Dear Friends

Many of you saw the Satel / Aeschbach article trashing the Swiss heroin trials, a
Personal Perspective in the US Journal of Substance Abuse Treatment.

I have sent the accompanying letter to that journals editors. Please feel free to
disseminate this as widely as possible.

Happy New Year to all

Ernie Drucker

To The Editors:

The Personal Perspective on "The Swiss Heroin Trials" by Satel and Aeschbach that you recently published (Vol. 17, 4 pp 331-5) does a disservice to the stated mission of your Journal - to "provide for the academic presentation of clinical practice issues that are meaningful to the treatment of drug abuse and addiction."

These pioneering Swiss studies have, for the first time, carefully evaluated the use of prescribed heroin for over 1000 of the country's most refractory, long-term heroin addicts. Although presented as an examination of "scientific soundness," the Satel and Aeschbach article presents a superficial, inaccurate, and generally misleading review of this work and fails to inform the reader about the most important context, intentions, antecedents, and consequences of the Swiss work - most especially its implications for the expansion of opiate pharmacotherapy and the need to improve its effectiveness.

The Swiss studies have shown that prescribing heroin under medically controlled conditions produces substantial declines both in illicit drug use and in criminal activity for this most problematic group - as well as providing clear evidence of improved social reintegration, including better housing, more gainful employment, fewer contact with drug associates, and more contact with families and friends.

Your readers should also understand that even the preliminary Swiss results were decisive in persuading Dutch public health officials to initiate their own randomized study of heroin prescription in Amsterdam and Rotterdam (for 750 participants), and plans are being formulated for conducting similar programs in Germany and Spain. And that a working group of treatment experts, research scientists, and bio-ethicists recently formed the North American Opiate Medication Initiative (NAOMI), which (based on the Swiss studies) has designed a trial of heroin stabilization for the United States and Canada.

Further, most of the methodological concerns raised by Satel and Aeschbach were addressed (in advance) by the Swiss investigators themselves, who went to great lengths to be conservative in their methods and cautious in the conclusions they drew from their results, e.g. see The Medical Prescription of Narcotics, a volume
of detailed discussions of all these matters from the Swiss Federal Office of Public Health, (English edition edited by David Lewis, et.al. and published by Hogrefe and Huber in 1997) - a work the authors do not cite.

Most alarmingly (for those of us concerned with treatment improvement) Satel and Aeschbach treat the limitations of the study design (all well recognized and repeatedly addressed by the meticulous Swiss investigators) as a basis for dismissing the true significance of the study - its discovery that alternatives to methadone maintenance may attract and retain addicts for whom methadone has proved unsatisfactory.

The authors assert that heroin administration diverted patients from enrolling in abstinence- oriented treatment. This claim is unsubstantiated (and probably unsubstantiatable) but reveals an important belief. There are those who see great threat in all drug maintenance approaches, believing that some moral ideology they hold (rather than clinical outcomes) should determine medical practice. The distortions that this position engenders, in this instance, even extends to misinterpreting history: They note that narcotic clinics established in the U.S. in the 1920s (quickly closed because of judicial and medical hostility), saw almost all of the patients revert to illicit use after they were detoxified. Exactly! That's why it's called "maintenance" treatment.

Perhaps these doctors (like many others) question the fundamental premise of narcotic maintenance - i.e. that for many patients addicted to opiates, the use of any one of a number of substitutes produce results far superior to drug free treatment. The goal of drug abstinence was not the goal of these patients, their doctors, or the Swiss Federal Office of Public Health - but is nonetheless imputed as a study objective by Satel and Aeschbach. In fact the original intent of the study was to improve retention of the patient in care, show improvements in the clinical course of their addiction (i.e. reduced illicit drug use), and in the social outcomes associated with a diminution in the use of illegal drugs. These were the projects major goals, and all had positive outcomes. Indeed it is this set of outcomes that accounts for the Swiss decision to extend and expand the program and for a half dozen other nations interest in replicating the Swiss work. Yet none of these outcomes (including the objective of reducing AIDS risk among the Swiss population) are given any weight by the authors.

The authors also present a seemingly careful and evenhanded presentation of the Swiss methodology that is, in fact, arbitrary and erroneous. The cornerstone of their case against the Swiss trials "scientific soundness" is that the results are not the product of an experimental randomized clinical trial (RCT) and that there was no control group. They criticize the use of self report and the failure to adequately control for the enriched provision of social services associated with the study.

Each of these claims is either untrue or irrelevant. The RCT is NOT the only means to determine clinical efficacy - indeed in public health programs it is rarely even an option. The successful introduction of methadone treatment occurred without one, likewise the widespread use of Penicillin. Contrary to their claims, self report by drug users in treatment is generally as reliable as any other means of collecting the most pertinent data and, in some cases, more so. The provision of social services (along with the heroin) is not only an appropriate and ethical requirement, but the availability of such services in the heroin study is similar to the level of services available throughout the Swiss treatment system and not really different than the many programs in which these patients had previously failed - a critical inclusion criteria and the principal rationale for the heroin trials inception (something the authors barely mention).

What then is the purpose of this piece? It attempts to discredit the Swiss experiment altogether by asserting (demagogically, in my view) a link of its conduct to an agenda of "drug legalization." Its first page serves notice of this intent, characterizing the investigators and project directors travels abroad to "promote" (rather than "present") their findings, and linking the decision of the Swiss Federal Office of Public Health (which sponsored the study) to expand the program as part of a plan by the Swiss parliament to decriminalize consumption, possession, and sale of narcotics for personal use. Something that the Swiss government and electorate have explicitly rejected. Finally they mention that prominent constituents of the "harm reduction and legalization movements"(sic) championed the study results. That several countries are beginning their own heroin trials is taken as further evidence of the influence this movement - not a recognition of the significance of the Swiss results or a responsible reaction by public health officials and clinical practitioners.

I suppose it is no accident that their citations do not include the Rolleston Commission Report of nearly 75 years ago - which addressed all of these matters with far less available science, but far more compassion and intelligence. This piece adds little to the debate and seriously distorts the reality it pretends to dispassionately evaluate. As drug treatment professionals and scholars your Journals readers deserve better.

Sincerely,

Ernest Drucker, PhD