Netherlands considers prescribing heroin to addictsBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7334.385/c (Published 16 February 2002) Cite this as: BMJ 2002;324:385
All rapid responses
Scientific information on the effectiveness of interventions for drug
addiction is increasingly available, despite obvious difficulties. This
scientific evidence should be used to inform policies. The different
approaches of Netherlands and Italy casts doubts that this is what is
Dutch investigators have recently recommended prescription of heroin
to addicts (1,2) on the basis of two randomised controlled trials
(www.ccbh.nl), showing that “the combined prescribing of heroin and
methadone on medical grounds to long term users of heroin is safe and
manageable and has health benefits over ordinary methadone programmes”.
The EU Drug Agency EMCDDA, has recently advised policy makers (3),
stating that “substitution treatment is a key component of a comprehensive
approach to drug treatment and can be effective in reducing the risks of
HIV infection, overdose, use of legal and illegal drugs and drug-related
A few days ago the Italian Government announced a major shift in
policy regarding treatment for drug addiction. “Harm reduction” strategies
will be abandoned and methadone treatment will be offered only as
detoxification schedule and only within a high threshold drug free
programme. The resolution approved by one branch of the Italian Parliament
states that “the use of methadone and other substitution treatments should
be confined within the restrictions of the law; it has to be limited to
three months, it has to be linked to a rehabilitation project and used
with low dosages”. This is yet another case of a clear conflict between
scientific evidence and health policies, determined by political
convenience and ideological fights.
The Italian government is therefore going to ban methadone treatment
as one of the possible intervention against the harms caused by heroin
drug use. To support this policy it states that too many patients of
public treatment services are on methadone treatment. The opposite is
actually true, as less than fifty percent of the 140,000 people who
entered public treatment centres in Italy in the year 2000, were offered
methadone treatment, and less than 30% on a maintenance basis, the average
maximum dose being well below the effective dosage (4). We believe the
problem is the inappropriate use of methadone treatment rather than the
excess of methadone use.
Heroin use in Italy is still a big issue. The estimated prevalence of
problem drug use is 7.1 to 7.8 per 1000 people aged 15-64 years in 1999-
2000, the highest in the EU and the prevalence of HIV infection among drug
users in treatment is 15%, still among the highest in the EU (EMCDDA
annual report 2001). Moreover, mortality of heroin addicts in Italy is
still very high, about fifteen times higher than in the general population
of the same age and sex, and it is particularly high among females where
the excess risk compared with female non drug addict is 30 times higher
Our government is probably not aware of the previous failure of a
similar effort by politicians trying to interfere with clinical decisions.
“In July 1998, Major Rudolph Giuliani of New York City introduced a
program requiring the 2100 patients in methadone maintenance programs in
selected clinics to terminate their use of methadone within 90 days. Seven
months of debate and controversy ensued. In January 1999, the mayor
announced that his program had been inadequately conceptualised, was not
realistic, and was being withdrawn” (6).
Methadone is well recognised to have a key role in reducing HIV
infection rates among injecting heroin users and in reducing death rates
in opiate dependent individuals. These important treatment and prevention
methods should not be abandoned as a result of political rhetoric.
Marina Davoli, Marica Ferri e Carlo A Perucci
Dipartimento di Epidemiologia ASL RME, Roma, Italy
Editorial Base Cochrane Collaborative Review Group on Drug and Alcohol
Italian Cochrane Centre, Mario Negri Institute, Milano, Italy
1. Sheldon T. Netherlands considers prescribing heroin to addicts.
BMJ 2002; 324: 385.
2. van Kolfschooten F. Dutch investigators recommend prescription of
heroin to addicts. The Lancet 2002; 359(9306): 590
3. EMCDDA Policy Briefings No. 1/2002 – 25 January 2002
4. D’Ippoliti) D'Ippoliti D, Davoli M, Perucci CA, Pasqualini F, Bargagli
AM Retention in treatment of heroin users in Italy: the role of treatment
type and of methadone maintenance dosage. Drug and Alcohol Dependence
5. Bargagli AM, Sperati A, Davoli M, Forastiere F, Perucci CA.
Mortality among problem drug users in Rome: an 18-year follow-up study,
1980-97. Addiction 2001; 96: 1455-1463
6. Winick C. A mandatory short-term methadone-to-abstinence program
in New York City. Mt Sinai J Med. 2001 Jan;68(1):41-5.
Competing interests: No competing interests