’No evidence,’ Minister Ambrose?

The Health Minister on heroin-assisted treatment

In an interview with the CBC yesterday, Health Minister Rona Ambrose said there was “no evidence” to suggest heroin-assisted treatment was a safe and effective option. Actually, she used variations on the phrase seven times in the space of seven minutes.

There is no evidence at this point that heroin—giving heroin to heroin addicts—is any way an effective treatment…

As I said, there is no evidence that this is an effective, safe treatment…

There is no evidence at this time, no clinical evidence…

There is no clear evidence to suggest that this a safe treatment and it’s not a good idea for Health Canada, for Health Canada, to be supporting giving heroin to heroin addicts when there’s no scientific evidence that this is a safe treatment…

There is no evidence at this time…

Here is a 176-page report that was released last year by the European Monitoring Centre for Drugs and Drug Addiction. It was prepared by researchers with the National Addiction Centre at King’s College in England. In addition to considering the history and context around heroin-assisted treatment, the authors review the results of six randomized controlled trials, conducted in Switzerland, the Netherlands, Spain, Germany, England and Canada respectively.

Those studies are detailed at length in chapter three of the report, but here is what is reported under the heading “scientific evidence base” in the executive summary.

Over the past 15 years, six RCTs have been conducted involving more than 1 500 patients, and they 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, for long-term refractory heroin-dependent individuals. These have been conducted in six countries: Switzerland (Perneger et al., 1998); the Netherlands (van den Brink et al., 2003); Spain (March et al., 2006); Germany (Haasen et al., 2007), Canada (Oviedo-Joekes et al., 2009) and England (Strang et al., 2010).

Across the trials, major reductions in the continued use of ‘street’ heroin occurred in those receiving SIH compared with control groups (most often receiving active MMT). These reductions occasionally included complete cessation of ‘street’ heroin use, although more frequently there was continued but reduced irregular use of ‘street’ heroin, at least through the trial period (ranging from 6 to 12 months). Reductions also occurred, but to a lesser extent, with the use of a range of other drugs, such as cocaine and alcohol. However, the difference between reductions in the SIH group and the various control groups was not as great (compared with major reductions in the use of ‘street’ heroin).

Patients receiving SIH treatment achieved gains in physical and mental health, as well as social functioning, although improvements in those receiving SIH were not consistently or significantly superior to the control group across all trials, particularly in relation to psychosocial functioning.

Reductions in the criminal activity of SIH patients were evident and were substantially greater when compared with patients under control conditions. Retention in treatment varied substantially across the trials. The available evidence suggests added value of SIH alongside supplementary doses of methadone for long-term treatment-refractory opioid users.

Furthermore, efficacy of heroin provision as a treatment modality on several outcomes (retention, mortality) was corroborated by a systematic review conducted by the Cochrane Group. Although the inclusion criteria of studies in the latter review were stricter from a methodological point of view, converging conclusions on the efficacy of SIH further strengthens the current evidence of this. However, it is important to note that more serious adverse events have been reported to occur in patients receiving SIH than oral methadone. This suggests that SIH may be less safe and therefore require more resources and clinical attention in order to manage greater safety issues.

Finally, countries that have conducted longer term (up to six years) follow-up studies have seen a high retention in SIH (55 % at two years and 40 % at six years), with patients sustaining gains in reduced ‘street’ heroin use and marked improvements in social functioning (e.g. stable housing, drug-free social contacts and increased rate of employment).

The results of the Canadian study were published three years ago. Heroin-assisted treatment has been officially adopted in Switzerland, Germany, Denmark and the Netherlands.

After her last declaration that no evidence exists, Ms. Ambrose said heroin-assisted treatment was not a “proven” treatment. “We are focused on using effective treatments and supporting effective treatments that are proven effective and safe for people that are suffering from addictions,” she explained. That at least raises the possibility of further discussion here. Has Ms. Ambrose reviewed the evidence? Is she familiar with the experiences in Switzerland, Germany, Denmark and the Netherlands? Is she open to the possibility that heroin-assisted treatment could be proven to be safe and effective? At what point would she consider the treatment to have been proven effective and safe? And will it be her or officials with Health Canada who make that judgment?

Meanwhile, British Columbia’s Health Minister, Terry Lake, disagrees with Ms. Ambrose.

“We’re reluctant to close the door on innovation and creativity when it comes to tackling these very challenging problems. We have to think out of the box sometimes,” he said at a Toronto hotel after the health ministers’ meeting. “I know that the thought of using heroin as a treatment is scary for people, but I think we have to take the emotions out of it and let science inform the discussion. And in this case, I believe this was an exceptional circumstance, compassionate use of a medication to help people transition, and provides information as to treatments that may in fact prove better than alternatives for some people.”

… “I would encourage the use of science and not limit the ability of research to explore opportunities that might seem taboo but at the same time provide real help for people that are in a terrible situation,” he said.

See previously: The politics of the heroin addict, Heroin-assisted treatment and politics-based medicine and Q&A: Dr. Perry Kendall on heroin-assisted treatment