti-social behaviour. Data was available from November 2004 through to September 2006, straddling the time when the RIOTT clinic recruited its first patients in October 2005. Over that time, 81 individuals were recorded as engaging in anti-social behaviour or being a part of the 'street population'; the vast majority were identified as street drinkers. Of these, six were patients in the RIOTT trial at the time they were identified. On average they remained on the forum's records for 15 weeks, 20 weeks less than the 45 weeks average across all those in the forum's records. None of the RIOTT participants who appeared in the forum's records progressed to being served with anti-social behaviour orders, were sentenced to custody, or arrested for criminal offences.
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's experience of street drinking and anti-social behaviour, as assessed by a local forum which exercised unprecedented surveillance of a street population.
All six RIOTT patients identified in the forum's records during the observation period were no longer identified by the time they had finished the trial's treatments, clearly indicative of a positive treatment effect. On average, they had been enrolled in RIOTT for 15 weeks before last being mentioned in the records – probably an overestimate of the time they were actually seen as causing any problems, because even after this they would continue to be recognised by the same observers. Nevertheless, it is clear that every individual who presented a problem for the local community prior to enrolling in RIOTT ceased to do so within an average of 15 weeks, 20 weeks less than the average amount of time spent on the register by the general street population.
These observations may have partly been due to the way people were selected for the RIOTT trial tending to sift out those less stable and committed to treatment. Patients had to be free of serious physical or mental illness, not dependent on alcohol or regularly abusing benzodiazepines, willing and able to comply with the study's requirements, and continuously in methadone treatment for at least the past six months.
commentary These findings complement those from another report on the same clinic, which found that local informants noticed no increase in drug-related nuisance or general crime and anti-social behaviour consequent on the opening of the RIOTT clinic, and that police records for the area revealed no increase in crime. The combined findings offer reassurance to communities which might host similar extensions to the work of existing treatment clinics that their public spaces and experience of crime should not deteriorate, and may improve.
Though some of caveats about the way patients were selected were specific to the research process, others would apply to any such clinic, and act as a restraining influence on the possibility of adverse community impacts. Possibly the main one was that patients had to be able and willing to attend a clinic up to twice a day and comply with stringent safety procedures. Such patients are unlikely to jeopardise their access to what in Britain is now a very restricted treatment by visibly upsetting the local community. Additional to the points made by the authors, it may be relevant that one of the safety procedures adopted by the RIOTT clinics was to test patients for the presence of alcohol before they took their drugs to avoid overdose due to the cumulative effect of sedating drugs. This too is likely to be a common strategy at any such clinic, helping to eliminate drinkers from the caseload and persuade those who were drinkers to reduce or stop in order to be able to take legally prescribed heroin. This and the requirement that patients not be dependent on alcohol will tend to have made sure that patients were initially and then became even further separate from the local street drinking population.
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
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
STUDY 2014 Drugs: international comparators