“The Modern Crime Prevention Strategy...highlighted the value of supervised injectable diamorphine/heroin in reducing crime... Police and Crime Commissioners and police forces wishing to explore issues relating to heroin assisted treatment are encouraged to engage with the relevant local authorities which commission drug and alcohol treatment in their areas.” - Brandon Lewis, Home Office Minister, Answer to Parliamentary Question, 2016
Prescribing heroin for some dependent users, usually for use in clinics under medical supervision, is called heroin assisted treatment (HAT). The practice is well established, already legal under UK (and international) law, and has a long history, including in the UK, Switzerland, Germany, the Netherlands and Canada.
It has successfully reduced fatal overdoses and needle sharing that can lead to infections, including HIV and hepatitis; high risk street injecting; fundraising driven acquisitive crime and street sex-work; and discarded needles, while increasing take-up and retention in treatment. Both the UK government and its official advisers - the Advisory Council on the Misuse of Drugs (ACMD) - actively support HAT. The ACMD from a health perspective, the UK Home Office from a crime reduction viewpoint as well.
“Central government funding should be provided to support HAT for patients for whom other forms of Opioid Substitution Treatment have not been effective.” - Advisory Council on the Misuse of Drugs, 2016
What is Heroin Assisted Treatment?
The HAT clinic model, initially developed by the Swiss, differs from the old “British System” (still in place for around 100 people in the UK) in that rather than being given ‘take home’ heroin prescriptions, patients attend a clinic once or twice a day, and use their prescriptions on site, under medical supervision.
The first Swiss pilot HAT clinics opened in 1994. In 1997, the federal government approved a large-scale expansion, aimed at 15% of the nation’s estimated 30,000 heroin users, specifically long-term users who had not succeeded with other treatments. Other countries followed suit, with the UK opening three pilot NHS supervised injecting clinics (London, Brighton and Darlington) in 2009 - the Randomised Injectable Opiate Treatment Trial (RIOTT) - extended to 2016 after proving successful.
A supervised drug consumption facility in Bern, Switzerland
Improving Health, Reducing Crime
HAT delivers the health benefits of prescribed supply - heroin of known strength, free from contaminants and adulterants, used with clean injecting equipment - but combined with the benefits of supervised use in a safe and hygienic venue. So HAT clinics prevent overdose and HIV infection, provide regular access or referral to counselling, social, health-care and treatment services, while preventing diversion of prescribed heroin to the illicit market. These positive outcomes have been widely reproduced. Reviews by the Cochrane Collaboration and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) concluded that HAT can lead to substantially improved health and wellbeing, and marked improvements in social functioning e.g. stable housing and a higher employment rate.
The reviews also found HAT lead to major reductions in participants’ use of illicit heroin; and major disengagement from criminal activities, such as acquisitive crime to fund their drug use. For example, in Switzerland, HAT was credited with reducing burglaries by half, stabilising users’ lives and improving communities. The UK trials found health benefits, and that acquisitive crimes per user fell on average by two-thirds among this extremely high-crime committing cohort - from around 40, to 13 crimes per month. Given estimates that around 300k UK opiate (and crack) users commit 44% of all UK acquisitive crime, there is huge potential to reduce crime by making HAT available to 10-15% of the heaviest long term users.
It has been estimated that the 10% heaviest users of heroin in Switzerland (who fall into the HAT target group) consumed around 50% of all the illicit heroin imported. As a result, the reduction in consumption of illicit heroin by those entering a HAT programme (and the absence of any increase in new users) could substantially reduce the scale of the illicit heroin market, depriving organised criminals of resources.
Is HAT Cost Effective?
Numerous studies have demonstrated HAT to be highly cost-effective - as the EMCDDA review put it - HAT saves money. The relatively high cost per client (typically £15k p.a. in the UK) is more than matched by savings across health, criminal justice and other services that cannot be achieved with other treatment options.
In 2017, following 75 HIV infections from needle-sharing in 18 months (lifetime treatment cost £380k each) the Glasgow NHS conducted a business case for HAT/supervised injection facilities: “Our proposals...would help to address a wide range of issues and so relieve considerable pressure on services elsewhere in the system. The evidence clearly shows the potential for these proposals to create long-term savings and so the economics of this issue are also compelling.”
Are There Downsides?
Concerns that HAT may encourage drug use have proven unfounded. The EMCDDA and other reviews found that rather than patients increasing their heroin doses, they stabilised and often started reducing them, usually within two or three months, and uptake of other treatments also increased. HAT also helped reduce heroin availability and recruitment of new users by medicalising use, and reducing street-dealing and the number of user-dealers. Clinics are also sited only where a street injecting problem already exists, and have soon won strong support from the public when their effectiveness is demonstrated, for example being backed by a resounding majority in a national referendum in Switzerland.
For more information on HAT see the Transform Briefing: ‘Heroin-assisted treatment in Switzerland: successfully regulating the supply and use of a high-risk injectable drug’
Advisory Council on the Missue of Drugs, ‘Reducing Opioid-Related Deaths in the UK’ (2016) https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
Despite proving highly cost effective central government funding was cut in 2016, closing the clinics
Ferri, M., Davoli, M. and Perucci, C.A. (2011) ‘Heroin maintenance for chronic heroin-dependent individuals’, Cochrane Drugs and Alcohol Group.
European Monitoring Centre for Drugs and Drug Addiction (2012a) ‘New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond’
BMJ, (2009), ‘Heroin clinics reduce street drug use and crime, shows study’ http://search.proquest.com/openview/fdc3469e4226909939d04059acad7dd6/1.p...
Mills, H. et al (2013) ‘Understanding organised crime: estimating the scale and the social and economic costs’ P68 https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
Killias, M. and Aebi, M. (2000) ‘The impact of heroin prescription on heroin markets in Switzerland’, Crime Prevention Studies, vol. 11, pp. 83-99 http://www.popcenter.org/library/crimeprevention/volume_11/04-Killias.pdf
EMCDDA (2012b) ‘EMCDDA report presents latest evidence on heroin-assisted treatment for hard-to-treat opioid users’
Susanne Millar, Glasgow Health and Social Care Partnership http://www.nhsggc.org.uk/about-us/media-centre/news/2017/02/safer-consum...
Reuter, P. and Schnoz, D. (2009) ‘Assessing drug problems and policies in Switzerland, 1998–2007’, Swiss Federal Office of Public Health.
European Monitoring Centre for Drugs and Drug Addiction (2012a) ‘New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond’, Lisbon: Portugal.
Killias, M. and Aebi, M. (2000) ‘The impact of heroin prescription on heroin markets in Switzerland’, Crime Prevention Studies, vol. 11, pp. 83-99