Beyond the Right to Injectable Heroin

Buchman and colleagues (2010) appeal to a respect for persons to justify the provision of heroin-assisted treatment (HAT) for persons dependent upon heroin. They argue that heroin-dependent persons, like persons with any other disorder, should have access to effective medical care, including HAT. We have argued elsewhere that as a matter of principle individuals should not be denied access to the most effective forms of treatment for their condition because of their mental health or criminal history (Carter and Hall in press). Nonetheless, we believe that an ethical analysis of any putative “right to HAT” needs to also take account of other ethical principles such as distributive justice and beneficence. In order to justify a right to HAT that is publicly funded, there needs to be evidence that HAT is safe and effective in randomized controlled trials (RCTs) and that it is costeffective when compared to other forms of opioid substitution treatment (OST), such as oral methadone or sublingual buprenorphine. Six RCTs seem to have established the safety and effectiveness of HAT compared to methadone maintenance treatment (MMT) as a second-line treatment for heroin-addicted persons who have failed to respond to standard OST. Critics have argued, however, that these trials may be biased in favor of HAT because they have selected patients who failed at OST and have usually compared HAT to suboptimal oral OST (Lintzeris 2009). In several of the studies, for example, insufficient doses of oral methadone were provided and the morphine equivalent heroin dose provided in HAT was significantly higher than that in the methadone condition. The quality of psychosocial care was also often superior in HAT. It is noteworthy that in several of these trials, patients who had not previously responded to MMT treatment responded to a new episode of MMT, particularly when it was provided according to “best practice.” In a Swiss study of HAT, around half of participants who had repeatedly failed to respond to MMT responded well when randomized to MMT, and over a third of these patients subsequently chose not to enrol in HAT when offered the chance (Perneger et al. 1998). Preliminary results from the Randomised Injecting Opioid Treatment Trial (RIOTT) support these findings (Strang et al. 2009). These studies suggest that significant gains may be achieved in treatment refractory patients by improving the quality of care in existing MMT (e.g., ensuring adequate methadone dosing, supervision, and psychosocial therapy).