Breaking the deadlock over an Australian trial of injectable opioid maintenance.

INJECTABLE HEROIN MAINTENANCE has been advocated as a form of treatment for opioid dependence that would attract, and retain in treatment, addicts who have either not sought treatment or who have failed at other forms of treatment, including methadone maintenance. Advocates of heroin maintenance argue that it would increase the proportion of addicts in treatment and reduce heroin use, drug-related crime, and deaths due to overdose. 1 A 1991 proposal by a Select Committee on HIV, Illegal Drugs and Prostitution of the ACT Legislative Assembly led to a feasibility study for a heroin trial in the ACT. 1 In 1997, the Ministerial Council on Drug Strategy voted in favour of a heroin trial, but the trial did not proceed, as the Federal Government would not amend legislation to allow heroin to be imported for the trial or allocate funds to monitor the use of heroin in accordance with international treaties. 2 Dramatic rises in deaths caused by opioid overdose in the late 1990s prompted more calls for a heroin trial. 3 The Federal Government refused to countenance a trial, creating a policy deadlock that prevented the evaluation of what proponents 2 claimed was a potentially valuable policy option. If we can avoid the fixation on a trial of heroin per se, there is a way out of this policy deadlock. The alternative option we are proposing is to trial hydromorphone (Dilaudid), an injectable opioid that has similar effects to heroin. 4,5 Even if the Federal Government's attitude towards a heroin trial were to change, we believe that trialling hydromorphone would be a better option than trialling heroin, for a number of reasons: s The subjective effects of hydromorphone are very similar to heroin in experienced heroin users and both have short durations of action. 5 s Hydromorphone is a registered drug (Schedule 8) in Australia, so it can be prescribed for medical purposes and used in clinical trials. There would be no need to change federal legislation to allow a trial of injectable hydromor-phone. Nor would there be any need for oversight of heroin importation and distribution by the International Narcotics Control Board. s The use of hydromorphone can be distinguished from the use of heroin by urinalysis, 6 thus allowing detection of any covert use of street heroin by trial participants. (A major criticism of the Swiss heroin trials was that this could not be done. 4) s Hydromorphone …