Heroin Assisted Treatment (HAT) is an innovation that engages long-term heroin users in treatment that includes the provision of pharmaceutical grade heroin (diacetylmorphine) along side other interventions that support individuals to work towards better health outcomes.
HAT programs were pioneered in the 1990’s in Switzerland as one component of the comprehensive response the Swiss developed in response to an devastating epidemic of injection drug use, HIV and overdose among people who used drugs. Alongside innovations such as low threshold methadone programs, supervised injection sites, shelters for people living on the street and an array of medical and health programs heroin assisted treatment plays an important role in engaging long term heroin users in treatment and other social programs. The results of the Swiss HAT programs have been positive and the approach has been replicated in other countries including, Germany, the Netherlands, Spain, Denmark and Canada.
The Canadian experience has been similar to the Swiss programs but Canada has yet to see a fully funded HAT program implemented. In Canada the North American Opiate Medication Initiative (NAOMI) clinical trial opened its doors in Vancouver and Montreal between 2005 and 2008. Results of the NAOMI trial were similar to those in the Swiss programs in that there were significant positive outcomes for participants in the heroin arm of the trial including:
- High retention rates in the treatment program
- Illegal heroin use fell by 70%
- The proportion of participants involved in illegal activities fell by half from over 70% to 36%
- Illegal activity among participants decreased significantly as did the amount of money spent monthly on illegal drugs.
- Marked improvements in participants ‘ medical and health status were also experienced.
The NAOMI trial ended in 2008 and the new Conservative government (elected in 2005) was not supportive of continuing the HAT experiment as a treatment program. Authorizations were not given by Health Canada to continue to treat patients who had done well in the NAOMI trial and participants had to choose between going back on methadone or attending an abstinence based treatment program.
A new research project was developed, The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) that began enrolling participants in 2011 with the aim of comparing diacetylmorphine, the active ingredient of heroin, and hydromorphone (HDM), a legal, licensed pain medication. This research is currently underway.
In May of 2015 the BC Supreme Court ruled that patients who had finished the one-year treatment protocol and who were benefiting from the receiving heroin would be able to continue receiving the treatment outside of the research setting. This was the result of a constitutional challenge to federal regulations that prevent doctors from prescribing heroin-assisted therapy to their patients. Providence Health Care and the Pivot Legal Society, which is representing five of the Salome participants, launched the challenge.
Effectively, heroin assisted treatment is proceeding in Vancouver but is in a precarious situation with a court challenge pending. Heroin treatment programs exist in Switzerland, Germany, the Netherlands, Denmark, Spain and the United Kingdom. In 2012, there were approximately 2,400 individuals on heroin assisted treatment in the European Union and Switzerland, and it has been integrated into the array of treatment options available for heroin users who have not found success with other treatment modalities available to them.
Given the wealth of evidence that has emerged over the past 20 years the Canadian Drug Policy Coalition strongly supports implementing heroin assisted treatment programs where they are needed in Canada.
- For an overview of Heroin Assisted Treatment in Europe see the European Monitoring Centre for Drugs and Addiction Publication, New Heroin-Assisted Treatment, 2012
- For information on the constitutional challenge see the Pivot Legal Society’s blog on the HAT Injuction: What Does it Mean.
- Study to Assess Longer-term Opioid Medication Effectiveness (SALOME)
- North American Opiate Medication Initiative