Heroin & injecting rooms

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1 Heroin & injecting rooms Tom Carnwath Sheffield 2003

2 Parliamentary committee 2002 We recommend that an evaluated pilot programme of safe injecting houses for heroin users is established without delay. We conclude that the Dutch and Swiss evidence provides a strong basis on which to conduct a pilot here in Britain of highly structured heroin prescribing to addicts.. We recommend that the Government commissions a further trial to look at the prescription of diamorphine to addicts who are not currently accessing any treatment.

3 Injecting rooms Clean environment, equipment Monitoring for overdose etc. Access to medical consultation Ability for onward referral Also often: Social and housing advice Drop-in club with activities Laundry, cafeteria, washing facilities

4 Aims of a legal injecting room to reduce the spread of infectious diseases from the shared use of injecting equipment to reduce the public nuisance associated with drug injecting in streets and parks to reduce inappropriate disposal of used injecting equipment to provide a gateway for injecting drug users to treatment and rehabilitation.

5 Safer injecting rooms 5 in Frankfurt, others in Hamburg, Hannover, Bremen and Bonn 13 in Zurich, Bern and Basel (Basel opened in 1986) Also in Rotterdam, Arnhem, Maastricht, Venlo & Apeldoorn. One in Australia (Kings Cross, Sydney)

6 Some outcomes In first 2 months, Kings X had 600 injectors, 1500 injections and had managed 17 overdoses No deaths yet in injecting rooms Safer behaviour develops in customers (e.g. Ronco study, Switzerland 1995) Many enter treatment, find housing & reduce crime (e.g. Frankfurt 1995)

7 Relative number of heroin overdoses (Adjusted as if 1986 values were 100) Germany Frankfurt Four injecting rooms established in Frankfurt

8 Some reasons for injecting rooms UK has highest overdose rate in Europe Overdose rate much higher in untreated Homeless have poor rate of service access Overdose rate higher when drug taken away outside Sharing of equipment more frequent in homeless

9 Prescribing heroin

10 Much demand recently for heroin prescribing

11 Heroin prescriptions as percentage of all prescriptions in UK %

12 UK research project Survey of addiction consultants Case-note study of those prescribed heroin Review of UK policy history and politics Based at Imperial College - Nicky Metrebian, Gerry Stimson, Tom Carnwath, Thomas Storz, Joy Mott and Zenobia Carnwath Funded by NTA & Home Office

13 Current practice 90 consultants in the UK with interest in substance misuse prescribing Between 40,000 80,000 patients receiving methadone 46 doctors prescribing heroin to 448 patients at 42 drug clinics Most prescribed to 1-10 patients (median = 5). 5 prescribed to patients ( heavy mob ).

14 Indications for treatment Long history e.g. 2, 5 or 10 years. Previous treatment e.g. oral or injectable methadone. Physical complications e.g. hepatitis, HIV, DVT. Age e.g. over 21 or over 35 years old. Mental state: stable or not stable. Compliant or non-compliant. Social stability: stable or not stable. Injecting : able to inject safely,or injecting dangerously. Other drug use: using or not using other drugs.

15 What would increase heroin prescribing? Better local or national support Less expense involved More demand, more failures with methadone Better facilities available Better evidence for its effectiveness

16 Heroin prescription (Swiss) Feasible and economical High retention rate Psychosocial and health improvement Additional consumption decreases Low mortality Valuable extension of the currently available selection of therapeutic instruments KODA-1, February 1998, cb

17 Poor physical and mental health 60% 50% 40% 30% mental physical 20% 10% 0% at entry after 1 year

18 Cocaine use % Before 18 month 0 No use Occasional Daily

19 Swiss mortality rates 9 % % 8 % 7 % 6 % 5 % 4 % 3 % % 2 % 1 % % % 0 % h e r o i n p r e - s c r i p t i o n ( 1 4 / , t = y ) i n p a t i e n t t h e r a p y m e t h a d o n e o u t o f t r e a t m e n t p o p u l a t i o n KODA-1, February 1998, cb

20 Respiratory depression O2-Saturation falls (some cases to 80% or less) Hypoxia is common, neurological problems are rare measures against it: check vigilance low single dose no smoking move and wake

21 Dutch study (1) 549 subjects, 6 cities, Treatment failures, use over 5 years Smoked and IV heroin prescribed in separate studies Heroin + methadone v methadone waiting list, crossover after 12 months Mean dose 549 iv heroin + 60mg methadone

22 Dutch study (2) Success criterion = 40% improvement in specific treatment domain e.g. crime, health Without other significant deterioration 25% more success than methadone for IV, 23% for smoked Success usually over all domains, whereas methadone improvement in one only 80% responders deteriorated after return to methadone

23 Responders % Methadone Heroin 10 0 IV Inhaled

24 UK patients (2000) 77% male, 23% female 66% had significant health problems 41% had been in prison Time prescribed diamorphine av. 6 years (<1 34) Age at initiation: av. 34years (range 16-52) History of heroin use: av. 10 years (range 2 36) History of injecting: av. 9 years (range 2-28)

25 How have they done? 70% retained in heroin treatment, 87% in treatment 63 patients left heroin treatment Moved to oral methadone 10% (22) Moved to subutex/naltrexone 2% (4) Commenced detox 1% (2) Completed treatment 4% (9) Discharged for non-compliance 5% (10) Prison 0.5% (1) Died 7% (15)

26 Retention in treatment Riverside CDT Hartnoll NTORS UK Dutch Swiss Methadone 6 m Heroin 2 yrs

27 Agreed issues in E.A.G. High quality standard treatment should have been tried first, or at least be available Inherently greater risks Reduced by expert selection & prescribing Requires considerable resources Should be available, and likely to be beneficial for some patients Monitoring & further research is vital

28 Supervised consumption Clinical safety and less risk of diversion Confidence to take on difficult patients Confidence to prescribe higher doses Would encourage more prescribers Increases threshold, and perhaps encourages moves away from drugs/ injections

29 Supervised consumption Interferes with rehabilitation to normal life Maybe discourages many patients Expensive Access difficult, particularly in rural areas Could increase postcode problem Probably best as initial measure only

30 Dosage of heroin Hartnoll et al. (1980): average dose of both methadone and heroin = 60mg./day Sell (1997): average UK dose 176 mg./day Swiss trials: average heroin dose = 600mg. /day Dutch trials: average heroin dose = 550mg. + 60mg. Methadone German trials: up to 1000mg/day

31 Thoughts about costs Holland Heroin: 500mg/day = 1,280 per year Total cost: 9,600 per patient year Switzerland Yearly benefits per patient 15,000, costs 8,000, therefore net savings 7,000 UK Heroin 500mg/day = 8,000

32 Morphine recovery by technique Mo & Way (1996) Chasing 26% Ack-ack 14% Seidenberg et al (1998) Sugarettes 10% Mo & Way (1966) Intravenous 68% Cone et al (1966) Intranasal 27-31% Intramuscular 34% Hendricks et al (2001) Chasing 45% (caffeine) Heater 45% (caffeine)

33 First beginnings It was cheap, it demanded neither layout nor hypodermic syringe, and could be taken for a long time without disturbing the health. It stopped the craving without diminishing working capacity to a degree which would prevent the earning of money to buy the drug, and last, but not least, as it is sniffed through the nose on a quill, the addict could take it without much fear of being interfered with. Dr. P. Bailey 'The heroin habit' New Republic, 6 (1916),

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