Martin Luther King declared that a riot is the language of the unheard. I don't think he meant this particular RIOTT but it’s good to see the Lancet paper on injectable heroin in the UK finally make it into print given the rather hasty pre-publication presentation at press conference in September 2009. This post is a follow up to 'I predict a RIOTT' I blogged back when the NAOMI study in Canada was published in the NEJM.
One of the biggest concerns I personally have had with injectable methadone therapy is the sheer difficulty in dislodging people once they are on methadone ampoules. And this is an issue that critics will highlight - where do we go with patients on injectables? It’s not clear if users will successfully engage with further services and perhaps move on to oral therapy or detoxification. We, and they, may have no further aspirations beyond this uber-harm reduction approach but I'd like to see some longer term outcomes, extending beyond the very limited 26 weeks in RIOTT, for people who are being given injectable heroin.
One can argue that this first dig at the RIOTT study isn’t particularly revelatory and the primary outcome (50% or more negative specimens for street heroin) is predictable. It is useful to see this measured objectively and it reduces the clear and obvious problems with self-reporting in a trial of injectable heroin. Again, critics could argue that it is a self-fulfilling study and as the authors comment there are already 5 randomised trials with over 1000 patients that showed similar reductions in illicit drug use. The study demonstrates that by giving people safe and pure heroin for free they use much less illicit street heroin with all its impurities. Surprise, surprise, many will say.
I feel that the secondary outcomes are going to be more crucial to convince a wider audience that extends beyond harm-reductionistas and, more importantly, appeals to commissioners. These outcomes are yet to be reported and include use of other illicit drugs, injecting practices, psychosocial and general health, crime and cost-effectiveness.
Cost-effectiveness is crucial and the future provision of IV heroin in the UK hinges around this issue. It's not one that will be easily ducked in an austere climate of treatment rationalisation. There are quite serious adverse effects with injectable heroin – RIOTT recorded 2 overdoses requiring resuscitation, though not hospitalisation, and a number of overdoses and seizures were recorded in the NAOMI study in Canada. These mean that decent, therefore expensive, clinical facilities and staffing will be required over and above current practice in many areas.
Injectable heroin is a worthy, evidence-based aspiration and there is a strong moral argument to provide this as a second-line treatment. However, the financial outlook may foster a more brutal approach. We may face some very tough choices when fighting for services in the future. We might do better to draw up and circle the wagons to defend our core treatment services and in particular to protect harm reduction services from future cuts. If we can't even provide key services such as needle exchanges we need to have a long hard think before advocating injectable heroin clinics without compelling cost-benefit data. However, if we deny this treatment to people we have to be certain it is not because they are simply the ‘unheard’ and it is politically convenient to be deaf to their plight.
Cross-posted at northerndoctor.com
