New approaches to heroin addiction aired in London
A symposium on two of the hottest topics in addiction medicine (heroin prescribing and rapid opioid withdrawal under anaesthesia) at the Royal Society of Medicine (London, UK, Sept 6) was slightly marred by the United Nations' refusal to allow Cindy Fazey (UN Office of Demand Reduction) to attend.
The chairman of the first session, John Marks (Liverpool, UK), said the UN had taken this action because the title of the symposium was "incompatible with her position in the UN and with UN policy".
Her replacement, anthropologist Anthony Henman (São Paulo, Brazil), had no such constraints, and his description of traditional drug use (eg, coca chewing in Peru)provided a different perspective from the usual western attitude to drugs. The ritualisation and discipline associated, for example, with opium dens in the hill-tribe villages in Thailand is, in effect, harm reduction.
A socially sanctioned market, he said, is not only more manageable, but also reduces HIV transmission and criminality. This view was endorsed by Marks who extolled the virtues of the so-called "British system" of maintenance heroin prescribing between 1920 and 1971. Its disintegration, he said, led to the creation of a black market, drug baron supremacy, and the current heroin epidemic.
Kanagaratnam Sathananthan (Croydon, UK) is one of the few doctors who still prescribe heroin, despite vigorous establishment opposition. In his experience, criminal activity decreases among clients on prescribed pharmaceutical heroin. Like Sathananthan, Jeffrey Marks (Cheltenham, UK), who prescribes maintenance heroin in his National Health Service clinic, is not advocating a free for all. Patients are rigorously selected, and continuation of treatment is dependent on strict preset conditions.
Preliminary results of a 3-year multicentre trial (which ends on Dec 31, 1996) in Switzerland are encouraging; they show, for example, that the daily dose of heroin needed by participants is decreasing and that they are gaining weight (Robert Hammig and Rudi Brenneisen, Bern). The final report, due next year, will not, however, show the wider public-health impact of such prescribing.
Equally controversial is rapid opioid withdrawal under sedation or anaesthesia, pioneered by Norbert Loimer (Vienna, Austria). The technique, which is not suitable for polydrug users, allows humane withdrawal from heroin without the highly unpleasant effects that deter many heroin addicts from entering detoxification, said Loimer.
Colin Brewer (London, UK) emphasised that rapid withdrawal does not obviate the need for subsequent treatment, yet, in his opinion, is the best way to transfer to the opioid antagonist naltrexone. Nabi Maksoud (Gizza, Cairo) agreed, adding that his 72·5% success rate (relapse free after 4 months) may well be influenced by the fact that such patients tend to be well-motivated. Brewer admitted that some patients wake up "feeling awful" and need further medical management for vomiting, diarrhoea, and insomnia.
