Drug and Alcohol Review (1997) 16, 301-302

COMMENTARY ON THE 1996 LEONARD BALL ORATION

"Slow ahead": a response to the proposed heroin trial

DAVID HAWKS*

Professor of Addiction Studies, National Centre for Research into the Prevention of Drug Abuse, Curtin University of Technology, 1/14 Stone Street, South Perth 6151, Western Australia

The progression of the proposal to prescribe heroin in the Australian Capital Territory has been exemp- lary in man), regards, not least its openness to public and scientific scrutiny. The report of the intellectual, practical and political challenges presented by the

proposal in the form of the 1996 Leonard Ball Oration maintains this tradition.

Born to some extent of the inadequate provision made for methadone prescribing in the A C T in the 1980's the "feasibility research", as it has been called, has proceeded in a cautious incremental fashion as befits a project proposing a radical shift in policy. Implicit in its cautious approach has been a willing- ness to consult all relevant stakeholders, including users themselves, and a phased implementation the results of which are to inform subsequent stages.

Despite these virtues and the level of professional support demonstrated at least for its initial stages the proposal has not yet been given the green light.

\Vhile the stringency of recent budgets, the cost of the project if pursued to its conclusion and the fact that the National Drug Strategy itself is under review provide more than enough cause for prevari- cation it is likely that there are other additional reasons for delaying its inception.

As already hinted, some of the pressure for intro- ducing such a trial in the A C T derived from the wholly inadequate provision of methadone in that territory in the 1980s. The wider provision of

methadone, and the liberalization of the criteria for entry to that programme have, one suspects, reduced some of that pressure as will the implementation of the Swiss heroin trial. W h y it might be argued should we, who are already accused in some inter- national quarters of having too liberal a drug policy, put ourselves further out on a limb when the 1996 English Drag Task Force [1] on the effectiveness of treatments found "no adequate research evidence on which to base a dear conclusion about whether heroin prescribing had a legitimate place in the rid1 range of services for drug misusers'. W h y not wait for the Swiss results before embarking on so radical a course?

Aside from these "political" considerations there are some methodological concerns, as the authors of the proposal are only too happy to acknowledge. The proposal to allow those in the experimental group to choose heroin in combination with or without methadone means that it will be more difficult to tease out the relative advantages of ei- ther; although the combination may be found to be advantageous when compared to methadone alone. The determination of the doses of heroin to be prescribed also presents problems. To what extent are users to be left to determine their preferred dose and what criteria are to be employed by prescribing doctors. Will the dose prescribed be sufficient to prevent supplementation from illegal sources? These

*The author was a member of the Advisory Committee appointed to assist the National Centre for Epidemiology and Population Health and the Australian Institute of Criminology in their consideration of the feasibility of making opiates available in a controlled way. While not responsible for the decision to recommend that the trial go ahead the author was party to the process which resulted in this recommendation.

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302 Commentary

are questions which those responsible for the project recognize need to be addressed in the first stage.

Of crucial significance for the reception given to the trial should it go ahead is the modesty or otherwise of the expectations held for it. While a principal rationale for the trial has been the expec- tation that the provision of heroin on prescription will "hook in" users who have not previously been enticed into treatment, not all such users will be hooked in nor will the illegal provision and use of heroin entirely disappear. Nor, one suspects, will all those involved in the trial eventually become absti- nent despite the fact, as Bammer acknowledges "support for the trial is contingent on abstinence

being an eventual outcome". What can be hoped for, and evaluation provide

for, is a significant improvement in the health and stability of a percentage of users without adverse consequence for society at large. For these reasons the trial should be allowed to proceed in the cautious manner intended.

Reference

[1] Strang J. & Sheridan J. Heroin prescribing in the "British system" of the mid 1990s: data from the 1995 national survey of community pharmacies in England and Wales. Drug Alcohol Rev 1997;16:7-16.