Norway contemplating Heroin Assisted Treatment
The recent report of the Stoltenberg Committee, set up by the Norwegian Health Minister to review the country’s drug situation, included a recommendation to begin offering Heroin Assisted Treatment (HAT) to the most marginalised users. The government, while supporting the introduction of new harm reduction measures, is still considering whether to follow the recommendation.
HAT involves the prescribing of heroin in clinically supervised settings, and a growing evidence base supporting its use has been quietly building up over the past 20 years.
Critics within Norway are resistant to the intervention, and have pointed to Dutch experiences with HAT, which, according to Sverre Nesvag, director of drugs research at Stavanger University hospital, has been a "failure". Nesvag’s evidence for this statement is sparse, being restricted to his claim that "at least 50 per cent" of patients dropped out of the four year follow-up treatment program offered to those who had benefited from the original Randomised Controlled Trials (RCT) carried out in the
Nesvag supports OST, but prefers to use methadone and buprenorphine. It is, however, widely recognised that a proportion of those dependent on heroin do not get along with these treatments, deriving little or no therapeutic benefit from them. It is for this group that HAT can make an enormous difference. In the Dutch 4 year follow-up treatment, which Nesvag uses to make his case, 56% of those who entered the treatment remained for at least four years. Of those who left, 10% went on to abstinence programs, while most of the rest were removed from the program by staff. It should be noted that 100% of these patients had already been through the Dutch RCTs and had benefitted from HAT—this being defined in terms of at least a 40% improvement across one or more of a range of measures, including physical health, psychological health and social functioning. Moreover, it is in the first year or 18 months that the most dramatic improvements are observed with HAT.
The logic by which Dr Nesvag arrives at his conclusion that the Dutch HAT experience was one of “failure” is therefore unclear. The follow up study he targets found, in fact, that those who remained in HAT had a much higher chance of being in good health than those not in the treatment, as well as demonstrating a much lower level of illicit drug and alcohol use.
Popular criticisms of HAT, appearing in the Norwegian press and from some politicians, rest on the folk foundations of the claim that, “You would not give free liquor to alcoholics!” This kind of attitude, while it chimes with an ideological form of ‘common sense’, betrays a lack of understanding of the issue. The real alternatives are these: do you wish those who have problems around addiction to buy heroin from organised criminals, to shoot up with dirty needles in alleyways, to rob your houses and cars to pay the inflated price of adulterated street drugs—or would you prefer they went to a clinic and received medical assistance of the kind they themselves might actually want ?
For more information: Heroin Assisted Treatment: The state of play, a recent IDPC Briefing written by Christopher Hallam.
