By Michael Liebrenz et al. - Harm Reduction Journal

In the context of the current opioid crisis in the USA, and against the backdrop that a quarter to a third of all US residents addicted to heroin pass through US prisons and jails each year, care for incarcerated opioid-using individuals (OUI) has become a focus of scientific interest. A smarter war on drugs, with addiction and overdose initiatives that address the current opioid epidemic and particularly envisage a criminal justice-based continuum of care for OUI, has been called for. This implies a need for studies that not only evaluate medications used to treat opioid use disorders (OUD) in certain populations, but also develop better ways of assessing the outcomes of relevant therapeutic interventions.

Similar considerations, demands, and research questions arose some time ago in Switzerland, a federally governed European country. At the height of its heroin epidemic in the late 1980s, Switzerland had an estimated 30,000–40,000 OUI, i.e., 0.5–0.8% of the total population. The drug policy response to this crisis was inconsistent, fluctuating between liberal and repressive approaches. After conditions had deteriorated to the point where open drug scenes existed in several Swiss cities, a national harm-reduction policy was adopted in 1991. It formally permitted the implementation of low-threshold medication-assisted treatment (MAT) with methadone and (later) buprenorphine, needle and syringe exchange services, and supervised consumption rooms. Severely dependent OUI over the age of 18, who had failed MAT (defined as using additional, illegally obtained opioids despite receiving prescription medication) at least twice, were eligible to receive heroin-assisted treatment (HAT). Permission and control mechanisms were put into effect by the Federal Office of Public Health.

Under HAT, illegal “street heroin” is replaced by medically prescribed, pharmaceutically pure diacetylmorphine. HAT is more strictly regulated than MAT and does not allow take-home administration. Thus, HAT restricts OUI in everyday life more than MAT does and represents a therapeutic last resort for a seriously ill subpopulation. This is also reflected in the distribution of treatment frequencies: Of the approx. 19,400 OUI in treatment today, over 90% receive MAT, while only 1752 or about 8% receive HAT with diacetylmorphine. In Switzerland, HAT was first evaluated as a treatment alternative in pilot trials in the 1990s. The positive findings were later confirmed in other countries as well.