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HAT Trick: the clinical, social and health gains of prescribing pharmaceutical heroin to people dependent on illegal street heroin

A bright sunny day above the River Tee in Middlesbrough

Heroin Assisted Treatment (HAT) is a form of opioid substitute treatment that involves the prescription of diamorphine (or pharmaceutical heroin) to people dependent on street heroin.  It has been an issue I have been aware of for some time, but until recently I have not seen it as a priority. 

My commitment to harm reduction has been focused on the repeal of the odious Misuse of Drugs Act 1971. The use of this Act, which leads to the imprisonment of thousands of vulnerable people every year, has caused huge distress and unfairness in our society. It has prevented innovative ideas such as drug consumption rooms (or safer injecting facilities) from becoming a reality in the UK. 

The idea of Heroin Assisted Treatment, for me, is a reasonable one. I have always argued for rapid access to substitute prescribing, which with a cheap drug such as methadone, is possible even with a very limited budget. Heroin Assisted Treatment is significantly more expensive (roughly £15,000 per year compared with about £1,000 for oral methadone) and thus would dramatically reduce the capacity of substance misuse treatment services to meet the first goal of helping as many people as possible. 

It was therefore with some reluctance that I was persuaded to start looking at this model of care. So off I travelled to Middlesbrough in November 2021with two colleagues, Rondine Molinaro the service lead for Gwent Drug and Alcohol Service (GDAS) and Elwyn ‘Tommy’ Thomas who provides assertive outreach to vulnerable people not currently engaged in formal treatment.  Tommy also advises on co-production and supports the involvement of people with lived and living experience of substance misuse problems in the design and delivery of services across our organisation.

Middlesbrough is very similar to Newport in terms of population, demographics, a post-industrial past with a history of docking, and both having a working transporter bridge. Both town centres have seen better times and many of the more interesting shops and restaurants reside outside the city centre. The primary treatment provider in Middlesbrough is Foundations, which provides substitute prescribing including the use of Heroin Assisted Treatment. 

Foundations provides substance misuse treatment and support to over a thousand people in the area.  However, only 20 people, on average, are on Heroin Assisted Treatment at any one time. The reason for this is simple - the HAT service in Middlesbrough is not for everyone.  It is a targeted service, funded via the Home Office and Project ADDER, aimed at the most challenging cohort of people.  To take part, service users must attend twice a day and commit to the programme by restricting their use of other drugs. 

Martin Blakebrough, Visiting Fellow, Centre for Criminology

Martin Blakebrough is Visiting Fellow in the Substance Use Research Group of the Centre for Criminology. Martin is the CEO of Kaleidoscope, one of the largest drug services in Wales. It was among the first substance use service providers to provide needle syringe exchange, computerised methadone dispensing and has always had a commitment to harm reduction. 

Danny Ahmed who leads the HAT service showed us around Foundations (which is sadly not as comfortable as it used to be because of COVID restrictions) and gave us a tour of the Heroin Assisted Treatment service. What was particularly helpful was how Foundations allowed us to talk to some of their service users. Each service user was asked beforehand if they would be willing to meet with us.  They all agreed, which was amazing and shows the trust they have in the staff working there.

So, how does HAT work for the service user?

This is where I relied on my colleagues Rondine and Tommy who met with people as they injected their prescribed doses of pharmaceutical heroin. Tommy, who is an assertive outreach worker, well acquainted with people who inject street drugs, noted: “Firstly, what struck me immediately was the presentation of the individuals that were receiving twice daily doses of diamorphine. The individuals were clean and tidy, well-nourished and hydrated, and they appeared to be calm and respectful to staff whilst waiting orderly for their turn to use the injecting room to receive their supervised dose of diamorphine.

"On entering the supervised injecting space, we were met with a nurse and a clinical key worker who took it in turns to prepare the diamorphine whilst the other supervised the injecting. I was offered the opportunity to shadow three males injecting, two of the individuals chose to inject in their legs and one individual injected into his arm. 

"The first individual injected into his shin, and did so with ease, no anxiety whatsoever. He reported using the same vein and leg for the last two years, with no damage to tissue or veins or reddening or inflammation of the injecting site whatsoever. 

"The second individual injected into the inside of his upper leg with no problem, it was done with no fuss and he completed the intervention quickly and efficiently and hit the vein the first time. There was no inflammation or infection, blood loss was minimum and the lack of anxiety around the practice of injecting was obvious. 

"The third individual was the only one to use a tourniquet. He used an alcohol swab to clean the prepared area for sterile injecting, as did the previous two individuals. There was, however, a problem with hitting the vein, but with very little fuss he changed his injecting site to his shin and was successful in hitting the vein with ease and no complications. 

"I might add that all three of the long-term IV users’ injecting sites were clean of any infection or inflammation.  There was also the importance of a time-allotted space for injecting, this practice allowed each individual time to inject at a pace that was not rushed, and the knowledge that the diamorphine is of a pharmaceutical grade, reduced the anxiety considerably.” 

They had regained hope, dignity, respect

Rondine, the Service Lead for GDAS, noted from her time with the service users: “I was allowed access to witness three individuals self-injecting their diamorphine and so was able to probe and ask them about their life stories and what the benefits of HAT were for them. Two of them were living in hostels and had endured decades of repeated cycles of drug use/harm-offending-prison. 'Without HAT' they both commented, 'I would definitely be back in prison right now or I would be dead'. 

As a contract manager, unfortunately the issue of cost is always a factor - but when you calculate the cost to the public purse of drug-related crime, imprisonment, probation, overdose and death, HAT is a no-brainer. 

"All three people I spoke with had something that is often missing from people who continue in this cycle whilst fighting to stabilise in treatment on other forms of OST - they had regained a light in their eyes and a spring in their step. They had regained hope, dignity, respect and most importantly - connection with their families and with wider society. All three of them smiled and giggled naturally while we chatted. 

'Colleagues who deliver services to similar cohorts stuck in these cycles will appreciate how refreshing that was to see. When you are stuck in that cycle, fake smiles are only reserved for your dealer and giggling is something that happened so long ago - you've forgotten what it feels like.”

So, what about costs?

Danny argues that when you look at the costs to society caused by the most prolific drug users, such as the people supported in this project, the estimated costs are in the region of £2 million per year. Even if these 20 people were caught and imprisoned, you are talking police and court time plus approximately £40,000 a year for a prison term, which together far exceed the £15,000 cost of providing HAT.

If we move away from pure costs, there are undoubted health gains. As Tommy noted, the wounds inflicted by injecting are significantly reduced. There are clear social gains too. The people accessing this care have failed to benefit from other substitute programmes, dropping out of them and living in the chaos of addiction. Some of the HAT service users we talked to said how they re-connected with family, others were able to go on holiday and for some it led them to become Peer Naloxone Champions, saving the lives of others by distributing kits of naloxone (a drug that reverses a heroin overdose) to their peers for use in overdose situations. 

If rolled out more widely, HAT might make the idea of drug consumption rooms, where a person brings their own bought supply of street drugs, unnecessary. The idea that you would give someone a safe, clean unadulterated supply of a drug they use, in this context just makes sense. 

So, would I support Kaleidoscope following the lead of Foundations and Danny Ahmed?  I would say ‘Yes’ without any real doubts.  

But, the challenge is cost and that would require additional resource from the Welsh Government. The current treatment budgets are very tight and if it was not for additional support from Welsh Government, we would not even be able to prescribe Buvidal (a long-acting, injectable form of OST that requires monthly rather than daily administration, which proved very useful during lockdown). 

The problem often is a lack of joined-up thinking. HAT would save money to the Criminal Justice System, it may help with less admissions into hospitals, it may mean fewer children put into care as drug-using parents’ functioning skills will be better.  But, for a prescribing service there is only costs, which means that many clinical decisions are not made on need but on the budget given. This is an issue that needs urgent remedy so the most needy (and the most costly to society) get the help they need to lead the best possible lives for themselves and the families and communities they live in. 

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