Emerging findings from the first area in the UK to obtain a Home Office licence for heroin-assisted treatment.

Heroin-assisted treatment is nothing new, but had been on hiatus in the UK for a long time. In the 1960s, heroin prescribing was restricted to a few hundred specialists working from hospital clinics, and then in the 1970s, was almost entirely phased out in favour of oral methadone. The report analysed here details what could – results and political will-depending – be the start of a new wave of heroin prescribing.

Key points

• Middlesbrough became the first area in the UK to get a Home Office licence for delivering heroin-assisted treatment.
• Despite being disrupted by the COVID-19 pandemic, the service was associated with reductions in criminal behaviour and the consumption of street heroin.
• However, the publication of the report detailing these early successes coincided with changes in leadership in the local area that threaten the continuation of the project.

In October 2019, Middlesbrough became the first area in the UK to get a Home Office license for delivering heroin-assisted treatment. This scheme was aimed at “people with a long-term dependency on heroin, who have failed to respond to any other drug treatment” and initially targeted up to 15 of the most ‘at risk’ people in the locality who were “causing most concern to criminal justice agencies and health and social care services”.

Participants were assessed by a medical professional to determine the appropriate dose of diamorphine, and invited to attend a specialist clinic twice a day. In the treatment room, participants self-administered the diamorphine under the supervision of medically-trained staff to ensure there was no adverse reaction – similar to the process inside drug consumption rooms in other countries, except that the drug was prescribed instead of illicit. Once their drug use was under control, participants spent time with specialists from other agencies to help them make progress in rebuilding their lives and reintegrating into society.

The year one progress report in Middlesbrough (covering the period October 2019–October 2020) detailed several encouraging positive changes associated with heroin prescribing. These included:

• Increased engagement with psychosocial interventions
• Reductions in consumption of street heroin
• Reduction in harms associated with risky injecting practices
• Improvements in physical and psychological health
• Improvements in secure housing
• Reductions in the volume and cost of criminal behaviour

The authors noted that there is a complex interplay of problems in Middlesbrough: Middlesbrough has the highest rate of re-offending, opioid use, and drug-related deaths in the country, and entrenched heroin use is a key driver of theft in the area of Cleveland where the clinic was based. This can make it difficult to single out which of the above outcomes would be the most important. But, given recent events, the criminal justice outcomes seem a sensible place to start.

Local support (and dissent)

A common refrain in the substance use field is that illicit drugs are a public health issue, not a criminal justice issue. Well, in 2021, a new Police and Crime Commissioner uttered these words, but not in the context of decriminalising drug use. Instead, his point was that a local heroin-assisted treatment service should (and would) no longer be part-funded from a pot designated for criminal justice, because it was a problem primarily for his colleagues in health:

“I have looked at the numbers and the output of the scheme and while I absolutely appreciate how fantastically beneficial it has been to the people that have been on it, I genuinely believe it is a public health issue. The [heroin-assisted treatment] programme when it started was controversial and it is still controversial now – the results on one hand are spectacular, but on the other hand they don’t deliver from a policing perspective.”

“Nobody has yet shown me a document that says crime in Middlesbrough has dropped since the scheme started.”

“It seems to be based purely on speculation and what these addicts say they used to steal, and the actual statistics don’t support that claim.”

“Even if we were able to scale the scheme up and put the same size operation in other areas in the borough we would still be helping less than 40 people and for the same money we could put anywhere between 20 to 30 officers onto the streets of Cleveland.”

Fortunately, in July 2021, it was announced that the project had been safeguarded until at least March 2022 with money from Project Adder, a government scheme to protect communities from crime caused by illicit drug use. Unfortunately, the narrative had already been put out there that heroin-assisted treatment was ineffectual at tackling drug-related crime.

It is too early to call whether this treatment, delivered in this context, works for the desired group of people. But, at the end of year one, most patients seemed to be making meaningful and positive changes across a range of domains despite services and lives being disrupted by the COVID-19 pandemic. This included meaningful and positive criminal justice outcomes, with sizeable cost-savings (estimated to be at least £97,800) passed on to the Ministry of Justice.

Heroin-assisted treatment is presumed to have an effect on criminal justice outcomes by reducing or eliminating illicit heroin use, and subsequently reducing or eliminating the need for people to engage in crimes in order to buy heroin (known as ‘acquisitive crimes’). These links in the chain were validated by data collected in the report:

• Almost all (80%) urine samples tested negative for street heroin.
• Nine out of 14 people reported shoplifting every day in the 28 days prior to starting heroin-assisted treatment; after commencing treatment, this reduced to zero days for six out of the nine.
• The overall rate of offending was cut by 60%, from an average of three crimes per person to 1.2.
• There was a 60% reduction in crime severity, from a median (mid-point in the range of values) severity score of 32.5 to 13.0.

The sample of this study was admittedly very small (14 people), but judging by current treatment guidelines, the point of heroin-assisted treatment is to offer a lifeline to the small number of people who have had persistently poor outcomes on oral opioid substitution therapies. This study therefore offered a way of testing the capacity of local services to deliver that, before scaling up the service in the future from the very small to the small number of local people who stand to benefit from daily attendance at clinics, with all of the intensive support which comes with that.

Earlier trials of heroin-assisted treatment

Much of the evidence base in support of supervised heroin prescribing is summarised in a 2015 Cochrane review. Across six trials in six countries, supervised injectable diamorphine has been associated with a greater reduction in the use of illicit heroin than among patients receiving an alternative (typically methadone maintenance).

The UK contribution to this body of work was the Randomised Injecting Opioid Treatment Trial (RIOTT) – conducted at clinics in London, Darlington, and Brighton between 2005 and 2008. RIOTT found that for patients who had previously not done well on methadone, supervised heroin consumption suppressed illicit heroin use much more effectively than oral methadone, but at least in the short term “did not do more to improve wider drug use outcomes, crime outcomes, social reintegration, and physical and mental health”.

These types of trials can help to convince a country to pilot an intervention – as in Middlesbrough – but do not lend themselves well to addressing whether opioid substitution therapies work in routine clinical care because they obscure important questions such as:

‘Who would choose what opioid substitution therapy, and why?’

As Rob Calder wrote recently for the SSA website, “The experiences of taking different forms of [opioid substitution therapy] vary, and therefore so do the people for whom those medications are appropriate.”

There are many reasons to deliver heroin-assisted treatment – some criminal justice and some health; some for communities and some for people who other forms of treatment have not been sufficient. In any case, the pragmatic pilot in Middlesbrough, shortly followed by one in Glasgow, mean that the evidence on implementing supervised heroin-assisted treatment is growing.

It would be a shame for this kind of intervention to be at an impasse because no-one can agree which department should pay. Time will tell whether Professor Dame Carol Black’s independent review recommendations – for example, for a cross-departmental Drugs Unit, and ring-fenced funding for treatment at a local level – could help to avoid this kind of situation.

by Natalie Davies

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