Heroin anyone?

BMJ has pro/con commentaries on the subject of heroin maintenance.

Opioid maintenance treatment generally seems to be well justified for treating this disease. And if maintenance is generally justifiable as a form of treatment, why should heroin not be used as one such pharmacological agent? ... Overall, we see no convincing reason why heroin assisted maintenance treatment should not be part of a comprehensive treatment system for opioid dependence.

No convincing reason? Obviously, they've taken a position, but they don't think that ANY of the arguments have ANY merit? At least they offer this caveat...

However, the development of an overall integrated treatment system is crucial.

Neil McKeganey responds with an argument against:

Prescribing heroin to heroin addicts is a strategy beloved by top police officers and successive home secretaries. It is a strategy, though, borne of utter frustration at our seeming inability to tackle an escalating drug problem. If you cannot stop addicts committing crimes to fund their drug habit then, so the argument goes, the next best thing is to provide them with the drugs that are the reason they are committing the crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question, "Is it treatment or is it social problem prescribing?"

I think he makes right argument. Opponents of HR strategies are often accused of moral panic. I think the moral argument is one of the most persuasive, but not trying to turn drug use or addiction into a moral issue. Rather, the way we respond to suffering addicts is a moral issue. Further, are our interventions motivated by despair or hope, and, who are they intended to serve?

Prescribing heroin to heroin addicts, however, makes sense only if your primary concern is to treat not their drug dependency but the consequences of their drug use. You may want to reduce their use of street drugs, the risks to health from HIV or hepatitis C virus, the risks of overdose, or their criminality. With all of these aims in mind you may conclude that it makes sense to provide addicts with a prescription for the drug that they have become dependent on. And yet the reason they are committing those crimes, and taking such enormous and persistent risks with their health, is because the drugs have become more important than life itself—that is the nature of drug addiction. And that is the problem that drug treatment services need to tackle.

In the commentary, McKeganey makes the case for the efficacy of treatment. The problem is not that addiction doesn't response to treatment, rather that we continually treat it with sub-optimal doses and duration and then despair at the intractability of the problem.

Along these lines, if the issue for advocates is really that we don't have widely effective treatments (an argument that I don't buy), why don't they ever advocate these programs as a temporary stopgap until more effective treatments are developed?

But do addicts coming forward for treatment actually want heroin to be prescribed to them? A study of over 1033 drug users starting treatment in 2001 asked participants what they wanted to get from the drug treatment services they were contacting. Most of those questioned said that they wanted the services to help them become drug free.