Löbmann R., Verthein U.
Law and Human Behavior: 2009, 33(1), p. 83–95.
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This German study shows that heroin maintenance treatment can contribute to greater reductions in drug and property offences than methadone maintenance.
Summary From seven cities across Germany, 1015 opiate dependent men and women were recruited to participate in this study about the impacts of maintenance treatments. The featured report focused on impacts on criminal activity. Participants had to be regularly injecting heroin and in poor physical or mental health despite currently being in methadone maintenance treatment or having been treated for their addiction in the past, but not in the last six months. Uniquely among modern trials, because the past treatment need not have been opiate substitute prescribing, the trial was not confined to patients who had previously done poorly on methadone.
Participants were randomly allocated to receive either heroin or methadone treatments. Supplemented by methadone, injectable heroin was provided in three daily doses to be consumed under supervision at specially equipped outpatient drug treatment units, while methadone was provided in a daily oral dose at existing outpatient clinics. Treatment included psychosocial support.
Self-reported criminal offences and police data on suspected criminal activity showed that among participants receiving both types of maintenance treatments, crime fell in the year after starting treatment compared to the year before. However, this decline was significantly greater among patients allocated to heroin, a gap due largely to greater reductions in property crime and drug offences. In turn these extra reductions seemed due to greater decreases in illegal drug use and less involvement in criminal circles (marked by the patient themselves becoming less likely to be a victim of crime) and in the ‘drug scene’.
commentary At the time of writing this paper, diamorphine (the pharmaceutical form of heroin) was licensed for this particular study, but was not registered for prescription use more widely in Germany. Compare this with the UK, where the prescription of diamorphine on a maintenance basis has been a feature of the ‘British system’ since the 1920s.
This study revealed that among patients still using heroin despite previous treatments, in the first year after starting maintenance treatment both methadone and heroin prescribing were associated with reductions in criminal activity, but heroin maintenance was associated with significantly greater reductions in drug and property offences than methadone maintenance. The effect seemed largely due to greater decreases in illegal drug use ( chart), which in turn helped the patient divorce themselves from drug using and criminal circles.
In this study the heroin was administered at the clinic. As this Effectiveness Bank review comments, this measure can be effective in preventing the diversion of diamorphine on to the illicit market, an ongoing concern for policymakers. However, it limits accessibility of the treatment to “patients who can cheaply, easily and quickly get to the clinic”. Refer to this review for a more in-depth exploration of the benefits and drawbacks of prescribing heroin, and whether there is sufficient evidence of extra benefits compared to oral methadone to justify extra costs and risks.
Heroin prescribing trials are typically limited to heroin-addicted patients who have done poorly on methadone. This study was the first to analyse the effects of heroin prescribing among patients with no previous experience of opiate substitute prescribing programmes. A further analysis of this study reports that heroin was at least as effective among patient with no prior methadone treatment, discusses more generally the relative effectiveness of heroin and methadone prescribing, and questions the assumption that heroin should only be implemented as a second line treatment following the failure of methadone programmes.
Last revised 21 December 2015. First uploaded 30 November 2015