Supervised injectable heroin treatment is expensive but cost effective, report says

BMJ 2012; 344 doi: (Published 23 April 2012) Cite this as: BMJ 2012;344:e2942
  1. Rory Watson
  1. 1Brussels

Medicinal heroin is being used successfully in several countries as a second line treatment for chronic heroin users previously considered untreatable, says a new report from the European Monitoring Centre for Drugs and Drug Addiction.

The report describes the treatment as “an important clinical step forward” and provides an overview of research on the subject setting out evidence and clinical experience gained in Denmark, Germany, the Netherlands, the United Kingdom, and Switzerland, countries where supervised injectable heroin treatment is legally available to long term, refractory opioid users. In Spain and Canada it may be used in research trials.

Presenting the report, Wolfgang Götz, the centre’s director, noted that heroin assisted treatment, where Europe is at the forefront of investigating and implementing the novel approach, “has attracted much attention, controversy, and often confusion.” The report, he insists, is “not to advocate but to inform.”

Around 700 000 of Europe’s 1.3 million problem opioid users currently receive substitution drugs such as methadone or buprenorphine as mainstream, first line treatment. The practice of using supervised injectable heroin as an option for patients who do not respond to traditional treatment began in Switzerland in the mid-1990s, when the country was confronted with a growing heroin problem.

Under the new approach all injectable doses (typically around 200 mg of diacetylmorphine per injection) are taken under direct medical or nursing supervision to ensure compliance, monitoring, and safety. This also prevents any possible diversion of diacetylmorphine to the illicit market. To achieve this, however, the clinics must be open for several sessions a day, every day of the year, because users are not permitted to take injectable heroin doses out of the clinics.

In all, about 1000 patients in the European Union and 1400 in Switzerland are currently receiving this treatment. Over the past 15 years six randomised controlled trials have been conducted, involving more than 1500 patients. The report notes that these “provide strong evidence, both individually and collectively, in support of the efficacy of treatment with fully supervised self-administered injectable heroin, when compared with oral MMT [methadone maintenance treatment] for long-term refractory heroin-dependent individuals.”

The benefits identified were substantially improved health, wellbeing, and social functioning; major reductions in continued use of illicit street heroin; and fewer criminal activities to fund drug use.

The costs involved are consistently and substantially higher than the cost of oral MMT provision, which ranges from €1600 (£1300; $2100) to €3500 a patient annually. Experience in Switzerland, Germany, and the Netherlands indicates that the annual cost of an individual supervised injectable heroin maintenance programme is between €12 700 and €20 400. This is largely due to higher staff requirements and the fact that clinics need to be open for extended hours.

However, the savings to society from reduced crime and imprisonment are significant. For every person receiving the treatment, societal savings in the Netherlands, for instance, are estimated at €15 000. The report notes that “if an analysis of cost utility takes into account all relevant parameters, especially related to criminal activity,” the treatment saves money.


Cite this as: BMJ 2012;344:e2942


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